Ryan Haumschild, PharmD, MS, MBA: Let’s talk about the unmet needs and future treatment directions for HR [hormone receptor]-positive, HER2-negative patients. dr. Moore, let’s get back to you, because we speak with many of the pharmacists who treat these patients. You have a very progressive practice. Love your team support and arts champions for you to be a PI [principal investigator] on a study, and all the management you do with the Duke University protocol. What general advice would you have for clinical pharmacists who have these HR positive, HER2-negative breast cancer patients? What advice would you give them to be successful and improve patient outcomes?
Heather N. Moore, PharmD, BCOP, CPP: That’s a great question. In general, be the drug expert. We are trained for that. There are 2 components to it. One is understanding the literature, efficacy data, sequencing of therapies, and guidelines. It is those who have background information and keep abreast of the rapidly evolving literature and guidelines on a daily basis and implement them. It’s having that background or basic information and then incorporating the drug therapies.
Knowing that so many therapies are approved so quickly and used so often, how can we manage that from a drug toxicity standpoint? From dose adjustments. How do we apply that to a more complicated patient? Consider comorbidity. It’s about using the many things we’ve already experienced and taking it home with us. Because how do we get this drug to this patient? That is what we do. It’s thinking about some of those views and drug interactions and co-morbidities, and using all of those things to make an impact in the clinic to help patients. And be an exceptional team member.
Ryan Haumschild, PharmD, MS, MBA: It sounds like there are a lot of opportunities for pharmacists to get involved. I totally agree with you. Like you said, it’s patient-centered. It’s about how you can help the team so that caregivers can focus on seeing more patients, bringing in more patients, and making sure the patients are ultimately successful in therapy.
Let’s move on to guidelines. Dr Dent, I’ll start with you, but I’d like your input on this question. Do guidelines accurately reflect the treatments you use in your practice? We have the NCCN [National Comprehensive Cancer Network] guidelines and other guidelines that are available. Or do you focus more on personalized therapy? You see patients who can be very acute at times. They may be highly advanced in their disease or heavily pretreated. How do guidelines reflect your current practice?
Susan Faye Dent, MD, FRCPC, FICQS: Guidelines are good at summarizing the evidence. They will talk about the studies, what the studies have said, and what reasonable treatment options are for you. Our job as healthcare providers is to take that guideline, take that evidence and apply it to the patient and make it a more patient-centered approach.
In other words, as we discussed earlier, if I want to use a CDK4/6 inhibitor, which spine do I use based on the patient’s previous exposure? What are their comorbidities? What can they tolerate? What is their disease burden? What other therapies have they had? It’s taking that information and personalizing it for that person, which I always think is the best way to go. However, the insurers do not always agree with me. But it’s the personal approach and use of that evidence. A guideline is a guideline. It doesn’t mean you have to go there, but it certainly gives you the information and evidence you need to make those recommendations.
Heather N. Moore, PharmD, BCOP, CPP: I agree. When I think about this, the way I sum it up is that one size doesn’t fit all. When we think about different therapies, we think about how we apply them to the patient. That’s something I struggle with, in terms of certain institutions that make formulas where they are only allowed to choose 1 CDK4/6 inhibitor. But is that the best choice? We don’t just think about the efficacy data, but so many things that influence that choice, in terms of where their disease is, the data we have behind visceral disease or brain metastases, or some of those patient-specific factors. Maybe they have a history of IBS? [irritable bowel syndrome]. We think of their ability to take 3 weeks on, 1 week off, in terms of therapy.
It has the clinical insight behind it to help determine the best choice for that patient. That’s something I also have a bit of trouble with in terms of trajectories. Pathways can be helpful in terms of general guidance, but sometimes those patient-specific factors are needed to determine the next treatment choice that best suits that patient. Because you may have a patient that it seems very obvious to be this, but if you knew that patient, when thinking about their comorbidities or certain factors that play into that decision-making process, there may be another therapy that is superior or preferable has for that particular patient. There are several things we need to keep in mind.
Ryan Haumschild, PharmD, MS, MBA: Those are good points because sometimes when you’re dealing with big oncology practices in the community or places where there are no sub-specialists, you want to direct people to the right selection. But like you said, it’s so patient specific. In your clinic, it sounds like having a collaborative decision-making conversation with that patient, recognizing where they are, what they can handle, and what will give them the best targeted outcome plays a big part in that. I appreciate your perspective.
Susan Faye Dent, MD, FRCPC, FICQS: It is also important to realize that it is often more than a 1-person conversation. We are lucky enough to meet for an hour each week at our center to talk about patients with metastatic breast cancer who are progressing. As a group, we discuss, “What do you think would be the next best therapy based on what’s available for that patient’s specifics?” Having that group discussion among ourselves as healthcare providers is also great for patient care because it takes into account all of those factors that we just mentioned.
Transcription edited for clarity.