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Fundamentals III: Targeted Therapy Options in HR-Positive/ HER2-Negative Breast Cancer

Cierra Ryan: Hey everyone, I am going to talk about your side effect management mitigation in your early-stage HR-positive/HER2-negative breast cancer.

Setting the Stage: Understanding Adherence With Oral Oncolytics

First of all, there are so many drugs these days. And as we heard from Kim and Kayla, basically just targeting what can I do to help the patient make it through their treatment regardless of what it is, focusing on quality of life as well as quantity, which is what we are trying to give the patient.

And so, we are going to dive into this.

Endocrine Therapies in HR+/HER2- Breast Cancer

So as far as endocrine therapies goes, for your HR-positive/HER2-negative breast cancers, you have your SERMs, your aromatase inhibitors, your SERDs and your CD4-6 inhibitors.

Oral SERDs: Selective Estrogen Receptor Degraders

Safety of Oral SERDs

And so for your oral SERDs, which are selective estrogen receptor degraders, we are going to see a lot of these things in terms of manageable side effects, but also trying to make sure that patients do not have to hopefully, be taking a whole bunch of other things in addition, trying to focus on what can I give patients that has the fewest number of other side effects so that I am not essentially robbing Peter to pay Paul.

So when I think about the gastrointestinal stuff, trying to explain to people that are like, listen, this is going into your GI system. Whilst most people are fine, here is some things that can happen, but no matter what happens, it is individualized for you. I am going to treat you as you, and I am not going to base what I do off of what is happening to someone else.

And so when I think about your GI side effects, your nausea, your vomiting, your diarrhea, we are going to tend to use more of the ondansetrons, prochlorperazines. We use a lot of olanzapine at bedtime for nausea. Most of that is coming in the chemo regimens, but you can use it. You have to tell people like, listen, I am not giving you an antipsychotic because you need an antipsychotic. I am giving it to you because it helps with nausea.

We are also, you know, breast cancer, we are dealing with a lot of mental, emotional, and psychological things that come with that. A lot of our patients, you know, are young these days, unfortunately. And so we are actually using a lot of lorazepam too. I find that is one bird that hits a lot of stones.

And so for diarrhea, you know, specifically thinking about your abemaciclib patients, that is going to be, you know, over-the-counter, telling them like, listen, we have bismuth subsalicylate, we have loperamide, we have diet modifications, ginger, things like that. A lot of people worry about the pendulum of diarrhea in the GI tract. And so when we think about, well, I treat your constipation by giving you diarrhea, and I treat your diarrhea by giving you constipation. And so, how can I keep that more midstream as opposed to very much one or the other? We do use a lot of loperamide and we tell them, listen, you can take it, you know, based on the box. If it is not working, let me know.

You know, we tend to use diphenoxylate/atropine a lot, explaining to patients that, listen, it is a controlled substance, but explaining why is it a controlled substance and how should I take it? But being very upfront about diarrhea is very subjective as well. And so what one person thinks is diarrhea might not be diarrhea to another person. And so, how can I manage this in a way that is fitting for each person?

A lot of times we are also seeing fatigue. Fatigue is the thorn in everyone's side. I feel like the world is tired at this point. And so, you know, when we are dealing in the early-stage setting, depending on the patient, you know, I talked to several physicians about this in terms of tailoring how they treat fatigue in the way that fits the patient. So if I have a 52-year-old who is still working and needs whatever her job is, right? One, hopefully she is not fatigued, so fatigued that she cannot go to work, but also, how can we empower patients to take ownership of that fatigue and take control of that fatigue, right? The body's not going to give you more energy if you are not using what it is giving you now. And so I tell people, listen, you sleep when you need to sleep, but you got to get out of the bed, right?

You got to work on your exercise. A healthy diet is always best. Understanding again, I am not going to put patients on specific diets, but if you are eating nothing but processed foods, it is probably not giving you more energy, right? And so, just having a very open, honest conversation and trying to figure out, is it your sleep hygiene? Is it the time of day you are taking your medications? What could be going into secondary side effects causing fatigue as opposed to the drug itself?

