A quick reminder around some of the updates that have happened in the last couple of years. ASCO published their guide rapid update in 2024 around the CDK4/6 inhibitors. It was really largely based off of two major clinical trials the monarchE trial regarding adjuvant abemaciclib and the NATALEE trial regarding adjuvant ribociclib. This is really focused on patients with stage 2 and stage 3 breast cancer. We are going to talk more about the specifics of what this means, as well as how this is applied.

Defining High-Risk Early Breast Cancer

Now, when you pull up a guideline like the NCCN clinical guidelines in breast cancer, you might find this footnote that refers to patients with high-risk early breast cancer. There is a lot of text here. It is very dense with a lot of details around things like positive lymph node status, as well as the size of the tumor, the grade, is it a grade 2 versus grade 3, and then at times might mention things like Ki-67, high genomic risk if you are doing the multigene expression tests. It is difficult to digest all of this material and this content, and figure out how do you now apply this in a busy cancer care setting? That is really what this project was all about, was to take this information and then to apply it.

Key Factors Consider

If we look at that previous slide and break it down into the various factors, depending on whether you are referring to the NATALEE versus the monarchE studies, you might look at things like the tumor size, whether or not there are positive nodes, or whether there is no nodal involvement, along with some of these other factors like the tumor size or the grade. Is it grade 2 or is it grade three? Did you perform a high genomic risk, one of those multigene expression tests? Some cancer centers do not do that, or they only do it for certain patients. Then, whether or not you are also doing the Ki-67 test, and if so, what percentage of those. All of these factors are things that we had every institution that was participating in this quality improvement project evaluate.

Checklists

One of the ideas, and we are jumping ahead, but the reason we are jumping ahead is to show you that one of the ideas that emerged from this project was to come up with some checklists that will help review the patient's case, anytime you have a patient who is stage 2 or stage 3, and then to see, do they meet any of the criteria for either monarchE or NATALEE?

If they do, then it might then lead to more discussions around things such as their high-risk status as well as the role of adjuvant therapy. Incorporating some a checklist, whether it is done on paper or done electronically, you are going to hear more about in just a moment. This is a clean and a structured way to look at things like the nodal status, the tumor size, the grade, and some of these other factors, as well as recognize the differences that these two trials had different criteria and that these checklists are not identical.

Quality Improvement (QI)

In the setting of quality improvement, we always try to think about how are we going to make an improvement in a way that is measurable. QI really represents a systematic but also data-driven approach. Often we know what we are supposed to be doing, but sometimes we do not know how well are we doing in this area? You have to measure it.

Some of the key questions that we wanted to answer were questions like how many patients with stage 2 and 3 early breast cancer who received surgery are considered high-risk? How many of them actually meet one of those criteria? How are these patients identified? How are patients told about their high-risk status? Is it the surgeon explaining it, or is it a medical oncologist or a nurse or a navigator, or an advanced practice provider? Who is explaining the high-risk status to the patient? This then obviously leads to discussions around the role of adjuvant therapy. These were some of the key questions.

Root Causes

For us, as we worked with each of the hospitals and cancer centers, we showed them how they are doing in regards to their data. We also wanted to know if there were certain things that were perhaps unexpected. Why was that present? What were some of the problems, and what were some of the root causes driving those problems?

Examples of this in the context of this program would be to say that, well, sometimes it is not easy to identify which patients are high-risk, even if we have a checklist, it may be difficult to use, we may forget to go through the checklist. We also recognize that the existing tools have some limitations that absolute risk calculations are imperfect.

Right now, we are going to talk about whether they are high-risk or not, in a binary fashion, but we also know that it is not quite that simple. Then, of course, when it comes to explaining the pros and cons of adjuvant therapy and engaging patients in things like shared decision-making conversations, that obviously has to be contextualized to each patient, really understanding what their goals are, what their preferences as well as what is ultimately the goal of the treatment that they are going to be receiving?

