Expert oncologists share brief notes on their real-world experience managing HER2+ metastatic breast cancer with trastuzumab deruxtecan.
Sara A. Hurvitz, MD: This patient did receive trastuzumab deruxtecan [T-DXd]. Remember, she had THP [docetaxel, trastuzumab, pertuzumab] induction for her de novo disease, had a great response lasting 18 months, progressed in the liver, and now she’s had T-DXd, with a partial response in both the breast mass as well as the liver lesions. We’ve talked a lot now about the toxicity of this therapy. I want to hear what your experience has been on a personal level with your patients with this drug. What have you noted in the clinic, Bill?
William J. Gradishar, MD: Most of our patients have responded; I can’t think of anybody who did not. I haven’t had anybody who had any significant ILD [interstitial lung disease] to date, and I think I’m seeing responses in those with CNS [central nervous system] disease as well. You mentioned the data with stable brain metastases, but there are data with some patients with active brain metastases as well. I think it is a very active drug. To date the toxicity that our group has seen has been modest, but we’re vigilant in looking for it and being sensitive to it. It inevitably will stop working, but to date it’s been a very active, very good drug.
Sara A. Hurvitz, MD: Sara, your experience as well?
Sara M. Tolaney, MD, MPH: It’s amazing to see the responses with this drug. When the drug first got FDA approved based on DB01 [DESTINY-Breast01 trial], we were using it in very late-line patients because there had been patients who didn’t have access to it until they had been through multiple lines of therapy. These are people who were progressing through several lines, and then all of a sudden had home run responses as their 7th or 8th line of therapy. It was unreal, and now it’s so nice to be able to use it earlier. The trick that we have learned though is that it does cause nausea for many people, so we do give prophylactic antiemetics with each dose. Some people are using Decadron, Aloxi, and Emend; some people can get away with just Decadron and Aloxi. Then some people need to use Zofran, even in week 2 and 3, there’s this delayed nausea that can happen. That has been helpful to many people to have access to that. We do sometimes see some hair thinning as you pointed out. I too have not had anyone go bald, but it is about a 10% rate of grade 2 that’s been noted with this agent. We don’t know if scalp cooling works, we have a trial ongoing at our institution [Dana-Farber Cancer Institute] looking at that, so we’ll see if that helps. But again it’s generally well tolerated, just some fatigue, nausea; those are the main symptoms I tend to notice.
Sara A. Hurvitz, MD: There are a lot of eyes on your data relating to the scalp cooling. We’re all waiting to see how that pans out with something that has a longer half-life. One wonders if it’s going to work, but we’re all hoping that in some way it will help.
Transcript edited for clarity.