Hot flashes and arthralgias, good luck. Hot flashes, you know, we have a lot of side effect management for that in terms of I have seen pretty good efficacy with vitamin E, which is a supplement. And so, you know, I always tell people, listen, I would rather you try something that has no side effects versus giving you something that could have side effects.

Understanding that for some people supplements work, and other people they do not work. And so, hot flashes, you have got your oxybutynin, you have got your gabapentin. Venlafaxine works really well for hot flashes. I try to use that as a two birds, one stone type thing because if I have got a patient who is a little bit more moody, if we are having more of the depression, anxiety symptoms and the hot flashes, venlafaxine is a great one because I can hopefully most of the time control both of those things in a way where it is a stable, steady dose. Patients are putting it in their pill pack just like they are with the other things. They do not have to think about, oh, I have to take this because it is just a once a day thing that they can take with everything else.

Arthralgias, glucosamine, your collagens, things like that. Again, I hate this saying, but motion is lotion. And so if we can get patients off the couch, you know, one, for a fatigue standpoint, but also, two, getting their bodies used to working through some of that.

The most common thing I hear is, you know, I go to stand up, and I feel like I am 80. I do not know why everyone chooses 80, but it is the most common age that they talk about. And so if I can get you off the couch, if I can get you moving, if I can get you in a realistic state of, you are not going to feel the same as you did before we started suppressing all of your estrogen, right?

And so expectations versus reality, I think, is also a huge part of this. People are not going to feel the same that they did before they started these drugs. And so again, medicine is not a cookie cutter. And so it is what is happening in this room may not be happening in that room, but I am going to work to fix what is happening here. And so, patients just have to be honest with us. So with your oral SERDs, you have your elacestrant, your imlunestrant, giredestrant, which will hopefully be approved in December, we will see.

But again, thinking about just, these things are going into the GI system. And so, anything like that with your nausea, your vomiting, your diarrhea, are you having reflux? How are you taking this?

What are you taking it with? Involving your dieticians if you have them. Involving the patient's family members in terms of, well, maybe it is some of the food that you are eating when you are taking it.

And so, again, tailoring the lifestyle choices that people are making to try to combat some of this stuff. And then if we cannot, then we work on, okay, well, you are on this drug for this thing. And so let me put you on this thing. As long as the side effects are worth it. I always tell people, the juice has to be worth the squeeze for me to tell you that I would do it. And so if I am not willing to do something, I am not going to ask you to do it.

Understanding again, though, that everything is an experiment. I do not know what is going to happen until it happens. And then I work to fix it, right? And so, we are still monitoring labs. We are still going to be monitoring the sugars. And less often, but monitoring every now and then, the chemistry or the lipid panels, and then tailoring things as needed.

CDK4/6 Inhibitors

CDK4/6, we spent a lot of time on this. Let me scroll here.

Key AEs With CDK4/6 Inhibitors: Monitoring and Prevention

Quite honestly, I love this slide because it breaks down each individual side effect and what medications you can see it with. Diarrhea is pretty much with any of these drugs. Again, who knows what is going to happen because the colon is such a finicky organ, anyway. But I think if we can go into it with a realistic expectation of, listen, here is what the package insert is going to say. So all of you guys who want to go online and read about all of these things and then come in here super freaked out. Like, yes, these things can happen. But let me tell you what I think is actually going to happen and how we are going to work to fix it, right?

And so diarrhea, I think most of us are pretty, probably hopefully pretty comfortable managing. These hepatobiliary toxicities are pretty interesting because I actually do not see a ton of them with Abema. But Ribo, absolutely. We have got early-stage breast cancer patients that come in for their first check and their LFTs are going up a little bit. Two weeks later, they come in and they are going up a little bit more.

First thing is making sure they are not taking any supplements that could be causing LFT abnormalities because a lot of the times, too, the more you start digging, the more you find like, yes, so-and-so told me to take this mushroom supplement, or I am taking a bunch of turmeric or something that they think is trying to help them, but in reality, it is actually harming them. And so that is the first thing that we do. But then also trying to make sure that like, this is something that I legitimately do not know is going to happen until it happens, but making sure that they understand, listen, this is more than likely not going to cause long-term damage, but as soon as we see it, we try to nip it in the bud quickly, right?