Q1 Program

We worked with five cancer centers across four different states. This program started in late 2024, and we just recently wrapped it up in early 2026. They looked at patients with stage 2 and 3 early breast cancer who had received surgery, and we began by identifying which patients were even labelled or identified as high-risk, and how were they going about doing that? Were they just doing that based on a single test, like a multigene assay? Were they doing it using a systematic list of criteria? Then, how many of those patients who were high-risk were ultimately receiving adjuvant therapy?

Some of the ideas that emerged, these are some of the key themes, were not only educating staff and educating members of the care team, but also streamlining from a process perspective how that risk assessment is performed, who does the risk assessment, who communicates the results to the patient, and then ultimately, how does the multidisciplinary care team come together to coordinate that adjuvant therapy? Those were some of the key themes that emerged from this program.

Posttest 1

With that brief introduction, let us revisit this posttest question. Which of the following is associated with a high risk of recurrence and would help to inform optimal adjuvant therapy newly diagnosed patients with hormone receptor-positive HER2-negative early breast cancer?

1. High estrogen risk/high progesterone receptor levels and postmenopausal status;
2. High BMI and PIK3CA or ESR1 gene status;
3. Premenopausal luminal A grade 2; or
4. Tumor size greater than or equal to 5 cm, high Ki-67, and axillary lymph node positive status.

It is great to see the response there. That once again, this is the correct response. You can see some of that explanation there. There is a lot more details about this in the guidelines. We would certainly encourage you to read more about it, to learn more about those specifics, as well as how to apply that.

Aggregate Findings: Identifying High-Risk Patients

Regarding the project itself, as we worked with these cancer centers, what you will see is that, among patients with stage 2 or stage 3 early breast cancer, the proportion of patients who had a documented assessment of risk recurrence, whether they were considered high-risk or not high-risk at baseline, was 75%.

As a result of this program, that increased up to 89%, close to 90%, and recognizing that the majority of patients with stage 2 and 2 breast cancer are going to be considered high-risk, but not all, and so going through that systematic risk assessment was one of the key process changes that occurred from this program.

Aggregate Findings: Adjuvant CDK4/6 Inhibitor Therapy

The other key finding was among those patients who are high-risk, who meet one of those high-risk criteria, how many of those patients are actually receiving the adjuvant CDK4/6 inhibitor? Here, what we found was that at a baseline, we were starting at around 45%. As a result of this program, as well as the different interventions you are about to hear of, that increased up to around 80%.

We know that not every patient is going to say yes or be willing to accept the adjuvant therapy, but certainly having the opportunity to offer the patient the therapy, explain it, and engage in that shared decision-making conversation, are really important components.

Interactive Panel Discussions

With all that background in place, we are now eager to dive into our panel discussion, and we are going to hear from each of the panelists. Once again, we worked with five cancer centers. We have got three of those cancer centers represented today. Regarding how do you ensure that every patient who is high-risk is identified? For this, let us start with hearing from Dr. Heelan first, and tell us about what your organization did to ensure that every patient who meets that high-risk criteria were identified.

Dr. Heelan: We really worked on formalizing this process. Prior to the project, we had already been stating that a patient may be high-risk, but that was not necessarily defined by the NATALEE or monarchE criteria, so we came together as a multidisciplinary tumor board, agreed that we would all consider NATALEE criteria, monarchE criteria patients high-risk, and that we wanted to follow those recommendations.

Then we moved forward with while the patient was presented at tumor board, we present all our new diagnoses of cancers. We would formally state this is a patient that meets those criteria and is considered high-risk. Then the second way that we made sure they were identified is when the patient has surgery, comes back through the surgery clinic, we worked on our pathologic staging.

Prior to the project, we were not using the Epic tools to routinely pathologically stage the patients within that software. It may be stated in notes and things like that and in the pathology report, but was not put into the actual Epic format that you can use there. We started doing that in our surgery clinic to help more formally flag those patients’ charts, and then created a smart phrase so that it would auto populate if the patient met criteria, and within that pathologic staging, that will now consistently come up when the patient comes to an appointment, it had a statement about them meeting that criteria. So that when they moved on - in our clinics, the medical oncologists are of course the ones doing the prescribing of these CDK inhibitors, but this would be additional flag to alert the medical oncologist that this patient qualifies.

