A Clinical Context Report

Transcription

1 Metastatic Breast Cancer in Practice An Expert Commentary with Carey Anders, MD A Clinical Context Report

2 Clinical Context: Metastatic Breast Cancer in Practice Expert Commentary Jointly Sponsored by: and

3 Clinical Context: Metastatic Breast Cancer in Practice Expert Commentary This activity is supported in part by an educational grant from Genentech BioOncology

4 Metastatic Breast Cancer in Practice Clinical Context Series The goal of this program is to provide upto-date information and multiple perspectives on the pathogenesis, patient identification, symptoms, risk factors, current and emerging treatments, and best practices in the management of metastatic breast cancer.

5 Metastatic Breast Cancer in Practice Clinical Context Series Target Audience Oncologists, hematologists, obstetricians/ gynecologists, primary care physicians, nurses, nurse practitioners, physician assistants, pharmacists, and other healthcare professionals involved in the management of metastatic breast cancer.

6 Activity Learning Objective Upon successful completion of this educational program, participants should be able to: Review the relevance and significance of the activity in the broader context of clinical care

7 CME Information: Physicians Statement of Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Projects In Knowledge and MedPage Today. Projects In Knowledge is accredited by the ACCME to provide continuing medical education for physicians.

8 CME Information Credit Designation Projects In Knowledge designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

9 CME Information: Physicians Credit for Family Physicians MedPage Today "News-Based CME" has been reviewed and is acceptable for up to 2098 Elective credits by the American Academy of Family Physicians. AAFP accreditation begins January 1, Term of approval is for one year from this date. Each article is approved for 0.5 Elective credits. Credit may be claimed for one year from the date of each article.

10 CE Information: Nurses Statement of Accreditation Projects In Knowledge, Inc. (PIK) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Projects In Knowledge is also an approved provider by the California Board of Registered Nursing, Provider Number CEP This activity is approved for 0.50 nursing contact hours. There is no fee for this activity. DISCLAIMER: Accreditation refers to educational content only and does not imply ANCC, CBRN, or PIK endorsement of any commercial product or service.

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12 Discussant Carey Anders, MD Assistant Professor of Medicine Division of Hematology/Oncology UNC Lineberger Comprehensive Cancer Center Chapel Hill, North Carolina

13 Disclosure Information Carey Anders, MD has disclosed the following financial relationships: Received grants for clinical research from: Geron, Novartis, and sanofi-aventis

14 Disclosure Information Vandana G. Abramson, MD, Assistant Professor of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn.; Charles Bankhead; and Dorothy Caputo, MA, BSN, RN, Nurse Planner, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. The staffs of Projects In Knowledge and MedPage Today have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

15 Tumor Factors that Influence Therapy Estrogen-receptor status Progesterone-receptor status HER-2 expression Triple-negative disease Clinical Components of first-line therapy Response to first-line therapy Current disease status: symptomatic or not

16 Phase II Primary Outcomes N=123 C I + C P-value Overall survival (mo.) Progression-free survival (mo.) Overall response rate (%) Clinical benefit rate (%) Source: NEJM 2011; 364:

17 PARP Inhibitor Plus Temozolomide N=41 PR/CR 7% SD>16 weeks 10% PD 83% Clinical benefit rate 17% Median PFS (mo.) 1.9 BRCA Subgroup: N=8 PR/CR 37.5% SD 25.0% PD 37.5% Clinical benefit rate 62.5% (5/8) Median PFS (mo.) 5.5 (versus 1.8 for non-brca, P=0.0042) Source: ASCO Abstract

18 Exemestane +/- Everolimus in Metastatic Breast Cancer N=724 Investigator Assessed E+ E- P-value HR Median PFS (mo.) < Overall response (%) <0.001 Stable Disease (%) Central Assessment Median PFS (mo.) < Overall response (%) <0.001 Stable disease (%) Source: N Engl J Med. 2012; 336:

19 Source: N Engl J Med 2012; 366: N Engl J Med 2012; 366: Von Minckwitz, et al N=1,948 Neoadjuvant Bevacizumab CT CT+B P-value No Residual Disease (%) No Disease in Breast (%) No Disease in Breast+Nodes (%) No invasive Disease in Breast (%) Overall Response (%) <0.001 Bear, et al N=1,206 No Residual Disease in Breast + Nodes (%) No Disease in Breast (%)

20 Managing Cancer-Induced Bone Disease Medical Denosumab Bisphosphonates Calcium Vitamin D Surgical Zoledronic acid Pamidronate Vertebroplasty Balloon kyphoplasty Other Radiation to bone

21 Primary Managing Cancer-Related Pain Narcotic analgesics Anti-inflammatories Neuropathic Gabapentin Pregabalin Psychological/Psychosocial Antidepressants Anxiolytics

22 Hospice/End-of-life Decisions Discuss sooner rather than later Be honest: An incurable disease Involve patients and family members Hospice care does not mean giving up Emphasis on a peaceful, reassuring environment for patients Suggest sources of assistance for planning, counseling, preparing

23 Summary More than 40,000 patients die of metastatic disease each year Metastatic tumors share certain characteristics with primary tumors but also have features that differ Multiple treatment options exist for metastatic breast cancer single agents, combination chemotherapy, and conventional chemotherapy plus a biologic agent Tumor phenotype influences treatment choices hormone receptor status, HER-2 status, genetics

24 Summary (cont.) Clinical factors influence treatment decisions prior regimens, response to previous treatment The role of targeted therapy in metastatic breast cancer continues to evolve Several new therapies have shown promise - HER-2 targeted therapy - mtor inhibitors - Conjugate therapies - PARP inhibitors

25 Summary (cont.) Investigation of bevacizumab will continue in an effort to clarify its therapeutic potential Bone-targeted therapy has become a routine component of treatment plans Pain management has a central role in the treatment of metastatic breast cancer Discuss hospice care and end-of-life decisions earlier rather than later Treatment decisions should be consistent with the goal of preserving or improving patients quality of life, comfort, and peace of mind