In general, ribociclib is my agent of choice in the first-line setting. There are certain scenarios in which I might consider abemaciclib up front over ribociclib, particularly if CNS protection might be important for that patient. I prefer ribociclib from a toxicity standpoint as well.
When thinking about ribociclib or abemaciclib from a toxicity standpoint, patients have to deal with diarrhea on abemaciclib, whereas neutropenia isn’t necessarily a day-to-day toxicity that patients experience or that impacts patient experience. That’s essentially because of the overall survival data. Ribociclib is my default choice in the metastatic setting. Jules Cohen, MD: Dr Iyengar, are you a convert to ribociclib, or are you still a palbociclib or abemaciclib guy? We should also check their labs because survival is the most important end point for these women. There are issues with administration of ribociclib with checking cardiac function, but given an improvement in overall survival, it’s worthwhile to get the ECGs and look at the QTc interval every 2 weeks for the first 6 weeks of treatment. Joanne Mortimer, MD, FACP, FASCO: My preference for an CDK4/6 inhibitor is ribociclib because it seems to have the best survival data. Jules Cohen, MD: Dr Mortimer, do you prefer a specific CDK4/6 inhibitor? That’s the right treatment at this point for this patient. Two of those 3 have reported overall survival data that are very positive and among the largest survivals we’ve seen in this subtype of breast cancer. There are 3 approved CDK4/6 drugs that have very similar hazard ratios and show a good progression-free survival. Slamon, MD, PhD: At this point, there are sufficient data that these patients benefit in a substantive way with a combined hormonal therapy and CDK4/6 blockade. Dr Slamon, would you like to discuss first-line therapy for metastatic ER+ disease?ĭennis J. The tumor still is estrogen receptor positive, progesterone receptor negative, and HER2 negative.
Her ECOG performance status is 1, and an imaging work-up showed 5 new subcentimeter liver metastases, which was confirmed by biopsy. Jules Cohen, MD: To go further into the case, 2½ years into her treatment with anastrozole, the patient presented after developing new symptoms-fatigue and right upper quadrant abdominal pain-that negatively affect her quality of life. Making sure that this patient is following up with her primary care physician and checking off the boxes in terms of routine health screening and screening for other cancers is an important part of cancer survivorship. Patients on adjuvant hormone therapy, especially if they’ve received chemotherapy, are at risk for other long-term comorbidities in the survivorship setting, particularly cardiometabolic comorbidities. Having the patient in the clinic for regular breast exams and an annual mammography is the predominant way that I monitor these patients. Iyengar, MD: In the adjuvant setting on an AI, clinical monitoring is probably our best tool in terms of recurrence monitoring. How would you monitor the patient going forward?
Jules Cohen, MD: Dr Iyengar, this patient has completed their treatment and is on the maintenance aromatase inhibitor.
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