Advanced Breast Cancer (ABC) 4 th ESO-ESMO International Consensus Conference Highlights 2 nd 4 th November 2017 Lisbon, Portugal

Transcription

1 Advanced Breast Cancer (ABC) 4 th ESO-ESMO International Consensus Conference Highlights 2 nd 4 th November 2017 Lisbon, Portugal Should you require further information on a molecule that is not produced by Roche Products Ltd., please contact the relevant manufacturer. Developed and funded by Roche Products Ltd. This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. Adverse events should be reported. Reporting forms and information can be found at or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events for Roche medicines should also be reported to Roche Products Ltd. Please contact Roche Drug Safety Centre by ing welwyn.uk_dsc@roche.com or calling +44 (0) For biological medicines, healthcare professionals should report adverse reactions by brand name and batch number. This report is provided in response to an unsolicited request from a healthcare professional and is not for further dissemination. 1/x

2 Dr Russell Burcombe and Claire Ryan (both based at Kent Oncology Centre) selected the content of this report as their highlights from the 2017 Advanced Breast Cancer Fourth ESO-ESMO International Consensus Conference, and provided the associated opinion and interpretation. Although no big-hitting data were presented at the ABC4 conference, this was nonetheless a very informative and engaging meeting that was relevant to clinical practice here in the UK: 1 There were many patient advocates at the conference, which gave it a different feel and perspective compared to more data-heavy conferences that we have attended, and made the sessions particularly engaging as patient advocates provided instant feedback and posed challenging questions for discussion. Highlights for us included discussions on managing treatment side-effects, which covered some practical, easily-implemented interventions that we can use in the UK to help reduce their burden. Interesting research on electrochemotherapy (ECT) in patients with skin metastases was presented. Since ECT is being introduced in parts of the UK, it is important for us to consider this research and implement the findings in our practice. Communication between healthcare professionals (HCPs) and patients was a prominent theme, including the importance of realistic expectations for both HCPs and patients, conversations about end-of-life care and helpful tools that we can use to help facilitate these discussions. The challenges of new oral therapies were discussed. These are particularly relevant given the National Institute for Health and Care Excellence s (NICE s) recent positive draft guidance on the use of cyclin-dependent kinase (CDK)4/6 inhibitors for patients with metastatic breast cancer (mbc). Interesting data on the use of vinorelbine versus paclitaxel for patients with mbc has made us consider how we use vinorelbine in our practice. Patient Advocacy, Policy and Politics In contrast to many UK breast cancer meetings, there were a substantial number of patient advocates attending the ABC4 conference, from all over the world. 1 Figures from the previous ABC conference (ABC3, held in Lisbon in 2015) showed that 5.5% of participants at that meeting were patient advocates. 2 Many of these patients were able to attend the conference through travel grants, and their participation highlights the increasingly important role that patient advocates play in decision-making and trial design. Consequently, patient perspectives were frequently heard throughout the conference, and patient advocates provided instant feedback on ideas suggested by HCPs during discussions, resulting in an engaging conference. 1 Key themes throughout the presentations, discussions and questions from patient advocates were having a voice, seeking evidence and provision and access to medicines. For example, issues of access to treatments across different countries arose on multiple occasions from Ugandan patients having to travel to Kenya to access relatively basic services such as bone scans (which gave some perspective on our challenges in the UK), to disparities in access to cutting-edge treatments. There were also key presentations on the various approaches different countries have on prescription and reimbursement and the impact of this on the population of patients with mbc. 1 1/4

3 Managing Treatment Side-Effects Patient advocacy session: ABC Advocacy: Managing side effects, sexual issues and fertility (Chairs: Dian CJ M. Corneliussen-James and Renate Haidinger); Tsuyuki S, et al. Breast Cancer Research and Treatment 2016;160: This patient advocacy session on the topic of managing side-effects, sexual issues and fertility was mostly anecdotal, but the sharing of experiences of side-effects and patient contributions to the session were informative. The session offered guidance and suggestions on how patients and clinicians can avoid and treat side-effects, and tips that can be taken back to the clinic. 1 One particularly interesting and practice-changing study, already published but discussed in this session, was a Phase II Japanese multicentre trial evaluating the effect of compression therapy using surgical gloves on nab-paclitaxel-induced peripheral neuropathy. Patients with breast cancer who were receiving nabpaclitaxel treatment wore two tight-fitting surgical gloves of the same size on their dominant hand for 90 minutes during chemotherapy infusions, but no surgical gloves on the non-dominant hand, which served as the control. In the 42 patients evaluated, incidence of grade 2 or higher sensory and motor peripheral neuropathy was significantly lower for surgical glove-protected hands than for control hands (sensory neuropathy 21.4% vs 76.1%; motor neuropathy 26.2% vs 57.1%). 3 The easy implementation and low cost of the intervention, combined with the potential substantial benefit for patients in tackling this debilitating side-effect, will certainly change our local practice. 1 Electrochemotherapy for Cutaneous Metastases Agresti R, et al. ABC 2017, PO113. Dr Roberto Agresti presented a proposal by the GISEL study group for a phase II international multicentre randomised controlled trial determining the efficacy of ECT during first line treatment, delayed ECT or no ECT in patients with skin metastases of breast cancer. In an earlier cohort analysis conducted by the same group, high objective response rates (>90%) were observed for patients with skin metastases of breast cancer who received ECT. Responses were best for both small, non-ulcerated, lesions without visceral metastases and for oestrogen receptor-positive, low-proliferating tumours. 4 This study could therefore help to inform UK clinicians which patients to refer for ECT, given its emerging use within the NHS. 1 Communication between HCPs and Patients Fallowfield L, ABC 2017, IN25; Beaumont C, et al. ABC 2017, PO51. Professor Dame Lesley Fallowfield gave an enlightening presentation on managing patients expectations regarding treatment, important conversations about end-of-life care and barriers to open disclosure, based on her research with UK HCPs. 5 This is an area we do not receive much training in as HCPs, yet is an important aspect of our role in caring for patients. Clinicians are often reticent to discuss end-of-life care with patients they know well, citing time pressures, uncertainty about disease trajectory and inadequate training in communication skills as barriers. 1 The unique relationship between HCPs and patients with mbc, whereby relationships evolve so that the HCP and patient consider each other as friends, can blur boundaries and make end-of-life conversations particularly difficult. Professor Fallowfield highlighted the need for more education and better tools to aid these discussions. Useful visual tools that can be used to provide greater clarity for patients when discussing their treatments and prognosis were discussed (e.g. the Help-Hurt tool 6 ). 1 A poster presented by Corrine Ellsworth Beaumont described how a series of illustrations using dandelions as visual aids can be used to help patients with mbc understand their diagnosis and treatment options. 1, 7 Chemotherapy was likened to spraying the dandelion and grass around it with weed-killer (killing both the dandelion and healthy grass), targeted therapy was portrayed as a selective weed-killer that only targets 2/4