And so that comes with your dose holds. Most of the time, what we will do, depending on the grade of the liver and enzyme abnormalities is hold the drug until they normalize. And then depending on the length of time it takes to normalize, thinking about restarting them versus can this patient be on this drug? Did these LFT abnormalities happen so quickly, and were they high enough that we just think it, you know, the risk is not worth it?

Neutropenia. So abemaciclib, again, I do not see abemaciclib having a lot of neutropenia clinically. It could happen, but clinically, I do not see that, but Ribo and Palbo, absolutely. And so, explaining to patients that you are more likely to be neutropenic at your third week coming into the end. And so if I check your accounts on day eight and you are neutropenic, it is a lot more meaningful than if I check your accounts on day 20 or 21 and you are slightly neutropenic, right?

And the grade of neutropenia matters as well. This is where you are going to get into your dose holds, your dose interruptions, things like that, your modifications when we think about this, because again, patients do not come in saying, oh, I think I am neutropenic today, right? We incidentally find it because we are looking for it.

And that is something that could have implications on their life, right? How do I tell my young 52-year-old patient to go out and enjoy her life when her neutrophils are 400 in the world that we live in today? And so, that is one of those things that I think as long as we start out explaining, this could happen to any of us at any time. So part of the reason why we marry you to the clinic in the beginning of treatment, because we need to make sure, based on where you are in your cycle, what your numbers are doing, because then it is going to help me trend you over time so that I can safely give you this drug so that you can go out and live your best life.

VTE, sure, it can happen. Clinically, I have never seen it, but if anybody comes in and says like, hey, I have got this sudden onset shortness of breath, and they are presenting with signs or symptoms that you think is a PE, we are always going to do our CTPE protocol.

So your ILD and your pneumonitis, I actually have seen quite a bit clinically, right? So with your Ribo, your Palbo, I had a patient recently that we started on Ribo. She was a month in, came in, her labs look great, she feels great, but hey, I have this dry cough, it is really weird. We are like, well, let us see. I mean, it could be allergies. In Georgia, all of our cars are covered in pollen. And so we are like, but let me get a scan just to make sure, right? CTPE comes back, tons of brown glass nodules in the bases of her lungs. And so clinically, she felt totally great.

We just happened to be chatting about how she was doing and she mentions this cough in the setting of having just started a medication that we know can cause pneumonitis, and boom, we caught an ILD. And so these things matter when patients are telling you all of these things that we do not tend to think about, right? It is like, oh, everyone's coughing in Georgia right now. Like, boom.

But in the setting of this patient just started this drug, so she as a human who is sitting in front of me, is telling these things when we know. And so is it common? Not really, but it can happen. And so just making sure that we know what we are looking for in relation to the times that we are seeing them, right?

QTc prolongation, we are doing a good job. I think hopefully we are doing a good job of monitoring before they start with these baseline EKGs and making sure that before we put anybody on Ribo that they have a normal baseline EKG so that we are not predisposing them to worsening of that. You know, we also have to think about in certain drugs, right? And so, if a patient is on a drug that can already prolong their QTc, making sure that we know that, making sure that they have updated MedList so that we are not accidentally giving a patient who is on a QTc prolonging drug, another medication that can prolong their QTc.

Again, open lines of communication. And so as long as patients, as long as we are asking, hey, have you started any new drugs recently? Most of the time, the QTc prolongation can be avoided.

NATALEE and monarchE: Tolerability and QoL

So this slide was brought up by Kayla. I think it is pretty interesting when we think about in terms of your neutropenia, your diarrhea, I like the little boxes that are surrounding these because again, it highlights basically what are you more likely to see in which combination of drugs, right? And honestly, I think most things clinically come over time, you know, repetition, repetition, repetition.

And so, again, telling patients, listen, what the trials show, they are going to write everything down, but what do I actually clinically see? And then just monitoring based off of that, right? And so this is just, I just find this to be a pretty interesting slide.

