Outcomes4Me sat down with Dr. Sara Tolaney, a medical oncologist at Dana-Farber Cancer Institute, to answer questions on what to expect in 2021 for breast cancer patients. Dr. Tolaney is the Director of Breast Oncology Clinical Trials and Breast Immunotherapy Clinical Research, as well as the Associate Director of Susan F. Smith Center for Women’s Cancers at Dana Farber Cancer Institute. 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 discussion with Dr. Tolaney:
Dr. Tolaney, let’s kick off the discussion with some of the most exciting developments for breast cancer patients, including the latest clinical trials?
- There are a lot of exciting drugs that have come along which is really nice to see. Some agents that have been making a large impact on clinical practice include antibody drug conjugates. The idea of these drugs is that you are able to deliver chemotherapy in a targeted manner into the cancer cells while sparing the healthy cells. The original antibody drug conjugate in breast cancer was T-DM1, but we now have approval for sacituzumab govitecan in metastatic triple negative breast cancer. We also have approval for trastuzumab deruxtecan, another antibody drug conjugate that has demonstrated impressive efficacy in metastatic HER2+ breast cancer. Trastuzumab deruxtecan also has trials ongoing in HER2 low cancer. In patients who are technically HER2-, but have a small amount of HER2 expression, trastuzumab deruxtecan is able to bind to HER2 and deliver chemotherapy into the cell. Also, immunotherapy has finally made its presence in breast cancer. There are novel immunotherapy combinations being explored in the preoperative and postoperative setting.
How can someone find and sign up for clinical trials?
- The best resource to find clinical trials like is your oncologist. They know you best and can help you understand what trials are best for you. The challenge is that each center has a different clinical trial portfolio. The central database for clinical trials in the US is clinicaltrials.gov and, even as an oncologist, I find it hard to navigate. After putting in diagnosis criteria, you get a large output of trials. I can’t imagine as a patient trying to sift through that data. It would take hours of time and in the end only a few trials would make sense for that patient. I know Outcomes4me has the ability to search for trials. I think tools like this are really helpful because finding trials is hard to navigate, especially when patients are trying to look for trials beyond their cancer center.
What’s happening in our current COVID-19 climate? Has COVID-19 impacted the detection and treatment of breast cancer?
- Unfortunately, there has been a delay in screening. Lots of sites stopped doing routine screenings in March and April of 2020 and many patients delayed screening to avoid coming into hospitals. We have seen a rise in the stage of the cancer we are detecting. We have more patients who present with palpable breast abnormalities or nodal involvement. It suggests delays in screening are increasing stage at the time of presentation. This highlights the need and the importance of screening. I would encourage people not to delay routine screening.
Is the COVID-19 vaccine safe for breast cancer patients? Can you take the vaccine if you are on active treatment for breast cancer?
- One challenge is we don’t have robust efficacy data on the COVID-19 vaccination in cancer patients. However, there is no reason to think there is any safety concern for someone on active treatment. We have every reason to believe the vaccine will be just as effective in cancer patients and we are counseling all our patients to get vaccinated. Our center is interested in gathering more data and has written a protocol to look at efficacy and safety of the vaccine in cancer patients. We are noticing patients developing enlarged lymph nodes after vaccination. We recommend not to have screenings immediately after the second vaccination because enlarged lymph nodes can be confused with cancer growth. For someone who has had a prior axillary dissection, you want to get your vaccine on the arm without axillary dissection.
Are there any current advancements for patients with triple negative breast cancer that has metastasized?
- There has been a lot of research in metastatic triple negative disease over the past couple of years. The standard previously had been chemotherapy, but now we have several other options. If someone has a PD-L1 positive metastatic triple negative cancer, we now offer chemotherapy with immunotherapy. There has been a proven added benefit to including immunotherapy with chemotherapy in this setting. Another advancement is the approval of sacituzumab govitecan. Sacituzumab govitecan has been compared to standard chemotherapy in pretreated metastatic triple negative disease and was found to be dramatically better than standard chemotherapy in terms of keeping the disease controlled and allowing patients to live longer. We have also seen the introduction of PARP inhibitors in patients that have a BRCA mutation. There are lots of exciting new therapies that are moving into metastatic triple negative disease.