4 plants with specific qualities (thereby killing just the dandelion) while surgery in patients with mbc was compared to digging up a single dandelion (but leaving other weeds in the garden). 1, 7 The use of these visual tools might aid discussions about treatment options with patients with mbc. Professor Fallowfield recommended that conversations about end-of-life care should not be a one-off, but rather discussed throughout a patient s care pathway to ensure they understand their prognosis and have realistic expectations of treatment. 1 The findings of a US study presented by Professor Ronald Chen at the American Society of Clinical Oncology (ASCO) 2016 conference were discussed. This research showed aggressive care is common at the end of life: 74% of younger patients with breast cancer received chemotherapy or an invasive procedure within the last 30 days of life and 33% died in hospital, whilst hospice use was only 14 18%. 8 It is important that patients are aware of the different treatment pathways and care options available to them, as well as the likely outcomes at this stage in their disease. 1 Challenges of Oral Therapies Boers-Doets C. ABC 2017, IN15; Barrios C. ABC 2017, IN11. Christine Boers-Doets gave an overview of the challenges oral drugs pose for oncology nurses. 9 Given the new era of oral drugs, there is a need to review nurse and nonmedical led services to ensure sufficient resourcing and expertise. 1 Indeed, with the recent NICE guidance recommending that the CDK4/6 inhibitors Ibrance (palbociclib; Pfizer) and Kisqali (ribociclib; Novartis) are routinely funded for the treatment of locally advanced or secondary breast cancer in the NHS, this is particularly pertinent. 1, 10 The approval of these new medicines is undoubtedly beneficial for patient care but will have significant resource implications across the NHS. 1 On a similar theme, Dr Carlos Barrios led an interesting discussion of an additional challenge of the growing use of orally administered anti-cancer medications, such as CDK4/6 inhibitors. 11 Although these new medicines appear a convenient treatment option for patients, there is a need to educate patients in how to manage their medications. In particular, patients must understand their condition in general, how to manage their side-effects and when to contact a HCP. This means that patients are required to become experts on their own condition in a very short space of time, which clearly represents a challenge for both HCPs and patients. 1 The Role of Vinorelbine Treatment in Patients with mbc Katselashvili L, et al. ABC 2017, PO78. Dr Lika Katselashvili presented a poster on an open-label, small prospective study comparing the efficacy and safety profiles of three frequently used chemotherapy regimens in patients with mbc: 3-weekly paclitaxel, weekly paclitaxel and weekly vinorelbine (95 patients, randomised 2:2:1). With a median follow up of 24 months, median time to progression (primary endpoint) was 10.3 months in the 3-weekly paclitaxel arm, 9.8 months in the weekly paclitaxel arm and 9.6 months in the weekly vinorelbine arm. Weekly vinorelbine was much better tolerated, with fewer grade 3/4 toxicity events (n=2) than weekly paclitaxel (n=23) or 3-weekly (n=16) paclitaxel. 12 These data suggest weekly vinorelbine should be considered as an early treatment option for patients with mbc in the UK. 1 3/4

5 References 1. Roche Personal Communication from Dr Russell Burcombe and Claire Ryan. 2. ABC. ABC3 Attendance. Available at: Accessed November Tsuyuki S, et al. Breast Cancer Research and Treatment 2016;160: Agresti R, Bianchi G. ABC 2017, PO Fallowfield L. ABC 2017, IN Beaumont C. ABC 2017, PO Chen R, et al. ASCO 2016, LBA Boers-Doets C. ABC 2017, IN NICE. News and features. Breast cancer patients to have routine access to two life extending drugs after new deal, say NICE in draft guidance. Available at: Accessed November Barrios C. ABC 2017, IN Katselashvili L, et al. ABC 2017, PO78. 4/4