Dr. Kim: Thanks so much for starting us off. Let us go to Amy next to hear about what did you do to ensure that every patient who is high-risk was identified?

Amy Baker: It was about the same approach. We presented the patients at tumor board and discussed their staging. We did also develop smart phrases with the NATALEE and monarchE trial that could be documented into the charts. We are using the staging and Epic more than we had been, and we try to do that now with every patient. It is time consuming and sometimes, but you have to make it happen.

Dr. Kim: Dr. Snell, do you have anything to add regarding some of the things that you all did within your organization based on what you have already heard?

Dr. Snell: Pretty similar. However, most importantly with our organization, the medical oncologist as well as myself are independent groups. Although the hospital has Epic, we do not have Epic. It was a bit more, you cannot send a chat, or they cannot see our notes without them being sent electronically.

We did present them at tumor board like that in our nurse navigator, though the hospital did document the staging in Epic. I will say one caveat that I would add, we have obtained a fluoroestradiol F18 PET for estrogen-positive breast cancers. That has enabled us to better stage the axilla to also deem these people more high-risk even prior to surgery. That helps get the ball rolling, so the patient knows that this will be a med that will likely be recommended if the fluoroestradiol F18 PET has activity in the notes. That is a little different caveat.

Dr. Kim: Thank you to all the panelists for explaining some of the processes. On one hand, you make it sound like it was very straightforward and simple. We know that there are a lot of nuances. Are we talking clinical staging versus pathologic, as well as the time it takes to document and capture this information? I am probably asking, can we automate any of this?

A number of things that might have either caused pushback, delays, maybe some extra time. We would love to just hear from you on what were some of the issues that perhaps made it a bit more challenging, as well as how did you navigate some of those challenges. Let us start with Amy. If you would like to begin regarding maybe whether it is time or process-related challenges that you faced at the very beginning here.

Amy Baker: I think time is the biggest restraint in our world, documenting. We want to spend more time with the patients. Documenting was the biggest challenge using the Epic, doing the documenting. Then once we developed the smart phrases, remember to bring them over into the charting and using them.

Dr. Kim: Thank you. Dr. Snell, how about you? What were some of the challenges faced at this early stage of assessing and identifying the high-risk patients?

Dr. Snell: I think just changing your pathway to make sure you talk to these patients about it every time. Like this is a new med. This is not something that - we have talked about tamoxifen, anastrozole, all these for years as a surgeon, but this is just a new med that I need to actually get into my speech to tell the patient that they are going to be offered this afterwards.

Dr. Kim: Thank you. Dr. Heelan, how about from your organization?

Dr. Heelan: I would say making it easy to do the right thing. So, time and asking others to increase or change their workflows. Trying to make that as simple as possible to relieve that workload, so that, as Amy said, we can focus on the patient.

We tried to disperse that workload among the different groups to overcome that barrier. Having certain nurse populations, the surgical nurses do the initial staging, but then having our med onc nurse practitioners, make sure they are the ones following up on, is that high-risk documentation within the Epic staging. Then they are following up with the medical oncologist about was that recommended and prescribed to the patient, and was the CDK inhibitor followed through on.

What is the role of each member of the multidisciplinary cancer care team in informing high-risk patients about adjuvant therapy?

Dr. Kim: This leads us to our next discussion question, which is really around the role of each member of the multidisciplinary cancer care team. What is their role, both in terms of informing the patient, discussing high-risk status as well as the role of adjuvant therapy? Several of you have mentioned things like tumor boards, as well as navigators and other members of the team.

Tell us, within your institution, who took the lead on communicating that high-risk result to the patient and who else was involved? You all have mentioned that it is the medical oncologist who prescribes, but who else is really involved in both guiding as well as informing the patient? Let us start with Dr. Snell if you would like to begin.

Dr. Snell: We again have a little bit different pathway than the majority of cancer places. The surgeons themselves do the biopsies and relate the pathology to the patient and see them first every time. It really was us that presented the opportunity for the additional medication to the patient first.

