NCCN Guidelines Expand First-Line Sacituzumab Govitecan for Metastatic Triple-Negative Breast Cancer

In this interview with Pharmacy Times, Jordan Hill, PharmD, BCOP, clinical pharmacy specialist in breast oncology at West Virginia University Cancer Institute and PGY2 Oncology Residency Program coordinator at West Virginia University Hospitals, discusses updated NCCN recommendations for first-line sacituzumab govitecan (Trodelvy; Gilead) in metastatic triple-negative breast cancer. Hill explains that the agent may be used as monotherapy or combined with pembrolizumab (Keytruda; Merck) depending on a patient’s programmed death ligand 1 (PD-L1) status. Patients with a PD-L1 combined positive score (CPS) of 10 or greater may be candidates for the combination, whereas those with PD-L1–negative disease may receive sacituzumab govitecan alone.

Pharmacy Times: How do the new NCCN Guidelines incorporate the expanded first-line role of sacituzumab govitecan in metastatic TNBC?

Jordan Hill, PharmD, BCOP: The National Comprehensive Cancer Network (NCCN) recently updated its guidelines regarding when sacituzumab govitecan is indicated. Previously, it was recommended in the second-line setting and beyond. The recommendation has now expanded to include the first-line setting, either as a single agent or in combination with pembrolizumab.

Pharmacy Times: What should oncology pharmacists consider when selecting between sacituzumab govitecan monotherapy and sacituzumab govitecan plus pembrolizumab?

Hill: The biggest difference between using sacituzumab govitecan as a single agent in the first-line setting and using it in combination with pembrolizumab is the patient’s PD-L1 status. Patients who are PD-L1–positive, defined as having a CPS of 10 or higher, are candidates for combination therapy with pembrolizumab. In contrast, patients who are PD-L1–negative are candidates for sacituzumab govitecan as a single agent.

Pharmacy Times: What are the biggest challenges pharmacists may face when implementing these new first-line treatment options for patients with metastatic TNBC?

Hill: I think the most challenging part is waiting for the PD-L1 testing results. This is an agent that we’re familiar with, so using it in the first-line setting is not particularly challenging. However, triple-negative breast cancer is a very aggressive form of breast cancer, and these patients have metastatic disease. We want to start treatment as soon as possible, but we must wait for the PD-L1 testing results to determine whether combination therapy or single-agent therapy is appropriate.

Some institutions conduct testing in-house and may receive results sooner, whereas others use a send-out test, which may take longer. One way we have tried to reduce the wait time is by starting the process of obtaining insurance approval for the medication. That way, when the result becomes available, the approval process is already underway, which may help reduce the time patients must wait before starting treatment.