Advancements in the Treatment and Management of HER2-Positive Early Breast Cancer - Episode 11

Influence of SQ and COVID-19 on Therapy

July 24, 2020

Jacob Kettle, PharmD, BCOP, and Allison Butts, PharmD, BCOP, consider the influence of COVID-19 on the therapeutic choice for patients.

Jacob Kettle, PharmD, BCOP: I was curious as we talked about how telehealth exploded onto the scene with the emergence of COVID-19 [coronavirus disease 2019]. Has there been any change in your choice of therapy in this time period? Especially around what we’ve talked about, subcutaneous dosing. Has that shifted preference at all?

Allison Butts, PharmD, BCOP: These 2 events, the move toward subcutaneous therapy and COVID-19, have aligned somewhat but not perfectly. The stars didn’t completely align. It’s obvious that a subcutaneous dosage form that could be given very quickly or even at home is certainly preferred in a pandemic scenario. Going forward, as these drugs come out, that’s definitely a great option that could decrease exposure and help patients stay at home and stay safe.

The other topic that came out that I’ve seen on the discussion boards going around is about whether we extend the interval between doses of these monoclonal therapies. As we’ve discussed, these drugs have long half-lives; they stick around the body for a long time, so is there a possibility? It may not be for the curative patients; there is a little more hesitancy there.

In some of our patients who are metastatic, is it possible to do a 4- or 5-week interval between doses of these monoclonals rather than bringing them in every 3 weeks? What is the risk benefit to doing that? We have not implemented either of those changes, whether that’s at-home dosing or extended-interval dosing, for our anti—HER2 [human epidermal growth factor receptor 2] therapies. It’s certainly worth a discussion, especially as we head into this unknown area about how long this will go on and what’s going to happen come fall. We’re going have to make some decisions there.

Jacob Kettle, PharmD, BCOP: Similarly, we [at the University of Missouri Health Care] adopted some more extended dosing strategies for agents for which there is an approval for that, at least pharmacokinetic data to support it. In my view, we have to stay cognizant of the cancer that we’re fighting and the known risks that we’re fighting. In this pandemic era, there are still so many unknowns. One of the things I’ve been very careful to avoid doing was forgetting about the knowns we’re dealing with. As we know, these cancers, especially if we let them grow unfettered and don’t continue care, there’s a definitive lethal consequence.

We have to remain cognizant of that, and that mission absolutely must continue to march on. It’s about finding a way to be innovative and creative to minimize or reduce those additional risks of infectious exposure. It would be very difficult to detract from that other mission without having potential serious consequences.

It probably sounds like you do too. It might be a neat idea to explore extended dosing intervals. But when we’re dealing with these scenarios, particularly compared with unknown risks or many questioned risks, it’s a tough question. I’m sure everybody wrestled with that early on: Do we keep people on therapy or do we delay? It’s a difficult equation to write that risk-benefit ratio when you don’t have all the data.

Allison Butts, PharmD, BCOP: I feel like a lot of patients ask that themselves: “If I don’t come, what’s going to happen?” As a clinician, we honestly don’t know. We could extrapolate, and we could use that kinetics that we understand about these drugs, but we don’t know what the impact is on that particular patient if we delay.