Then they are presented in tumor board after we get all staging, MRI, those things. If that is confirmed, they see medical oncology prior to surgery in the medical oncologist, reinforce that based on the tumor board recommendations, and then post-op, I would reinforce it. These are the meds that are going to be offered going forward.

Dr. Kim: Amy, how about at your organization?

Amy Baker: Of course, it begins with our surgeon. She is making sure that she talks to patient about potential adjuvant therapy. Then, once they get to the medical oncologist, and he makes the recommendation, it is my job to educate the patient on their risk factors. They are knowledgeable and also side effects to help keep them on regimen.

Dr. Kim: Dr. Heelan.

Dr. Heelan: Similarly, we had multiple people at least mentioning the medication pre-educating the patient right up until the point where it is prescribed. Myself and my partners would mention this at the post op appointment that this may be prescribed. Our nurse navigator will again reinforce that as the patient moves on to med onc.

Then, thankfully, many times we have our clinics right next to each other. Sometimes it is as simple as walking over and saying the patient's about to go to med onc. We have mentioned it, they know it is coming. Then that conversation continues, but sometimes, of course, those appointments are not coupled. Again, the nurse navigator, the nurse practitioner, is just continuous communication, and everyone mentioning it in every step to give the patient multiple opportunities to be warned and know that this is coming and set expectations.

Dr. Kim: Many of you have also mentioned the role of tumor board. Please tell us during tumor board, especially at the beginning of this project and some of the sentiments and attitudes of different members of the care team, was there either any resistance or pushback towards this whole concept of identifying high-risk, or did everyone pretty much embrace it and agree that we should be doing this, or was there perhaps even just a lot of back and forth as to like, well, can we even agree on what the high-risk criteria are? Give us a sense of what some of the topics that might have come up during tumor board pertaining to this issue of identifying high-risk, as well as the role of adjuvant therapy. Let us start with you, Dr. Heelan.

Dr. Heelan: I alluded to this before, but we had a little bit of resistance around why do we need to formalize this process. We already do it. Why do we need to put it on paper? Working through that and how standardization would help make sure that patients did not fall through the cracks. Then also the question around added workload to certain individuals, so trying to make it as easy as possible to do it without asking a lot more documentation or a lot more of any certain individual.

Dr. Kim: Dr. Snell, how about your organization?

Dr. Snell: The three separate groups, they were all on board. It was pretty. They were happy.

Dr. Kim: That is great to hear. Amy, how about at your organization?

Amy Baker: I presented the recommendations at our tumor board. Everybody was open. They were excited to have a tool to use, the monarchE and then NATALEE to be used in smart phrases. Everybody was great.

Dr. Kim: Certainly, making it simple as well as showing them the evidence, getting them all on board.

What factors affect whether high-risk patients agree to adjuvant therapy with abemaciclib or ribociclib

Now we are going to talk about the factors that might impact whether or not patients who do meet the high-risk criteria agree to adjuvant therapy. We also recognize that, when it comes to high-risk, that even among the medical oncologists, they may have differing interpretations as to what exactly is high-risk.

We have got these trials, but the trials are very broad in regards to the criteria and the eligibility. What are some of the factors that either emerged or that came up during conversation with patients, or even among the medical oncologists, regarding which patients really should be the ones receiving adjuvant therapy? Let us start with you, Dr. Snell.

Dr. Snell: From the medical oncology perspective, there was not much pushback as we said previously. In general, we see patients from rural areas that are not necessarily keen on additional medications and cost, as well as the underlying distrust of the health care system. Another med is sometimes difficult, specifically if they are going to have to have EKG, etc., additional testing for that, along with the people who already had cardiac abnormalities, they were very concerned at first.

Dr. Kim: Amy, how about at your organization?

Amy Baker: Just keeping the patient very well educated on side effects and being compliant. We also, as you spoke of the financial aspect of it, we have navigators in place to help with financials and grants to get the medications, and just ensuring the patient that they have support and make sure that they are knowledgeable.

Dr. Kim: Dr. Heelan.

