Managing Sacituzumab AEs and Looking Forward to Next-Line TNBC Therapy

Article

During a Targeted Oncology™ Case-Based Roundtable™ event, Hope S. Rugo, MD, discussed adverse event management in patients treated with sacituzumab govitecan for triple-negative breast cancer and other therapy options. This is the second of 2 articles based on this event.

Rugo headshot

Hope S. Rugo, MD (Moderator)

Professor of Medicine

Director, Breast Oncology and Clinical Trials Education

UCSF Helen Diller Family Comprehensive Cancer Center

San Francisco, CA

DISCUSSION QUESTION

  • How do you counsel your patients with metastatic triple-negative breast cancer (TNBC) regarding sacituzumab govitecan-hziy (Trodelvy) with respect to toxicity?

HOPE S. RUGO, MD: Do you give patients information about the neutropenia and diarrhea risk before you start them?

CHRISTOPHER CHEN, MD: Yes, and also alopecia. Out of all the adverse events [AEs], the one that bothers my patient the most is her hair loss because she thought it was over and done with it already [after chemotherapy]. I started sacituzumab, and I warned her about the hair thinning, and that was probably the most intolerable AE for her.

RUGO: Do you have any patients using scalp cooling?

CHEN: No. I think it’s out of budget for a lot of my patients.

RUGO: There’s a philanthropic organization called HairToStay. We just did our fundraiser, and a lot of the haircare industry donates to it, as well as wealthy people, philanthropists, and some organizations donate to it. So, for example, some organizations that support a certain segment of the population will create their own funds, but they’ve given out tons of grants. I tell my patients to go to hairtostay.org because they can help with the costs. The patient still has some cost, but insurers will cover it now because there’s a Medicare code, so it’s worthwhile.

Dana-Farber Cancer Institute is doing a study [NCT04986579] looking at different scalp cooling techniques with sacituzumab. I’ve had quite a number of patients use it with good effect. Not everybody, but quite a number of patients do keep their hair. So it’s worth mentioning it to patients. It’s hard because they would be getting it day 1 and day 8 every 21 days and they have metastatic disease. They may not want to do it, but if hair is incredibly important to them, it is worth talking to HairToStay.

CHEN: I think it’s $1800; that is what our patients are telling me. That’s pretty pricey.

Rugo: Yes, it is. HairToStay will cover—I think their grants are $1500 and they have a sliding scale. But, if your patients can’t afford the $1800, it’s likely that they will qualify for the HairToStay grant. It’s worthwhile talking to them. They’re incredibly helpful. So, if a patient who is worried about losing their hair, then it’s worthwhile mentioning that. It depends on their insurance. I don’t think the California Medical Assistance Program or Medicaid would pay for it, but there are private insurers that have paid for the patient out-of-pocket cost, or at least a part of the cost, 80%. I think the Medicare code has a cap on the amount which is in the $1200 to $1500 range.

DISCUSSION QUESTION

  • If you aren’t using sacituzumab govitecan in the second line, what are you using and why?
  • What are you using most often as next-line therapy for progression on/after sacituzumab govitecan? ​

RITA MAITY MUKHERJEE, MD: I generally use sacituzumab, but if not, then eribulin [Halaven] is an alternative. If the patient is elderly or has more frailties, that is something I would use.

RUGO: What would you use next [after sacituzumab]?

MUKHERJEE: Eribulin.

RUGO: Do you start at a dose reduction for eribulin?

MUKHERJEE: I do. I’ve had some bad episodes, so I do generally use it and then go up.

RUGO: Growth factors are [used] almost always for patients on eribulin, andyou also get hair loss.

Does anybody else have a different drug they give in the next line?

CHEN: You also have to look at the HER2 expression. If it’s HER2-low disease, you have another option.

RUGO: You would give trastuzumab deruxtecan [Enhertu; T-DXd].

CHEN: Right. If their disease is HER2 low, it’s pretty effective.

RUGO: Yes. Although, in DESTINY-Breast04 [NCT03734029], there were just 58 patients with TNBC and 18 in the control arm, but the results were quite impressive.1 I think that is a good next-line option and you could even use it after eribulin. Generally you can get it approved too, even though its sequencing, which wasn’t studied in DESTINY-Breast04.

Would anybody start with trastuzumab deruxtecan rather than sacituzumab if this was HER2-low disease?

BRENDA ERNST, MD: Yes, in a patient that did have HER2-low activity, I would start with that prior to sacituzumab.

RUGO: Why is that?

ERNST: Based on the tolerance that I’ve seen in patients, as well as the activity.

RUGO: [Although for patients with TNBC] it was a secondary analysis.

ERNST: Right.

ELISA BOMGAARS, MD: My impression was [T-DXd could be a] better treatment if the patient had brain metastases. Since TNBC has a higher risk for brain metastases, I thought that would hopefully help prevent it.

RUGO: I don’t know [if that is true]. I think that there are some data in patients with brain metastases with both drugs, but in small numbers of patients. The data for trastuzumab deruxtecan for HER2-positive brain metastases, even though the datasets are tiny, are quite intriguing. Even for leptomeningeal disease, [the results are] nice. But in TNBC, we don’t have that data in terms of preventing brain metastases or even treating them. But I think it’s a quite fascinating question and it will be addressed in one of the trials, [DESTINY-Breast12; NCT04739761]. I tend to use sacituzumab first because it has large robust phase 3 data with a survival benefit, but certainly we’ve seen these data in DESTINY-Breast04.

Reference

1. Modi S, Jacot W, Yamashita T, et al. Trastuzumab deruxtecan in previously treated HER2-low advanced breast cancer. N Engl J Med. 2022;387(1):9-20. doi:10.1056/NEJMoa2203690

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