HER2-Positive Breast Cancer Treatment Continues to Change

Recent years have brought landmark changes for the treatment of patients with human epidermal growth factor receptor 2-positive (HER2+) breast cancer, with the advent of targeted therapies and other new regimens. Therefore, it is essential that oncology nurses have effective approaches to managing this patient population, especially as they receive neoadjuvant or adjuvant dual HER2-targeted therapy.

As if adverse events (AEs) and evolving guidelines were not enough to manage, the novel coronavirus disease 2019 (COVID-19) pandemic also brought about challenges to nurses and clinicians nationwide. Participants in the OncLive® Breast Cancer Talk: Nursing Perspectives on HER2-Targeted Agents in Breast Cancer, discussed these topics. The talk was moderated by Madelaine Kuiper, NP, a nurse practitioner at UCLA Santa Monica specializing in hematology and oncology.

Kuiper was joined by 3 other nurse practitioners: Loyda Braithwaite, NP, from the University of Wisconsin Carbone Cancer Center; Susan Hays, NP, from the Washington University Siteman Cancer Center, and Elahe Salehi, NP, of the Dana-Farber Cancer Institute.

KUIPER: Please discuss treating your patients who are in the neoadjuvant/adjuvant setting. How often do you see them? Do you do education prior to starting treatment with your patients, and what tend to be the issues that continue? Obviously, adherence to therapy, but particularly at the moment in this current time of COVID-19, how is that impacting your patients’ treatments?

HAYS: I want to address the adherence to therapy in multiple settings; neoadjuvant, adjuvant, and metastatic. The barriers placed by COVID-19 have been difficult ones. We’re in an area where there are socioeconomic demographics, and racial disparities can impact the patient’s ability to even get to the clinic. And so that has impacted some of our abilities to give and keep them on a regular regimen.

But first and foremost, I think just identifying barriers that keep them away—lack of knowledge, anxiety, transportation issues, all of the things that play into the ability to even get to the clinic.

KUIPER: Does that then cause problems where you’re seeing patients with more aggressive or larger disease when they present to you?

HAYS: We’ve had people that have delayed therapies, and unfortunately, at the height of our pandemic in St. Louis, we were not doing smaller breast tumor cases. Those patients were put on hold, and a determination had to be made whether or not to continue therapy or wait. So yes, I think it has impacted outcomes to a certain extent.

KUIPER: Elahe, have you anything to add to that about your experiences during this current time?

SALEHI: At Dana-Farber, we do have pathways for every disease, and we have it for breast oncology patients. And doing the pathways, it’s a combination of the NCCN guidelines and the new practices and new research focused on patient care. With COVID- 19, we did have to change a little bit in the aspect of how we treat our patients with breast cancer and we communicate that actually with everybody, and it’s on our intranet. We tend to use a lot of patients who were able to get sub-q injections for Herceptin rather than bringing them and having an IV infusion with longer duration.

As per how we treat the adjuvant and neoadjuvant setting in our patients, at Dana-Farber, we mostly use anthracycline-based chemotherapies unless there is a contraindication. So mostly our regimens depend on the staging of the cancer, and nose positivity depends on the THP component versus AC-THP or TCHP regarding anthracycline sensitivity.

KUIPER: Let’s move on now to how we counsel our patients on the common AEs and adverse reactions associated with pertuzumab and trastuzumab. Obviously, there is a variety, usually with naïve patients, so how do we ensure that they know how to handle a lot of these AEs. Loyda, would you like to give us your perspective, please?

BRAITHWAITE: I think education is very important for our patients. At our institution, whenever we start a patient either in neoadjuvant or adjuvant treatment, or perhaps for a patient with metastatic disease, we make sure we set up a time with a nurse educator so the patients can have one-on-one time to go through the information. We provide written material and a lot of follow-ups because we anticipate that patients are likely not going to be able to grasp all the information … So make sure that they have preparation beforehand in the education, so it’s likely to be more effective. We anticipate that session happening usually about a week or 2 prior to the initial infusion.

I think we do a combination of phone calls, one-on-one teaching, well, prior to COVID- 19, it was a one-on-one teaching, but we still do a one-on-one but in alternative ways. We make sure there aren’t any last questions to be answered prior to treatment and make sure that we make ourselves very accessible to them too, because I think a big factor when patients start treatment is this uncertainty of what to do if they need to contact [someone.] So I think that reassurance of this is education, but there is also the human factor next to it. It provides a lot of that pathway for patients to be able to access us.

KUIPER: What would you say are some of the key points or some of the key, I should say, AEs that you tend to cover with your patients in your teaching?

BRAITHWAITE: We make sure patients know about the cardiac toxicity that can come with anti-HER2 treatments; also fatigue and nail changes, which is something that we don’t address but it’s very common and patients can become quite affected and distressed. So [we discuss] that, among the other well-known symptoms, like alopecia and so forth, [which are] not as frequent, but we still see quite a bit of hair thinning, so we make sure that we hit those points for patients and the fatigue among those as well.

KUIPER: Elahe, I’d like you to further expand on the potential cardiac toxicity long-term from these HER2- targeting therapies, and the use of an anthracycline, particularly in the early breast setting. Could you tell us how you treat your patients and how you monitor them?

SALEHI: Our protocol is based on the treatment prior to initiating any anthracycline or HER2-directed therapy. We obtain an echocardiogram to evaluate the ejection fraction of every patient. For adjuvant-setting patients, they will continue on it every 3 months with echocardiograms. In our metastatic population, it depends, but mostly it fluctuates between a 6-month to 12-month period.

We are lucky in our institution. We have an oncocardiologist program that we tend to refer patients, whether they come in with a cardiac dysfunction to begin with, whether they were lymphoma patients who had low body radiation, or whether patients will have a lower ejection fraction due to our treatment. And most of the time, they were seen by these providers urgently. Cardiac toxicity, most of the time, is reversible. So we have some beta-blockers and ACE inhibitors and hold the treatment for a 3-week period and reevaluate patients starting on anti-HER2-directed therapy.

KUIPER: What advice would you like to give clinicians who are seeing a lot of these new agents now, either in their infusion centers or those who do a lot of education with their patients?

HAYS: I would say that I have been an oncology nurse for many years, and I was around in 1998 when trastuzumab was approved. So just seeing how cancer, particularly breast cancer, has evolved over the years has just been an amazing thing to watch. I feel really old. I feel like I’m getting out soon, but I would encourage oncology nurses that this is the best thing you could ever do—it’s the most challenging, it’s the most rewarding. I would say you’re ever learning, ever-growing, and probably will always be touched by the fact that you’re involved in someone’s life, making an impact.

So from that point of view, I would also say that they should take a molecular biology course and a genetics course as part of their educational learning. I feel like I’m on the back end, trying to catch up. But certainly, it’s exciting just to see how things are just moving along.