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Accreditation/ Credit Designation

Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is not approved for AMA PRA Category 1 Credit

Acknowledgment of Commercial Support

This activity is supported by an educational grant from Puma Biotechnology, Inc.


Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer - PER Pulse™ Recap
PER Pulse™ Recap

Resources

Community Practice Connections: Current and Emerging Strategies in the Management of Early Breast Cancer
Earn up to 1.0 AMA PRA Category 1 Credit™
Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer, is a series of short video interviews with Drs. O’Shaughnessy, Jahanzeb, and Holmes, who address a variety of questions commonly faced by practicing community oncologists. This online activity serves as an update on advances in the management of early-stage breast cancer, with a focus on the clinical implications of novel therapies, recent clinical trial data, and the management of predictable adverse events in patients with HER2-positive disease.

PER Pulse™ Recap
PER Pulse™ Recaps for Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer focuses on common clinical questions related to the management of early-stage, HER2-positive breast cancer.



PER Pulse™ Recap PER Pulse™ Recap
Medical Writer: Kim Farina, PhD


1 of 3
PER Pulse™ Recap

This first of 3 PER Pulse™ Recaps summarizing the online CME publication Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer focuses on adverse-event monitoring and management in patients who are receiving adjuvant HER2-targeted therapy.

The Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer was designed to update physicians on key clinical data and highlights in breast cancer presented at a CME-certified, ancillary satellite symposium of the 14th Annual International Congress on the Future of Breast Cancer®. The activity is accompanied by video interviews with the symposium faculty—Frankie Ann Holmes, MD; Mohammad Jahanzeb, MD, and Joyce O'Shaughnessy, MD—that explore clinical implications of novel therapies, recent clinical trial data, and the management of predictable adverse events in patients with early-stage, HER2-positive disease.

Cardiotoxicity

Drs. Jahanzeb and Holmes reiterate guideline recommendations that patients receiving anti-HER2 therapy be screened for baseline cardiac ejection fraction (EF), with monitoring every 3 months while on therapy. They note that although late toxicity is not common, EF should be rechecked at 6 months and 12 months after completion of therapy.

  • Dr. Holmes shares a personal experience with a patient who developed reduced EF while on trastuzumab, and comments that while she has not had many patients who have experienced cardiac toxicity with adjuvant trastuzumab, early detection of any potential cardiotoxicity is critical.
  • Dr. Jahanzeb remarks that anti-HER2-therapy–related EF reduction tends to occur early or not at all; he views it as a cardiosuppressive effect more than a cardiotoxic event.

GI and Skin Toxicities

Drs. Jahanzeb and O'Shaughnessy also discuss their experiences and approaches in prevention and management of diarrhea and skin toxicity related to anti-HER2-targeted therapy.

  • Drs. O'Shaughnessy and Jahanzeb emphasize the importance and effectiveness of implementing a prophylactic loperamide regimen to manage treatment-related diarrhea. A typical regimen entails loperamide (4 mg) at first loose stool of the day, followed by additional loperamide (2 mg) at each loose stool (not to exceed eight 2-mg pills per day).
  • Dr. Jahanzeb discusses that skin toxicity, while rare, is variable. It typically starts about 2 weeks after initiation of therapy with dry skin that may develop into acneiform rash. He reviews key elements of patient education and reviews management of cases grade ≥2.


2 of 3
PER Pulse™ Recap

This second of 3 PER Pulse™ Recaps summarizing the online CME publication Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer focuses on adjuvant therapy for patients with early-stage, HER2-positive (HER2+) breast cancer.

Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer was designed to update physicians on key clinical data and highlights in breast cancer presented at a CME-certified, ancillary satellite symposium at the 14th Annual International Congress on the Future of Breast Cancer®. The activity is accompanied by video interviews with the symposium faculty—Frankie Ann Holmes, MD, Mohammad Jahanzeb, MD, and Joyce O’Shaughnessy, MD—that explore clinical implications of novel therapies, recent clinical trial data, and the management of predictable adverse events in patients with early-stage, HER2+ disease.