Neutropenia Prevalence With CDK4/6 Inhibitors

Again, neutropenia. So again, neutropenia, when we think about, it is about half of what it was with the Abema versus what it happened with Ribo and your Palbo. And so again, interesting to note and telling patients, especially if your patients have been on chemo, hopefully most of them probably have, your chemo is going to likely cause count suppression.

And so explaining to patients that, listen, this is count suppression, but I do not know, you know, we talk about chemo, like you are going to have some version of bone marrow suppression. It is what it is, we will work to fix it. Same thing here, but what is the likelihood based on which drug you are taking, right?

And so abemaciclib, I am telling people we are monitoring your accounts, but I am not concerned about the neutropenia, whereas your Ribo and your Palbo, I absolutely am. And again, because Ribo and Palbo are on cycles, making sure that every time a patient comes in, I am asking, okay, well, what day are you in your cycle? Because it really does make a huge difference when I am thinking about, is this patient above 1,000? Is this patient less than 1,000? Do I need to hold their medication? Can I let them just ride out the week off, or do I need to dose-reduce them?

Managing Neutropenia With Adjuvant CDK4/6 Inhibitors

So managing neutropenia, you know, it is a little bit tricky sometimes because I think it depends on, well, one patient, but also two, how long is it taking that neutropenia to resolve? And so it is understandably annoying to have to get blood work every single week, especially if you have got a job and you have got a life outside the clinic.

I always tell people, listen, I am here all the time, but it does not mean you have to be here all the time unless something happens. And so if you come in neutropenic, you do need to come in the next week because I need to know how quickly are you recovering because that matters when we think about what we do in terms of restarting the medication and at what dose do we restart it, right? And so we do not use, and this is something to tell people because those individuals who have been on chemo often will say, okay, well, what about growth factor support?

I got pegfilgrastim with my chemo. Can I just do that now? And the answer is, yes, it would work, but no, we do not do that in the oral outpatient setting like this because it is something where we are going to have to give you something that you can manage on a day-to-day basis, and giving pegfilgrastim is not an option, and nobody wants to do growth factor in this realm.

And so thinking about consistency over time versus getting the highest dose, you know, one of the most common questions is, well, how do I know this dose is going to work? Because if I was supposed to be on this higher dose, why would you dose-reduce me? And it is like, well, consistency over time, right?

We have seen that these dose modifications do not decrease efficacy, and it is better to be at a lower dose at a more consistent dosing schedule than it is to be on the highest dose but have to modify every now and then for these side effects.

Summary of ILD From CDK4/6 Inhibitors

The ILD, and this is a big one, most of the time we think about, okay, how long does it take? How many steroids do they need?

We tend to loop in our pulmonology colleagues pretty early, pretty quickly, just so that they can review the scans and from their perspective, hey, what do you think we should do in terms of steroids? And how quickly did the ILD occur? Was it a year and a half in, or like my patient from before was a month in? And so, if she is that sensitive a month in, we are not going to be able to continue her on that drug. You know, that juice is not worth the squeeze. It is difficult when we think about, if you look in the left side of this, my left side, I am assuming your left side, you know, 3% of the patients on the abemaciclib developed ILD but 0.4 were grade 3 or four. And so we did not have to dose-reduce those.

And so, in NATALEE, 1.5% of patients developed ILD. But again, it is, can I put you back on the drug? And if I do, what dose? So that we are not risking other vital organs trying to treat something that you do not have. You know, in the early-stage setting, I make it very clear, you do not have cancer. I am treating you so that you never get it again. And so, I need to make sure that whatever we are doing is not worse than a disease you do not have. And I think, again, nobody's going to feel 100% like they did before.

But as long as I can keep them as close to normal as they had without potentially life-threatening side effects, that is what we go for, you know. And again, making sure when we are going through the medications, and I do not know what everyone's setting is here, but we have a pharmacist who goes in and does our chemo teaching for us and stuff. And so, she makes it very clear to patients, and we make it very clear when we are seeing them, how are you doing from a respiratory standpoint? Cough, chest pain, wheezing, and not taking, you know, oh, it is just allergies, taking it with a grain of salt, but really looking into these symptoms because you do not know until you know.