Are there any immunotherapy trials for hormone positive cancer?
- In the metastatic hormone-receptor positive setting, there are ongoing immunotherapy trials. Originally, there was concern about using immunotherapy in hormone positive disease because hormone positive cancers tend to be less immune rich, but now there is interest in studying immunotherapy in hormone positive disease. We are currently doing a trial for hormone positive metastatic breast cancer with PD-L1 positive tumors. On the trial, if your tumor is PD-L1 positive, you are randomized to sacituzumab govitecan alone or sacituzumab govitecan with an immunotherapy agent, pembrolizumab. The trial is looking to see if adding immunotherapy to sacituzumab govitecan makes it work better for PD-L1 positive hormone positive patients. In the early stage setting, there are also trials looking at immunotherapy. There are two large trials looking at adding immunotherapy to chemotherapy in patients prior to surgery. There is also a trial looking at adding CDK4/6 inhibitors with immunotherapy to endocrine therapy prior to surgery.
If genomic testing was not undertaken at diagnosis, is it worth doing upon progression?
- Yes. I recommend that all patients have genomic testing. Particularly in hormone receptor positive disease, for example, where knowing you have PI3K mutation could impact treatment recommendations. Generally speaking, the optimal time to get genomic testing is at time of progression. Particularly, if you are getting a ctDNA assay to assess genomics, you will have the highest yield of ctDNA at the time of tumor growth. It is also when you can expect to see changes in gene mutations.
How does the level of positivity of HER2 expression affect treatment? For triple positive, HER2 low, patients, is adding trastuzumab to chemotherapy appropriate? For patients considered triple negative, but also HER2 low, would you consider triple negative or HER2 low regime for neoadjuvant treatment?
- This is becoming a big question. HER2 low cancers are defined as technically being HER2 negative, but have 1+ or 2+ IHC staining and are not FISH amplified. About 60% of all breast cancers are HER2 low. It may be important to understand how HER2 positive you are. We always want to be able to treat HER2+ cancer with HER2 directed therapy because the benefit of HER2 directed therapy is so great. If someone has HER2 positivity, I will generally add trastuzumab to chemotherapy. We are learning that even in someone who has HER2- breast cancer, but low HER2 positivity, there may be benefits of antibody drug conjugates like trastuzumab deruxtecan. There is a large randomized trial comparing trastuzumab deruxtecan to standard chemotherapy in metastatic HER2 low patients. This study included hormone receptor positive and some triple negative HER2 low cancers. We are waiting on that data. Right now we don’t know specifically that using trastuzumab deruxtecan will be better than standard chemotherapy in HER2 low tumors. In someone with early stage cancer, we would not do anything differently for HER2 low patients, outside of a clinical trial.
How effective are artic cold caps in preventing chemotherapy induced hair loss?
- Cold caps have shown tremendous benefit to our patients. It is always important to discuss with your oncologist if you are interested. Scalp cooling works better with certain chemotherapies than others. Generally, it does not work as well with anthracycline chemotherapy, like Adriamycin, but works very well in patients receiving non-anthracycline based chemotherapies. Whether you are receiving metastatic treatment or early disease treatment, it is worth a discussion with your oncologist. One area I struggle with is it is not uniformly covered by insurance and you could end up paying out of pocket for it.
I’ve seen studies using Zometa with aromatase inhibitors to boost prevention of metastases. Have there been developments in these studies?
- In the early disease setting, there is robust data for postmenopausal stage II and III patients on aromatase inhibtors that shows adding Zometa can help prevent recurrence. A large meta analysis confirms that Zometa can help prevent recurrences in this setting. Adding zometa with aromatase inhibitors has become something that we standardly incorporate into discussions with our patients.
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