Dr. Heelan: I would say that the similar barriers in terms of cost and education. We do have a variety of patients with fairly low health literacy, so helping them understand why this is being recommended was sometimes difficult. Then, being a tertiary care center, having some very comorbid patients. That was more of a risk-benefit discussion between the patients and the oncologist, but certainly a barrier for some of these patients.

Dr. Kim: As we worked through this project and also engaged and interacted with the other cancer centers, one of the other topics that came up was regarding patients who are node negative. Even among node-negative patients, if they have some of those other factors in their stage 2 or 3, they technically meet the criteria under NATALEE.

We heard from some sites that not every medical oncologist felt like these node-negative patients who met the criteria really were considered high-risk. I am curious to hear from you all, did you hear of any things similar within your organizations or from your colleagues? If you did hear anything similar, what ended up happening over the course of time, because part of this was also just needing more time, more data, more evidence to emerge. I am curious about this topic of node negative. Let us start with Dr. Snell again and see if this came up at all.

Dr. Snell: Minimal. I think I maybe heard it once, but we also just briefly reviewed the papers at the start of the process in our tumor board and went over why and the expectations. I will also say I do limit my practice. We do not have breast-specific medical oncologists, but there are three in town that see mostly breast. I try to refer my patients to them. It was easier to implement with a limited number of providers, physicians.

Dr. Kim: Dr. Heelan, how about at your organization?

Dr. Heelan: We have only breast-specific medical oncologists, and so did not hear a whole lot of resistance around this. Did not have too much trouble with it other than they felt like they had already mostly adopted this, and why did we need to formalize the process, because they felt like they were already doing it.

Dr. Kim: Amy, how about at your cancer center?

Amy Baker: There was no resistance or anything. Our providers were already doing this, and they were just glad that we were coming attention to it and making it more formal.

Dr. Kim: I think once again, pertaining specifically to that issue of the node negative, as well as some clinicians really wondering are we potentially even overtreating patients? That was something that we heard towards the beginning of the project at some of the other centers. As time went on, it seemed like there was greater agreement that, indeed, these are the correct criteria to be using to not only identify the patients, but then also to offer the adjuvant therapy, recognizing that not everyone is going to say yes to the adjuvant therapy or not stay on the entire time.

What was a key lesson you learned as you went through this QI journey?

This next question has to do with some of the key lessons learned in terms of going through a QI journey, every QI project is different, and there are clearly going to be different types of lessons learned. Let us hear about what was some of your key lessons that you learned along the way? Let us start with Dr. Heelan.

Dr. Heelan: I have a background in quality. I have done a number of these projects. Something that I learned every single time is just keeping it simple, making it easy to do the right thing. I think this time around, I was actually very pleasantly surprised about how certain roles were willing to step up and take on some of that extra workload.

I think I was reminded that it is really important to engage all the different stakeholders. I think, particularly as a physician, sometimes we just take it on ourselves or as other providers and say, we well just do it, but our team really was willing to take on various components of the project to make it successful, so remembering to engage everyone.

Dr. Kim: How about, Amy, for you?

Amy Baker: Once again, the team approach everybody was willing to help and everybody put in their part. It did not put a lot of strain on everyone. Not much more to offer there. I am sorry.

Dr. Kim: That is okay. Dr. Snell, how about for you? What was a key lesson learned?

Dr. Snell: I agree with that. My question is, you shine a spotlight on something, and it is fixed. Then, if that spotlight goes away… Obviously, I saw your percentages. Obviously, we all say that we are doing this, but we were not if the percentages went up. We have decided - so when we go through tumor board, I run tumor board, and we do the staging, the NCCN and guidelines, and that is when it gets discussed. We have met NCCN guidelines for this particular patient based on that. I think it will keep going. I wonder if we had not implemented this, if we would have had that same percentage two years from now, if we had not shown a spotlight on it.

Dr. Kim: It is a great comment that we run into often. You ask a cancer center or the clinicians there, how often does this happen? Often, the answer is that, oh, we do this all the time. We are like, oh, every patient gets that whether it is biomarker testing or whether it is some a risk assessment.

