Pharmacist-initiated treatment options for patients with HR+/HER2- breast cancer

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: Dr. Moore, we’ve talked a lot about what pharmacists do in selecting treatments and managing toxicity. But in HR [hormone receptor]-positive, HER2 [human epidermal growth factor receptor]–negative space, pharmacists do a lot for patients because there is a lot of work to be done to maintain patient compliance: motivational counseling and making sure they understand the therapies, the sequence, what it is is a trip, and that if they are dose reduced in the future, it could be part of their normal treatment. But we’re going to keep them on treatment for as long as we can, until we move on to a new agent.

Knowing that you do a lot of these activities in the clinic, tell us about your role with supportive care and some of the drug interactions. Review any type of contraindications and motivation for joining. You can see great efficacy in clinical trials, but it’s a very controlled space. How does this relate to the real world? People who have high compliance and are on this therapy as long as they can have a great pharmacist to encourage and treat them. Please talk about some of these things.

Heather N. Moore, PharmD, BCOP, RPC: I am thinking above all of the pandemic and COVID-19. This is something that we also have to consider in terms of vaccination and consideration of treatments. When should patients be vaccinated? What are the guidelines around that? The NCCN [National Comprehensive Cancer Network] and ASCO [American Society of Clinical Oncology] provide some of those recommendations, but in terms of individual patients, what does that look like in terms of vaccination status?

The other thing we need to be aware 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 interactions. When should therapies take place? When can they be restarted? We’re thinking about the different types of COVID-19 treatments and what may work best for a patient based on their cancer treatment. It’s super important.

In terms of other supportive care, with all of these therapies, you also have to think about nausea and vomiting. How can we support patients through this? From a cardio-oncology perspective—because I have Dr. Dent here, our cardio-oncology specialist—we think of QT prolongation with some of our therapies, supportive medications that prolong QT interval and some of our anti-nausea medications. The standard things we think about in primary care include bacterial infections and viral infections. There are so many of these things that you need to address as part of their cancer treatment. What does it look like?

We also think about drug interactions, whether they are pharmacodynamic or pharmacokinetic interactions. Not only do we have to worry about what other therapies are prescribed as part of our cancer therapies and how best to alter the dose or toxicity, but most of the time we overlook the pharmacodynamic interactions and how one therapy may aggravate the toxicity of another. . We think about the other therapies that patients follow. How should we change what we do?

In general, how do we help patients to be compliant? It is important for patients to know why they are undergoing treatment, how their medicine affects their disease and that it is essentially their treatment to prevent the progression of cancer. We need to make sure they understand the importance of this. It is also important to provide resources. Especially for some of our complicated therapies, we will make patient calendars so they can track and note the dates. We’ll be thinking 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 cannot stress enough the importance of empowering patients to be involved in their treatment, not only in making these decisions, but also in overall management.

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: I am also thinking of special patient populations. I have pharmacists who are involved if someone has kidney dysfunction and there is complicated dosing or some type of monitoring. Pharmacists play a huge role in this. Talk a bit about the role you play with unique patient populations. I’m sure there are many people from all over your center who could be unique. Explain to us what these populations look like and how you intervene on their behalf.

Heather N. Moore, PharmD, BCOP, RPC: From a comorbidity perspective, a lot of the patients we see are excluded from clinical trials. These are patients with CKD [chronic kidney disease], hepatic dysfunction at baseline, or some of these other comorbidities. They are excluded from clinical trials, so we may not have data in terms of dose modifications or toxicity in this group of patients. It is important to understand how the drug is eliminated. What is drug metabolism? It is important to think about pharmacokinetics. How can we modify the doses when we don’t have a lot of data for that? Our patients who may be on dialysis. This goes back to the pharmacokinetic metabolism information surrounding these therapies. That’s why you need a pharmacist.

Another useful thing to think about in poorer patient populations is to think about how best to help patients get the resources they need. We practice in an academic center, but we always see patients who may not have the resources to come to the clinic or who cannot afford their medications. I’ve been through all the toxicity surrounding alpelisib, but we overlook the ability of patients to get those supportive therapies, like metformin or a glucometer. It is important to also have the resources for these patients and to involve other members of the team, such as nurse navigators and social workers. We have a great patient assistance team at Duke University that helps patients get therapies. It takes all of these things to make sure we’re providing what we need for our patients.

Susan Faye Dent, MD, FRCPC, FICQS: If I may add to that, when we look at patient care, in medicine, we tend to operate in silos. This is how we are formed. Whether you are an oncologist, cardiologist or pulmonologist, we take care of this part of patient care. But we need to focus more on a holistic approach to managing the whole person and not just their cancer.

As Dr. Moore mentioned, we are seeing great data coming out of clinical trials, but we need to translate it into the real patient who is sitting in front of us in our clinic. This patient may be older. They may have diabetes, pre-existing heart disease, high cholesterol, all sorts of things. Their performance status may be poor, but we want to take the results of this trial and apply them to this person. How can we do this without compromising all other parts of their health? This is the challenge. We can’t say, “You have cancer, and this is the best therapy for you according to the clinical trials that have been published. We need to look at the whole person and keep in mind, “What we do or offer you for your cancer is going to have an impact on your overall health. How can we handle this? Dr. Moore and I had some pretty significant challenges. For example, we’ve even had a few people in our practice with heart transplants who later had breast cancer. How do you handle this? It’s not written anywhere in the books.

Heather N. Moore, PharmD, BCOP, RPC: There is no data for this.

Susan Faye Dent, MD, FRCPC, FICQS: There is no data for this. But this person is in your clinic and you should use all the knowledge and help you have to try to find the best treatment for them.

Heather N. Moore, PharmD, BCOP, RPC: Yes. It is always about adapting the medicine to the patient instead of trying to adapt the patient to the medicine. Ultimately, especially thinking about how we implement the efficacy data that we’re seeing from these therapies, we have patients living longer with multiple comorbidities and all these other things that are going on. As she said, we have to find a way to integrate all of these things to treat these patients.

Transcript edited for clarity.

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