Hepatotoxicity

Okay, so hepatotoxicity.

So again, this is one where we tell patients in the beginning, we are going to monitor your labs the closest when you first start. I need you to just bear with me while you come in constantly to have these labs checked because I need to make sure that your LFTs are not going to increase. And telling patients, for as much as it is worth, do not start any new medications, do not start any new supplements without letting us know because of the fact that the liver pathways that a lot of our drugs go through, supplements also go through.

And so, for what it is worth, most people, I do think, are very open when wanting to start new things. But again, making sure that if a patient comes in and has these LFT abnormalities, hey, have you started anything new? Are you drinking a whole bunch? How many NSAIDs are you taking? Things like that. Because if we can eliminate outside factors and we know it is specifically the drug, then we are going to have to figure out, okay, maybe a patient just really is not tolerating the drug.

And it is hard because a lot of the times patients will feel okay, but they will be neutropenic or their liver enzymes. And so they will say, well, what can I do for this? It is really nothing you can do. It really just is what it is when it comes to these drugs. Some people's bodies are just more sensitive to these drugs, and that is okay, right? Sometimes we have other options, and sometimes we do not.

In the patient who was high grade and had nodes, we could do Ribo or Abema. And so maybe she tolerates one versus the other. In the patient I had that was on Ribo before she had no nodes. And so we tried the Ribo, she cannot tolerate it. And so we are going to give her what we can without potentially endangering her in other ways. Depending on where you work, we have walk-in laboratories that connect to our system at Emory.

And so we are saying, even if you cannot come into clinic, that is fine. I just really need you to get labs every two weeks for the first two months and then monthly. And then we can back off once we know, once I can trend how you are doing and what your labs are doing, we can take a step back.

And so, everything in the beginning is going to be a lot more intense. And just telling patients like, this is not what the next two or three years of your life is going to look like. We just got to get through the first couple of months, and then we can back off, right?

And so just, again, clear lines of communication in terms of you do not have cancer, I do not want you to feel like you have cancer, I do not want you to be married to the cancer clinic, but in the beginning, bear with me, we are going to become best friends.

PI3K, AKT, and mTOR Inhibitors

Key AEs With PI3K/AKT/mTOR Inhibitors: Monitoring and Prevention to Maximize Adherence

So your PIK3, your AKT and your mTOR inhibitors. So with these ones, again, I love these slides.

Diarrhea, we are going to add like, listen, it is going in her GI tract, good luck. The stomatitis is interesting. You know, we have, you are a novel, and when we think about all of the things that we do to try to be proactive instead of reactive, the mouth sores can be legit.

I mean, I have seen some pretty bad mouth sores with this stuff. And so again, explain it to patients like, listen, you are going to be married to this thing, you are going to see this mouthwash more than you probably see a lot of other people in your life because we are going to tell you to take it three or four times a day, right? And so the juice is worth the squeeze here, and patients will tell you, listen, I slacked off, and I got those mouth sores, and I will never do it again.

And so the mouth sore part of it is very real, and so take what patients are saying to heart. You know, we have got our mouthwashes, we have got our magic mouthwash, we have got our steroid mouthwashes. We use triamcinolone paste a lot when there are actually true lesions as opposed to just generalized soreness, and I see pretty good efficacy with that.

But again, it is trying to get ahead of that train instead of trying to slow it down once it is happened because once a patient has stomatitis and I am trying to treat it, it is going to take a lot longer, and then I am going to start running into secondary side effects like nausea because they are not eating, fatigue because they are not eating, you know, like things like that. And so just trying to slow that train or even stop it before it starts.

Hyperglycemia, again, you know, we are checking fasting glucoses, we are checking your A1Cs. For the patients that are coming in in the afternoon, I am not going to ask them not to eat until they come and see me and so just most of the time trying to take it like, okay, like if it is 15.00 and your glucose is a little bit high, what have you had to eat today? Do I need to send you later for some fasting labs? We and, you know, capivasertib, alpelisib and inavolisib, they all have different monitoring from that perspective. But again, open lines of communication. Here is why I want these labs all the time. Here is what I am looking for, and here is what I am going to do if I see it.

