Targeted Treatment of HR+/HER2-Breast Cancer - Episode 8
Pharmacist-Driven Treatment Options for Patients With HR+/HER2- Breast Cancer
Heather N. Moore, PharmD, BCOP, CPP, drives a discussion on the role of pharmacists in treatment strategy and optimizing patient adherence to HR+/HER2- breast cancer treatment.
Ryan Haumschild, PharmD, MS, MBA: Dr Moore, we talked a lot about what pharmacists do for treatment selection and toxicity management. But in the HR [hormone receptor]–positive, HER2 [human epidermal growth factor receptor]–negative space, pharmacists do a lot for patients because there’s a lot of work that has to be done to keep patients adherent: motivational counseling and making sure they understand the therapies, the sequence, that it’s a journey, and that if they’re dose reduced in the future, that might be part of their normal treatment pathway. But we’re going to keep them on therapy as long as we can, until we progress onto a new agent.
Knowing that you do a lot of these activities in clinic, talk us through your role with supportive care and some of the drug-drug interactions. Review any type of contraindications and motivation for adherence. You might see great efficacy in clinical trial, but it’s a very controlled space. How does that relate to the real world? The people who have great adherence and stay on that therapy as long as they can have a great pharmacist cheering them on and treating them. Please speak to a few of those things.
Heather N. Moore, PharmD, BCOP, CPP: First and foremost, I’m thinking about the pandemic and COVID-19. That’s something that we also have to be mindful of in terms of vaccination and being mindful of treatments. When should patients get vaccinated? What are the guidelines surrounding that? The NCCN [National Comprehensive Cancer Network] and ASCO [American Society of Clinical Oncology] provide some of those recommendations, but thinking about individual patients, what does that look like in terms of vaccination status?
The other thing we have to be mindful of is that as we have so many of these COVID-19 treatments, like Paxlovid, which is a wonderful thing, and they have quite a few drug-drug interactions. When do therapies need to be held? When can they be restarted? We think about the different types of COVID-19 treatments and what may work best for a patient based on their cancer treatment. That’s super important.
In terms of other supportive care, with all these therapies, we also have to think about nausea and vomiting. How can we support patients through that? From a cardio-oncology standpoint—because I have Dr Dent here, our cardio-oncology specialist—we think about QT prolongation with some of our therapies, QT prolonging supportive care medications and some of our nausea medicines. The standard things that we think about in primary care include bacterial infections and viral infections. There are so many of these things that you’re having to treat in the setting of their cancer therapy. What does that look like?
We’re also thinking about drug-drug interactions, both pharmacodynamic and pharmacokinetic interactions. Not only do we have to worry about other therapies that are being prescribed in the setting of our cancer therapies and how we best modify dose or toxicity, but a lot of the time we overlook pharmacodynamic interactions and how 1 therapy may compound the toxicity of another. We think about the other therapies patients are on. How do we need to modify what we’re doing?
In general, how do we help patients be compliant? It’s important that patients know why they’re on treatment, how their drug is impacting their disease, and that this is essentially their treatment from preventing cancer progression. We need to make sure they understand the importance of that. It’s also important to provide resources. Especially for some of our complicated therapies, we’ll do patient calendars so that they can follow along and put down the dates. We’ll think about doing cell phone alarms and making sure their family and friends are involved in their treatment and helping them remember some of those things. I can’t emphasize enough the importance of empowering patients to be involved in their treatment, not only with making those decisions but also helping with general management.
Ryan Haumschild, PharmD, MS, MBA: I also think about special patient populations. I have pharmacists who are involved if someone has kidney dysfunction and there’s a complicated dosing or some type of monitoring. Pharmacists play a huge role there. Talk a little about the role you play with unique patient populations. I’m sure there are lot of people coming to your center from all over who might be unique. Talk us through what those populations look like and how you intervene on their behalf.
Heather N. Moore, PharmD, BCOP, CPP: From a comorbidity disease standpoint, a lot of the patients we see are excluded from clinical trial. These are patients who have CKD [chronic kidney disease], hepatic dysfunction at baseline, or some of these other comorbidities. They’re excluded from clinical trials, so we may not have data in terms of dose modifications or toxicities in that patient group. It’s important to understand how the drug is cleared. What’s the drug metabolism? It’s important to think about pharmacokinetics. How can we modify doses when we don’t have a lot of data for that? Our patients who may be on dialysis. That’s going back to the pharmacokinetic metabolism information surrounding those therapies. That’s why you need a pharmacist.
Something else that’s helpful in thinking about more indigent patient populations is thinking about how we can best help patients have the resources that they need. We practice in an academic center, but we still see patients who may not have the resources to get to the clinic or can’t afford their medications. I went through all the toxicity surrounding alpelisib, but we overlook the ability of patients to get those supportive therapies, like metformin or a glucometer. It’s important to have the resources for those patients as well and to involve other members of the team, like nurse navigators and social workers. We have a great patient assistance team at Duke University that helps patients get therapies. It takes all those things to make sure we’re providing what we need for our patients.
Susan Faye Dent, MD, FRCPC, FICQS: If I can add to that, when we look at patient care, in medicine, we tend to operate in silos. That’s how we’re trained. Whether you’re an oncologist, a cardiologist, or a pulmonologist, we take care of that part of patients’ care. But we have to look more toward a holistic approach of taking care of the whole person and not just their cancer.
As Dr Moore alluded to, we see great data coming out of clinical trials, but we have to translate that into the real patient who’s sitting in front of us in our clinic. That patient may be older. They may have diabetes, preexisting heart disease, hypercholesterolemia—all sorts of things. Their performance status may be poor, but we want to take the results from that trial and apply them to that person. How do we do that without compromising all the other parts of their health? That’s the challenge. We can’t say, “You’ve got cancer, and this is the best therapy for you based on the clinical trials that have been published.” We have to look at the whole person and keep in mind, “What we do to you or offer you for your cancer is going to have an impact on your overall health. How can we manage that?” Dr Moore and I have had some pretty big challenges. For instance, we’ve even had a few people in our practice with heart transplants who then had breast cancer. How do you manage that? That’s not written anywhere in the books.
Heather N. Moore, PharmD, BCOP, CPP: There aren’t any data for that.
Susan Faye Dent, MD, FRCPC, FICQS: There aren’t any data for that. But that person is in your clinic, and you have to use all the knowledge and help you have to try to find the best treatment for them.
Heather N. Moore, PharmD, BCOP, CPP: Yes. It’s always making the drug fit the patient instead of trying to make the patient fit the drug. At the end of the day, especially thinking about how we implement the efficacy data that we see from these therapies, we have patients who are living longer with multiple comorbidities and all these other things going on. As she said, we have to find a way to integrate all these things to treat these patients.
Transcript edited for clarity.