Then, when you actually go back and actually review the data, reflect that data back to them, sometimes they are surprised when they actually see how often something is not happening.

Clearly, from a process perspective, a lot of opportunity when it comes to QI. Also I feel like we are at a very different place today in 2026. If we were to start this project today from scratch and also have access to certain tools at our disposal, certainly AI is one of these tools that could potentially automate and do a lot of this in the background, but also recognizing that some of this information lives perhaps in a pathology report, or you have to really dig to find the information. It is not necessarily going to just live in the discrete field.

Thoughts on if you were to start this exact project today, are there any things that you would either do differently? Are there any other departments or groups that you might want to involve to streamline things based on what you have learned, but also knowing what tools are at your disposal and what might be possible?

How might you redesign what you do if you were to start the same project today for those who are thinking about doing something similar, and let us go in the same order? Dr. Heelan, what are your thoughts in terms of if you were to do something similar with the tools and technology, as well as the lessons learned, what might you do differently?

Dr. Heelan: I would probably put in my Epic change request at the very beginning. It is amazing how slow some of these things can be, particularly within my system. I think others can probably relate too. That has been something that has taken a long time, which seemed like a very simple change to create the smart tech. Not just a smart phrase, but auto-populated smart text within the pathologic staging format of Epic.

Also, since we started this project, we started using AI documentation in our clinic, so ambient listening during our clinic visits that then contributes to our notes. That has been phenomenal for a lot of different reasons. I would have integrated that component into this project, which we did not have at the beginning, and we are now using.

Then finally, I think, as you said, if there are ways to put things into discrete fields to again, make it easy, auto populate where you want this information to end up, that makes it easier for everyone, as opposed to, again, having to pull it out of a pathology report and re-enter information, duplicating that work that is already been done in one other space. Trying to increase that efficiency and reduce the actual manpower required is something I would continue to work on, and we are continuing to work on it.

Dr. Kim: Amy, how about from your perspective, what would you do differently if you were to start this project today?

Amy Baker: I agree with the use of AI that has made a big difference in pulling data together, answering questions. I do not have much other because I thought the project went pretty well in my facility. Everybody was on board. I did not really hit a lot of snags or issues.

Dr. Kim: Dr. Snell. How about from your perspective?

Dr. Snell: Maybe it is easier that we do not all share Epic EMR, because it was maybe easier to implement. I think that would make AI more difficult for us because we literally have four different EMRs for all the specialists. I just again give a testament. We have talked about this for currently though, that it all depends on who you work with and your team, and if you have a good team, you can get most things accomplished.

Dr. Kim: The last question before we get ready to wrap up here is one of the key differences we saw across the different centers had to do with things like the multigene assays, or even when do you order a Ki-67 for breast cancer? In some centers, that changed in regards to whether, for example, increasing the use of the multigene assays or being broader around which patients are eligible for testing? In other settings, we saw a decrease in the use of Ki-67 as one of those tests. Once again, when we compare monarchE to NATALEE, we do not see both of those tests reflected in both of those studies. The science seems to keep changing regarding, like, what is the role of these tests?

I am curious to hear from you all. Did either the multigene assay or Ki-67, did the role of either one of those tests change over the course of this program, and if so, how did it change? Let us start with Amy. Did either one of those tests - or the role of those tests change within your organization.

Amy Baker: No, we have been using both of those. Nothing changed. We feel very strongly on continuing with both of them because you can identify patients either way. You do not want to miss the opportunity to offer somebody additional medication to decrease the risk of reoccurrence.

Dr. Kim: How about Dr. Snell at your organization with either Ki-67 or the multigene assays?

Dr. Snell: No, will not change.

Dr. Kim: No changes there. Dr. Heelan.

Dr. Heelan: No change for us. I would say, we had as an academic center, we have a lot of availability and all this data, and something we did not talk about too much. I do not want to get too much down a rabbit hole. I think all of these different components tell you about the biology of a person's tumor.

