Improving Care for Patients With Metastatic Breast Cancer

Sara M. Tolaney, MD, MPH: Adherence is such a challenge because I think many of us don’t even realize that all our patients aren’t really taking all the medications we prescribe. Even when we would just give hormonal therapy by itself, about 25% of patients weren’t even taking the medication. And so it’s striking. And I think you’re never going to know unless you ask. But I think Lindsay and I have made it a point with all our visits to not only ask what adverse effects are they experiencing, but are they actually taking their drug, and how many times did they miss taking their drug, and why did they miss taking their drug?

You know sometimes it’s because of an adverse effect and they really just can’t bear the thought of taking a drug that’s causing them adverse effects. Sometimes it’s financial reasons. You know sometimes the copayment is just too high and they didn’t pick up their last prescription. But, again, you’re not going to know unless you ask. And so we’ve made it part of the routine visit. “How many times have you missed taking your drugs this past month,” or whatever it’s been. We do this just so we get a sense of what’s going on and then see if we can fix it. We work to find out what the reason is so that we can help with their drug.

Lindsay Shaw, NP: I feel anecdotally though with these drugs that it seems less likely to occur than with other drugs. With people taking their supportive medications, they’re often very erratic with that. But this is a new level beyond just endocrine therapy for them and they feel that they really need to take it because they’re worried about their cancer having recently progressed. So I hear less about adherence with these than some other drugs that they’ve been prescribed.

There’s a team at our institute that is required to call patients who start any oral antineoplastic agents. So that’s built in. And usually the program nurses that we have are in touch with them anyway about procuring the drugs. So, if anything, I sometimes get reports that they’re having too many phone calls. But, yes, it’s rare that they’re not hearing from 1 or more people.

Sara M. Tolaney, MD, MPH: I think the class of CDK4/6 [cyclin-dependent kinases 4 and 6] inhibitors has really revolutionized the way we treat patients with metastatic hormone receptor-positive disease. I think it’s unique that these agents are able to control disease for twice as long as endocrine therapy would have, and now we see a survival benefit in the second-line setting. Generally they’re pretty well tolerated agents that allow patients to get oral drugs. They’re not coming into clinic as much as they would be with IV [intravenous] chemotherapies. And yet, they’re also able to cause significant objective responses. You know we typically think of endocrine therapy as not causing significant reduction in tumor volume, but that isn’t the case with CDK4/6 inhibitors added to endocrine treatment where the first-line response rate is as high as 50%.

And so, I think it also allows us to see patients in clinic, and even though they may have significant visceral involvement, we’re able to give them endocrine therapy with a CDK4/6 inhibitor. Whereas 10 years ago, these are patients that would have been getting chemotherapy in the first-line setting. So it’s completely changed the way we practice. And, again, it’s so hopeful to see that it’s also improving their long-term outcomes. So I really do feel like it is standard of care to give a CDK4/6 inhibitor with endocrine therapy, whether it be in the first- or second-line setting.

Lindsay Shaw, NP: It’s amazing that they have an opportunity to take something oral that we see such wonderful responses to. A lot of these patients are coming off of having maybe progressed on endocrine therapy and they’re not facing having to do IV chemotherapy. And I always tell people that this is something that’s doable. You can live your life pretty normally while you’re taking this. And that, in the end, is what everybody that has metastatic breast cancer wants to do. They want to just keep living their life as they were, and this really lets them do that.