And then I think once patients, like Adrian had said about, you know, taking ownership of those things. I think once patients can feel like they own this and it is not owning them, they are a lot more compliant.

Rash is interesting. We have a derm that we consult early. It is hard because again, rash is sometimes where first it might be on your cheeks, and then on your off week it goes down, or your off days it goes down, and then it is your cheeks and your torso. And so making sure that we are obviously asking, hey, have you changed anything in your life recently other than these new drugs?

But rash, for as much as it is not going to necessarily quote-unquote hurt somebody, one, it can be unsightly, and two, when we think about photosensitivities and photophobia and stuff, like depending on where you live, it can be a big deal. If you live in Pittsburgh and it does not have sun for eight months, having a rash where you are covered is maybe not the worst thing, but for most of us, especially going back to the young women who want to be as normal as possible, they do not want to look like patients. They do not want to give anybody a reason to ask them, like, oh, hey, is that new? Like, why do you have a rash all of a sudden? And so that is a big one. I think consulting derm, if you have it early and then just going over basic topical options and steroid options if you need it.

And then your ILD and your pneumonitis, always just looking out for your cough, your chest pain, any things that would key you into an ILD or a pneumonitis picture, and then doing your imaging early.

Posttest 3

So posttest. So you have a patient taking adjuvant abemaciclib and the patient says, hey, you know, this diarrhea is still really affecting me. I do not know if I am going to be able to continue this. I do not know if it is worth it to me. What is your next best step when explaining to the patient what to do?

Yes, so most of the panelists say, discuss the patient's concern and goals and their grand supportive care and follow-up.

And I think that is absolutely correct. And so, I think it depends on what is the patient willing to put up with? What are they willing to do to try to help themselves? And then really having this, you know, come to terms with, again, I may not be able to get the diarrhea completely down, but maybe during your really busy days at work, we have your diphenoxylate/atropine, or if you want to go on vacation where you are hiking, you take diphenoxylate/atropine instead of loperamide, but open lines of communication. And again, going back to what Adrian said, it is all about ownership. I really truly believe that if the patient feels like they have control, because cancer is so uncontrollable for most things, giving the patient that ownership of what they are doing and having them actively involved in discussions and options and what they want to do, I think makes a huge difference in terms of compliance.

Yes, see, so C is the best answer to address the patient's concerns. And again, changing to Ribo at this point is a little bit too early because number one, you know, we do not know what, if she is even a candidate, but also we need to make sure we optimize anti-diarrheal management before we just change.

Skill Building and Feedback IIIA: Toxicity Triage and Adherence Support

So, skill building. A 49-year-old woman with high-risk, HR-positive/HER2-negative breast cancer is receiving adjuvant abemaciclib plus endocrine therapy. At week three, she reports diarrhea that is affecting work despite loperamide and says treatment may not be worth it if symptoms continue. This scenario focused on supportive care, when to hold or reduce dose, and how to explain the value of dose optimization while supporting adherence and quality of life.

So for those of you who are willing to answer, how would you manage the supportive care and when would you consider holding the treatment versus reducing the dose?

Dr. Freeman: I will chime in, Cierra. I think, well, great job, by the way, but I think the first thing I am going to do is try to optimize my anti-diarrheals, as you mentioned. How often are we using them? Are they working? And then, of course, you know, can I consider adding additional anti-diarrheal depending on the day-to-day of what the patient is doing? I think if we optimize, but yet our symptoms are still not being well controlled, that is when I would suggest that maybe we should consider a dose reduction.

Also getting, trying to see how my patient feels about going down on a lower dose and then letting them know, right? Our data supports that this drug is still going to be effective, right? Even if we go down so that we can ultimately make sure quality of life is good.

Cierra Ryan: I 100% agree. Quality of life means the most, right? Because again, they are humans. They are only patients when they are in our office. And so, how would you explain the role of dose adjustments without making the patient feel like the treatment is failing and that they are not going to have as good of efficacy?

Kimberly Podsada: Well, we have the data where the dose reductions show that there is continued efficacy. You know, I will start off with standard, this is how you take loperamide. This is what we recommend.

