HER2-Positive Breast Cancer - Episode 4

Case 1: Subcutaneous HP Therapy in HER2+ Breast Cancer

Targeted Oncology

Ingrid Mayer, MD, MSCI, and panel share the benefits of subcutaneous HP instead of IV HP therapy, particularly for the patients’ quality of life.

Sara Tolaney, MD, MPH: It sounds like most of us are comfortable using dual-HER2 [human epidermal growth factor receptor 2]–directed therapy in our higher-risk—particularly node-positive—patients, given the benefits seen and the node positive subgroup APHINITY and the lack of data for use of pertuzumab in the node-negative patient population. Looking at subgroup data with about 6 years of follow-up from APHINITY, we do have access to newer ways to give subcutaneous HP [trastuzumab, pertuzumab] instead of IV [intravenous] HP [trastuzumab, pertuzumab]. Is that something people here have been adopting in clinic? What has your experience been with that in terms of how your patients have liked it? Ingrid?

Ingrid A. Mayer, MD, MSCI: For us, we use it when insurance allows it. Unfortunately, that has been a big barrier in transitioning all patients to that. We’re talking not just subcutaneous trastuzumab but the subcutaneous trastuzumab-pertuzumab combination. Whenever we can, we do. From a patient perspective, it’s fantastic because they spend a ton of less time in the fusion room. But selfishly, it allows us to cram our people in infusion rooms, so our times are also better distributed. But in the bigger scheme of things, it’s less time that you need a port. And some people choose not even to have a port, whereas before you needed a port for the whole year of treatment because you’re getting infusions every 3 weeks. Let’s say I have a patient whose insurance covers either HP [trastuzumab, pertuzumab] or H [trastuzumab] subcutaneously, and their image looks amazing prior to surgery. I tell the surgeon, “You don’t have to go ahead and take the port out because I can get away with subcutaneous. I don’t think you’re going to need T-DM1 [trastuzumab emtansine] because they’re unlikely to have residual disease.” From a quality-of-life point of view, from a patient perspective—from time saved from their jobs and time saved in infusion room, economically if you think of a Whac-a-Mole system, it makes a lot of sense to use the subcutaneous. The data comparing the 2 formulations is solid. I have no reservations in transitioning. I’m hoping that the COMPASS people are hearing this so they can amend the protocol and let us use subcutaneous stuff in there.

Sara Tolaney, MD, MPH: I agree. In fact, our center changed the orders in the computer so that it’s easy to order the subcutaneous formulation instead of IV [intravenous], which is great.

Carey Anders, MD: We’ve had the subcutaneous trastuzumab in the metastatic setting, but we haven’t had it yet for early-stage breast cancer. One of the things that we had discussed was home administration with a home health nurse. Is that something your team does? For the folks who are in the adjuvant phase, they would come in to see you for routine follow-up. But have you been able to have a better experience for the patient if you’ve also seen home administration?

Sara Tolaney, MD, MPH: There’s a trial ongoing looking at this. We’re participating in it, and some of you also may be. I have 1 patient doing it who has loved it because a nurse comes to your house and administers the drug. Think of the patients who come from so far away. This is a tremendous time-saving advantage for them.

Carey Anders, MD: Absolutely.

Sara Tolaney, MD, MPH: This is a pilot that we’ll get more data from to learn safety and feasibility. I hope in the future there can be a movement toward that, because it’s a long time for patients even in the adjuvant setting. Think about those maintenance metastatic patients who sometimes are on HP [trastuzumab, pertuzumab] for years. It really would be tremendous.

Transcript edited for clarity.