mBC Treatment Optimized Through Shared Decision-Making Process


Medical experts weigh in on the strength of collaborative care and shared decision-making in the management of metastatic breast cancer (mBC).

Ryan Haumschild, PharmD, MS, MBA: So…far, we’ve talked a lot about CDK4/6 inhibitors. We’ve talked about their use, how they’re emerging in treatment, where they fall in the NCCN [National Comprehensive Cancer Network] guideline with strong compendia support and how to manage the [adverse] effects and how those are unique. But one of the main things that I want to reemphasize is the importance of multidisciplinary care. I think multidisciplinary care brings together better decision-making, better overall monitoring, and overall better outcomes for our patients. And really this does center around CDK4/6 use that we’ve talked about. So Dr DiMarco, if you could, how has your institution implemented CDK4/6 inhibitors since they were originally approved by the FDA [US Food and Drug Administration]?

Rose DiMarco, PharmD, BCPS, BCOP: We started using palbociclib right around the time it was approved. It was the first FDA-approved CDK4/6 inhibitor. We were involved in the original trials and that was kind of our go-to. We’re very comfortable with it and we really loved it. And if I remember correctly, the overall survival data for ribociclib hit…right during COVID[-19]. So we were super excited about that, but we were also shut down so we couldn’t get patients in for ECGs [electrocardiograms],and that was a huge barrier. And I think it took us a lot of time to overcome that, to start using ribociclib more and more. Now I think we [use] a fair amount of ribociclib and abemaciclib, but again, it’s very patient specific there. We’ve mentioned a couple of times now there are patients [who] are just not candidates for that Category 1 ribociclib and also abemaciclib to that extent with preexisting GI [gastrointestinal] comorbidities. So it really depends on the patient, it depends on the provider, and it also depends on where the location of that practice is. I think we see that across all disease teams and the treatment paradigm can shift no matter where you’re at. But in general we are using CDK4/6 inhibitors with the first line of diagnosis.

Ryan Haumschild, PharmD, MS, MBA: It’s great to hear your experience. And also… during the pandemic, I think there [were] some things…that we were forced to learn how to do better...[such as] how do you monitor a patient at home so they can still be successful in therapy. And it’s great to hear you all got through that. And especially with the new emerging data, it’s exciting…that something that you were involved in can provide even further benefit and greater justification around use. So, Dr Kettle, as we talk about it, shared decision-making is core to treatment decisions. And…my question to you is…built on that shared decision-making framework. How would a pharmacist, physicians, and even patients optimize that shared decision-making process when they’re selecting and making decisions around most appropriate medications?

Jacob K. Kettle, PharmD, BCOP: What a what a big…question that is, because I think that’s what we all strive to do––how do we make this decision-making process better? I think it is really the gift and also the challenge simultaneously with where we’re at in oncology today. And it’s radically different than when I entered in[to] this world 15 or so years ago. (I stopped doing the math a while back.) We used to have one or two things we could do, and that was it. And it was just [deciding] should we treat with this or not. And now we talked previously about the NCCN guidelines as very common, particularly in breast cancer, but just really across many malignancies to have 3 or 4 or 5 different options to choose from. And so I think a real critical part…is making sure [patients] have a real understanding of what their choices and options are––boy, is this is hard to do––but make sure we’ve spent the time educating the patient on what different treatment journeys might look like, what are the pros, what are the cons. And then also really understanding what motivates a patient. What’s their value system? What do they most want to achieve? Are they most invested in, [for example,] “my primary goal is to live absolutely as long as possible, regardless of the [adverse] effects” or is their primary goal,…“I just want to have the fewest[adverse] effects and fewest clinic visits,” and everybody is going to land somewhere on that spectrum. So I think particularly with patient engagement,…we talk about value-based care, but I think in this case, it’s a values based care. What [does] the patient value? We can assess what means the most to them because [for] all the clinical trials in the world that matter to us, maybe that outcome improvement doesn’t register for what a patient’s looking for in their care. So I think that’s really critical. From the care team side in particular, [what matters is] developing those collaborative working relationships where we build respect, we build trust, we build an environment where every member of the team has an opinion that gets heard and received and all factored into the decision to make the ultimate best choice for our patients.

Ryan Haumschild, PharmD, MS, MBA: Excellent. Well with those decisions, there [are] many different considerations for a pharmacist. And…even that depends on if you’re working with an academic provider or a community provider. And a lot of us have large integrated delivery networks [IDNs]…where we have the academic site and academic clinics. But there [are] also community oncology hubs that are part of our IDN. We want to make sure that we’re pulling through appropriate decision-making there as well. But that always has a little different approach because some may not be as familiar with the clinical trials [and] some might be treating [patients with] GU [genitourinary] GI [gastrointestinal], and breast [cancer].…How do we inform their decision-making? So, Dr Moore, coming from a large center that may have to interact with academic and community providers, what are some of the different considerations that pharmacists should be thinking about when working with community oncologists vs subspecialists at academic medical centers?

Heather Moore, PharmD, CPP, BCOP: Now, that’s a great question, and you…hit the nail on the head there. When we’re thinking about academic medicine,…I work in a breast clinic [and] what we see all day, every day are breast patients. So we know the data for breast cancer in and out. It’s what we’re doing, so we know some of those niche things. We know the caveats of certain drugs and we’re going to use them. And maybe some of those things that may not be implicitly stated within the guidelines. But when you think about…community centers, you’re right. A lot of those [have] general oncologists and they’re seeing [patients with] GI,…thoracic, [and] breast [cancer]. They’re not using some of the agents everyday like we are….We have hundreds, maybe close to a thousand, patients [receiving] CDK4/6 inhibitors, whereas they may see a handful of these [patients] sometimes within certain areas. So I think it’s being mindful of how we disseminate that information,…having an understanding of the drugs themselves,[and also,] like some of the things I went over today, what some of the key differences are between these agents from both an efficacy standpoint [and] also…toxicity profile. So…if you have a general idea of the important things that we need to know when [we] are making the decisions about a patient’s treatment in that regard, we’re also thinking about specific choices around [adverse] effects, how to manage those. [We’re] making sure that we’re educating on that and disseminating that out to the community for some of these community centers.

Transcript is AI generated and edited for clarity and readability.

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