But I found that if, again, the patient does not feel like this is how to do it, that there is not a failure. When I talk about each patient has to find what is right for them. I will have someone who just wakes up every morning and takes loperamide or to be proactive about it.

So everyone seems to take the time to find out what works best for them. And so, again, it is really letting them know that there is not a right or wrong answer. We have to find the right thing for them. And sometimes that may mean a dose reduction so we can continue them on therapy.

Cierra Ryan: I 100% agree. I literally will say, listen, if the studies did not find efficacy at these different doses, they would not even be options. And so I feel like if that does not make you feel better, and then how would you counsel this patient about symptom reporting, work impact, and staying on therapy?

Which Kim, I think you actually just talked about in terms of basically, you know, just telling us when are you taking these drugs? And Kayla, you know, like, when are you taking, are you waking up and taking loperamide, or are you waiting until the diarrhea has gotten so bad that you cannot, that you cannot manage it with, you know, over-the-counter medications? You know, and I always tell people, you know, diarrhea is not going to kill you.

It is one of those things where it is probably more annoying than it is anything else. But to the point where if it is getting so bad that you cannot leave the house, we obviously need to have a discussion.

Skill Building and Feedback IIIB: Toxicity Triage and Adherence Support

So skill building number, whatever.

A 55-year-old woman with HR-positive/HER2-negative metastatic breast cancer is receiving capivasertib plus fulvestrant. She has baseline obesity and prediabetes and now has rising fasting glucose. She asked whether treatment needs to stop. This scenario focuses on monitoring early intervention and how to involve primary care or endo while helping the patient continue on therapy safely.

So what monitoring and early intervention steps would you take now? And how would you involve the PCP or endocrinology?

Dr. Freeman: So early on, getting baseline labs, of course, and then we are monitoring hemoglobin A1C every three months. Getting endo on board sooner than later can be helpful, right? We want to make sure the patient is tipping over into diabetes. Like, what are things that we can do? Can we be proactive. Because for some of our patients, we actually are starting metformin.

So, we like to help regulate things as they are on treatment. So those are just some of the things I would probably take up front just to be proactive, knowing what capivasertib, the symptoms that can occur with this patient.

Kimberly Podsada: Yes, and I also, we have a registered dietitian. We actually have several that treat specifically for our breast patients. And so that is someone who I also introduced early on in this process as a part of, this is your care team. We are all here to support you. And so I connect them with the registered dietitian as well, because I do think that having a little more insight and information about healthy choices, especially being on this therapy is very beneficial for patients. And honestly, most of them want to learn that.

So I think including our registered dietitians is important, making sure some of these baseline issues are already managed or there is something in place.

Cierra Ryan: I 100% agree. I mean, I think it is also important when talking to patients because she is already prediabetic, but making her not feel like it is her fault, but also empowering her to make better choices potentially, because she may be saying she is doing the best she can, but maybe one little tweak here or there could even bring that down. But also just explaining to her that, like, listen, this is a drug side effect. You could do everything right and it could still happen to you. And so, trying to decrease the shame that patients can feel when they do feel like they are not doing enough, I think, is a great idea.

Skill Building and Feedback IIIC: Toxicity Triage and Adherence Support

And then a patient receiving oral therapy feels overwhelmed by treatment instructions and is missing doses.

The patient is unsure when to call or how to manage ongoing symptoms. This scenario focuses on practical education adherence, caregiver support, and team-based follow-up to help the patient stay engaged. I think we have honestly already hit all of these, what education strategies, adherence tools, Kayla, you mentioned those apps and those websites.

When would you tell the patient to call versus managing these things at home? I think these are all things that we are hopefully doing in the beginning, like prior to start, just explaining how the call system works or do you have inboxes, things like that. And then involving caregivers, like we talked about.

I think it is great when people bring others to their appointments because I might not think I am moody, but my wife might think I am moody. And so getting people to look outside of what I can see would be great. Nurses are wonderful, our pharmacists. And then I think it is all really dependent upon what your resources are. Like Kim, we have dieticians that can help. We are blessed with pharmacists.

And so, I think getting those people on board early is a great idea.