The faculty reiterated the recommendation of the National Comprehensive Cancer Network (NCCN) Guidelines for Invasive Breast Cancer that pertuzumab may be added to standard docetaxel, cisplatin, and trastuzumab (TCH) or anthracycline-cyclophosphamide (AC) chemotherapy prior to surgery for patients with ≥T2 or ≥N1, HER2+ breast cancer. Dr. O’Shaughnessy commented that the field is seeing less usage of anthracycline-based regimens due to its associated toxicity. For patients who have already undergone surgery, the NCCN guidelines allow for use of pertuzumab. Dr. O’Shaughnessy remarked that use of pertuzumab in the adjuvant setting is largely dependent on regional reimbursement trends. She noted that preoperative pertuzumab is not used to increase breast conservation rates; rather, it is used to elicit systemic outcomes. With that goal in mind, she routinely offers 6 cycles of adjuvant pertuzumab to her eligible patients.

For patients not eligible to receive perioperative pertuzumab (eg, low-risk, node-negative, subcentimeter disease), Dr. O’Shaughnessy turns to adjuvant TCH or 12 weeks of weekly paclitaxel plus 12 months of trastuzumab, based on recently reported, positive phase II trial data.

Dr. Jahanzeb underscored the importance of considering the benefit–risk ratio when making decisions about adjuvant therapy for very ill patients, very old patients, or patients with multiple comorbidities. Dr. Holmes agreed and remarked that the adjuvant weekly paclitaxel-plus-trastuzumab regimen offers an effective alternative therapy for older patients and for any patients for whom there is concern about tolerance. Dr. Holmes also discussed data from an open-label, phase II study suggesting that docetaxel, cyclophosphamide, and trastuzumab may be a well-tolerated, effective alternative for patients with toxicity concerns.



3 of 3
PER Pulse™ Recap

This third of 3 PER Pulse™ Recaps summarizing the online CME publication Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer focuses on adjuvant trials for HER2-positive (HER2+) breast cancer.

Community Practice Connections™: Current and Emerging Strategies in the Management of Early Breast Cancer was designed to update physicians on key clinical data and highlights in breast cancer presented at a CME-certified, ancillary satellite symposium at the 14th Annual International Congress on the Future of Breast Cancer®. The activity is accompanied by video interviews with the symposium faculty—Frankie Ann Holmes, MD, Mohammad Jahanzeb, MD, and Joyce O’Shaughnessy, MD—that explore clinical implications of novel therapies, recent clinical trial data, and management of predictable adverse events in patients with early-stage, HER2+ disease.

ExteNET

Dr. Jahanzeb discussed results from primary analysis of the randomized, placebo-controlled, phase III ExteNET trial of neratinib after adjuvant chemotherapy and trastuzumab for early, HER2+ breast cancer. The addition of neratinib to trastuzumab garnered a 2.3% absolute improvement in the primary endpoint of 2-year invasive disease-free survival (iDFS). Three-year data from an exploratory analysis was presented in December 2015 and showed similar iDFS benefit with neratinib (2.1%).

  • Dr. Jahanzeb explained that in preplanned subgroup analysis, up to an 8% benefit was observed among patients who were HER2-amplified by central testing. A lower iDFS hazard ratio was also reported for patients with ER/PR+ disease.
  • Putting these results into context, Dr. Jahanzeb remarked that the magnitude of benefits observed in ExteNET were in the ballpark of older, practice-changing, cooperative group trials and should not be considered an outlier to be dismissed.

ALTTO

Dr. Jahanzeb discussed the disappointing results of the phase III ALTTO trial that evaluated dual anti-HER2 adjuvant therapy with lapatinib and trastuzumab. ALTTO was a 4-arm study that randomized patients to 1 year of adjuvant therapy with trastuzumab, lapatinib, trastuzumab followed by lapatinib, or concurrent lapatinib and trastuzumab. The lapatinib monotherapy arm was discontinued early when it met its futility boundary for noninferiority to trastuzumab. Results from the study showed no significant difference in 4.5-year DFS across the study arms. Subgroup analysis did not reveal any positive results.

  • Dr. Jahanzeb commented that the results of the trial were disappointing and have no bearing on adjuvant management of HER2+ breast cancer. He noted that lapatinib remains an agent that is used as third-line therapy for metastatic disease, along with capecitabine or, possibly, trastuzumab.
     


Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is not approved for AMA PRA Category 1 Credit™.

Supported by an educational grant from Puma Biotechnology, Inc.





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