Even if they do not meet one criteria, but other criteria are showing that they have an aggressive biology, I think it is about the seeing the forest for the trees, or using the trees to see the forest. All these different components, I think, always help inform us about the patient's tumor biology and whether we consider them high-risk ultimately. It is nice to have a checklist. Again, using these data points to think about the whole picture is helpful.

Key Takeaways

Dr. Kim: With that being said, here are just some of the key takeaways that emerged, and we really want to thank the panelists again for your insights, but also for participating in this program, for sharing in this journey.

We know, as many of you have said, that QI is a multidisciplinary. It requires that whole team that it is a systematic, data-driven approach. The importance of reviewing both clinical processes but also the actual data. What is being documented? What is being captured? Reflecting that back to the clinicians, because sometimes they may be surprised. Then, of course, going through the systematic process of identifying the gaps as well as the opportunities to streamline some of this.

Even though several of you have mentioned that our clinicians feel like we are already doing this automatically, clearly the data showed that at times things either fall through the cracks or there may be inconsistencies in how things are done. Certainly, if you are at a teaching program with residents, fellows, there is always an opportunity to make sure that they are not missing something as you as we go through that.

Early on, we came up with a variety of different potential ideas. In terms of interventions and identifying the appropriate ones, assessing feasibility clearly those are really important. Then, of course, measuring and then thinking about sustainability. As Dr. Snell mentioned, how can we make sure we sustain these changes? How can we change processes in a way where we really ensure that both sustainability but also potentially the scalability when it comes across at other organizations?

We are excited to not only share these findings through this webinar but also to have an opportunity to disseminate further, and really help other cancer centers incorporate something similar, given some of the complexities and challenges of actually systematically identifying patients who have high-risk early breast cancer.

Poll 3

Let us get ready to wrap up with a few polling questions. Also, I want to remind the audience that if you have any questions for the panel, please be sure to type them into the chat. We will get to as many of those questions as possible.

The first poll, do you plan to make any changes in your practice based on what you have learned in today's program?

1. Yes;
2. No; or
3. Uncertain.

Poll 4

Then the next poll is, please take a moment to enter one key change you plan to make in your practice based on this education.

Poll 5

Then here is our next polling question. If you are interested in implementing a QI initiative at your cancer center or at your site, please enter your information so that we can then follow-up with a participation survey. These project opportunities are constantly popping up and emerging. If there is interest, please indicate your interest.

Q&A

Just as a quick reminder, if you do have any questions for the panel, please be sure to type them either into the chat or into the Q&A box, and we well get to as many of those as we can.

Now it is time for Q&A with the panel. There was one question that came in so far. This question has to do with the fact that there was both the NATALEE as well as the monarchE criteria, and if you go back to that idea of a checklist, the checklists were different. The question has to do with did you find that your team tended to prefer using one checklist over the other, or were you always using both. Can you provide us a little bit more about how you were using those two clinical trials?

Let us start with Dr. Heelan. Did you use both monarchE and NATALEE, or was there a preference towards one versus the other?

Dr. Heelan: We used both. Like I said in the beginning, we discussed it as a group to make sure everyone was comfortable with it and in alignment. We opted to use both.

Dr. Kim: How about Amy at your institution?

Amy Baker: Yes. We used both to make sure that no patients fall between the cracks are left behind.

Dr. Kim: Dr. Snell.

Dr. Snell: I agree, same.

Dr. Kim: I am just looking to see if there is any other questions from the audience. Panelists, do you have any questions you would like to ask each other based on the discussion so far? We will just give the audience another minute to see if anyone else wants to type in a question, but do any of the panelists have questions for each other?

Dr. Snell: I have a question. Not particularly about these trials, but CDK4/6 in general. Is there any open trials that you guys are thinking of for preoperative therapy for these cancers that do not really respond well to chemo but are often nearly unresectable? We cannot find one, and we are struggling-

Dr. Heelan: I was going to say there is none that I know of. I have not specifically looked for that, but that is a really interesting thought. In terms of trying to downgrade the omalizumab or similar.

Dr. Snell: Exactly, or even just the skin.

Dr. Heelan: Yes, if you have a really locally invasive tumor.