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ESMO 2020 wrap-up webinar (RECAP)

October 02, 2020

Outcomes4Me sat down with Dr. Sara Tolaney from Dana-Farber Cancer Institute to answer questions on the latest advances for breast cancer patients announced at ESMO 2020. ESMO (European Society for Medical Oncology) is Europe’s most prestigious oncology conference, attended by the world’s top oncologists and cancer researchers. The research studies shared at conferences like ESMO often become the basis of clinical guideline updates.. Dr. Tolaney is a breast oncologist and the director of clinical trials at Dana-Farber Cancer Institute with a particular interest in getting access and information out there to all breast cancer patients.

We have included the entire webinar video above for anyone who missed it and wants to watch it in full.  Here is a recap of the key takeaways from the presentation and discussion with Dr. Tolaney:

>> EARLY BREAST CANCER ADVANCEMENTS MADE AT ESMO

CDK4/6 inhibitors have dramatically changed outcomes in metastatic breast cancer. The question is, does adding these drugs to hormone therapy prevent recurrence in early stage breast cancer? Data presented at ESMO showed the CDK4/6 inhibitor, abemaciclib, combined with hormone therapy decreased HR+/HER2- breast cancer patients’ risk of recurrence. We have more to learn about CDK4/6 inhibitors in early stage breast cancer, but Abemaciclib shows promise in preventing recurrence in high risk patients within this setting. There were also developments in early stage triple negative breast cancer (TNBC). A study showed that adding atezolizumab with chemotherapy improves complete response rates after surgery, compared to chemotherapy alone. More research is needed to understand the long term implications of immunotherapy in early stage breast cancer

>> METASTATIC BREAST CANCER ADVANCEMENTS FROM ESMO

Another advancement in TNBC was confirmed in the ASCENT study which showed sacituzumab govitecan is superior to chemotherapy in terms of slowing disease progression and increasing overall survival for metastatic TNBC patients. Sacituzumab govitecan should become the standard of care in this setting. Additionally, the recently approved therapy, alpelisib, showed clinically meaningful increases in overall survival for patients with HR+ PIK3CA mutated metastatic breast cancer, particularly in patients with liver or lung metastasis. 

>> As a physician, has this conference changed how you go about treating patients today? 

As physicians, we asked ourselves are we going to do something different in the clinic today. I was already using sacituzumab govitecan, so this study confirmed my use of the therapy. To me, one of the take homes is we should be testing all HR+ patients for a PIK3CA mutation and if they have the mutation they should consider alpelisib in the metastatic setting. We should test all TNBC patients for PD-L1 to see if immunotherapy will be effective for them. Another question is, should we use immunotherapy in early stage breast cancer. The challenge for me there is that some of the side effects from immunotherapy could be permanent. We need to learn more. For example, we don’t know the implications of immunotherapy on fertility for younger patients.

>> At Outcomes4me, we did a study with metastatic HR+/HER2- patients using our app, asking if they have undergone genomic testing to see if they have the PIK3CA mutation? Only a third had received testing. Is the recommendation today that all patients in that category get tested for this mutation to see if alpelisib could be a treatment option for them?

Generally speaking, I’d say yes. We should be testing our patients for genomic mutations, but at this point the only mutations that impact our treatment decisions are the PIK3CA mutation and the BRCA mutation. For patients with a BRCA mutation, we are seeing benefits from PARP inhibitors. It’s important to have genetic testing and to get your tumor tested. That being said, there are patients for whom it can be contraindicated to get tumor testing. If someone has significant diabetes, we won’t use alpelisib, in which case one could argue you don’t need to test the tumor. We are learning more and more, but personally I’m testing all my patients.

>> From what we have learned from ESMO, are there any recommendations for patients starting a conversation with their doctor today?

If you are an early stage HR+ breast cancer patient with several lymph nodes involved, the question is, is there any benefit to adding abemaciclib to the treatment. If you have metastatic breast cancer and you are HR+, then you should consider genomic testing to know if alpelisib could be of benefit and germline testing to know if you have the BRCA mutation. If you have metastatic TNBC, make sure your tumor is tested for PD-L1 to know if immunotherapy could be beneficial to you. If you have metastatic TNBC, ask about sacituzumab govitecan given the dramatic benefits we have seen. 

>> I have metastatic HER2+ breast cancer to the bone, I tested positive for the PIK3CA mutation. I’m on the third cycle of alpelisib and have level three hyperglycemia. Not having luck controlling the hyperglycemia, but the tumor markers have decreased dramatically. Have you seen success in a treatment with hyperglycemia pills or insulin?

Unfortunately, this is common with alpelisib. Tight glucose monitoring is really recommended. What has been most beneficial is the initiation of a drug called Metformin which helps reduce glucose levels. It turns out it is more effective than insulin with high blood sugar related to alpelisib.

>> Is TDM1 now the more effective treatment for HER2+ cancer compared to Herceptin and Perjeta when residual disease is present after chemotherapy and surgery? What if patients are unable to complete 14 cycles of TDM1. Should they then resort back to Herceptin and Perjeta?

It turns out that when there is residual cancer seen at the time of breast surgery, we know that giving TDM1 is better than giving Herceptin in that setting. I would agree that TDM1 should be the standard for patients that have cancer left behind after anti-HER2 therapy, chemotherapy and surgery. Even if patients don’t finish 14 cycles of TDM1, we still see benefit in the overall population. If patients stop TDM1, many of them receive Herceptin

>> Is ESMO a conference I can attend in the future? Why/why not?

Yes, patients can attend. However, the registration fees for the conferences are not cheap. With the move to a virtual platform, there have been price reductions. Hopefully, that will be the case next year. If someone has interest, I would encourage them to attend. The only challenge is that the presentations are geared towards oncologists so the conversations are not in a patient friendly format. It can make it challenging to interpret without context. It depends on the patient preference.

If you are looking for more support, resources, or have additional questions, submit your question using the “ASK” tab in the Outcomes4Me app and our O4ME clinical care team will do their best to help you find an answer.