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HR-Positive HER2-Negative BC

CE / CME

Improving Outcomes in Patients With High-Risk Breast Cancer: Expert Guidance and Team Training for HR-Positive/HER2-Negative Disease

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour

Physicians: maximum of 1.00 AMA PRA Category 1 Credit™

Pharmacists: 1.00 contact hour (0.1 CEUs)

Released: March 22, 2024

Expiration: March 21, 2025

Joyce O'Shaughnessy
Joyce O'Shaughnessy, MD
CME/CE Information

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Proactive Management of AEs and Adherence to Oral Therapies

Last but not least, I would like to share a few thoughts on patient adherence with some of the treatments previously discussed, particularly in regard to oral therapies, including planning for and management of toxicities.

Key AEs With CDK4/6 Inhibitors: Monitoring and Prevention to Maximize Adherence

We are well aware of the AEs we see with CDK4/6 inhibitors in MBC. Diarrhea, neutropenia, and interstitial lung disease/pneumonitis are possible with all 3 CDK4/6 inhibitors, with hepatobiliary toxicity more common with abemaciclib and ribociclib, and venous thrombotic events more common with abemaciclib.8,50,51

The most important point that I would like to make about monitoring and management of AEs is that we want to see our patients every 2 weeks for the first 2 months as they are starting on their CDK4/6 inhibitors. Patient education on what to expect with regard to diarrhea, especially with abemaciclib, is important. Patients may consider a low-fiber and low-fat diet for the first 6-8 weeks after starting a CDK4/6 inhibitor to reduce the risk of diarrhea. I would recommend that patients take loperamide for more than 2 loose stools per day while staying well hydrated to offset fluid loss from diarrhea. It is important to monitor each patient’s hepatic function (with abemaciclib and ribociclib) and closely monitor their neutrophil counts in the event that a dose reduction is needed.

To maximize adherence to oral therapies and minimize the potential for AEs, we often recommend to patients to always take their medications at the same time, as part of something they already do routinely. We also talk about placing pill bottles/boxes in an area they use every day to remind themselves to take their medications (eg, nightstand, bathroom, kitchen). Patients also can take advantage of technology (eg, use pill reminders and alarms or apps on their smartphone or tablet). Lastly, I tell my patients to take notes on whether grapefruit and grapefruit juices can affect how their medications work and to always check with their pharmacist or nurse before starting herbs or supplements.

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Management of CDK4/6 Inhibitor‒Induced Diarrhea

Because diarrhea-related deaths have been reported with CDK4/6 inhibitors, I would like to go over some recommendations I offer to my patients to mitigate the incidence and severity of diarrhea. For example, dietary modification is important. As previously mentioned, a low-fiber, low-fat diet for the first 6‑8 weeks is a good start. Smaller portions and more frequent meals can help with food absorption and prevent dehydration. Use of antidiarrheals such as loperamide can help manage frequent diarrhea―but note that optimal use of loperamide can be variable based on each patient’s needs. Some patients may need a full pill, whereas others may need one third of a pill to manage the diarrhea. In those patients with 4-6 stools/day over baseline, we may hold the dose of the CDK4/6 inhibitor until the diarrhea resolves to grade ≤1, then start at the same dose if the diarrhea resolves within 24 hours, but if it persists, we may need to restart at a reduced dose.8 In those patients with ≥7 stools/day over baseline, we may hold the dose of the CDK4/6 inhibitor until the diarrhea resolves to grade ≤1, then start at a reduced dose.52,53

Patient Communication Checklist

The slide on the right has a screenshot of a downloadable, printable patient communication checklist resource made in collaboration with Clinical Care Options. I think resources like these are very helpful for our patients. This one in particular suggests questions for patients to pose to their care team with regard to their intended therapy, including for CDK4/6 inhibitors and the AEs associated with their therapy. This patient resource also provides strategies to promote adherence to oral therapies and includes what to expect during treatment, when their healthcare team may decide to stop treatment, and when to call their provider.

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Go Online for More CCO Coverage of Breast Cancer

I invite you to visit the program page to access downloadable slides, clinical commentaries, and interactive decision support tools that may help inform selection of appropriate therapy for your patients with high-HR-positive/HER2-negative EBC and MBC.

In addition, I encourage you to download the patient communication checklist resource that we’ve created for this program, which you can share with your patients.

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Which of the following would you recommend to your patients with early-stage HR-positive/HER2-negative breast cancer who are currently receiving an oral targeted therapy, to improve adherence to therapy?

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