The Role and Rationale for Oral Options in the Treatment of Metastatic Breast Cancer - Episode 9
Adam M. Brufsky, MD, PhD: I was struck, for example, to have the PrefHER trial. This is in Europe: they did a trial of subcutaneous vs IV [intravenous] trastuzumab, and they found that, 9:1, patients preferred the subcutaneous delivery. Is it because they spend less time in the chair? They are there for 20 minutes and they leave, so they do not have to spend several hours there. Do you think that is the reason behind it?
George W. Sledge Jr., MD: They do not even have to be in the chair. It is eminently possible to give those therapies at home. You can have a visiting nurse come out and give it in 5 minutes.
Adam M. Brufsky, MD, PhD: Have you started to do that at Stanford Cancer Center, by the way? I know Mark Pegram, MD has been talking about it for quite a while.
George W. Sledge Jr., MD: We are part of a larger Genentech trial that is doing subcutaneous delivery for both trastuzumab and pertuzumab.
Adam M. Brufsky, MD, PhD: Can you do it at home? You get a visiting nurse to give it to people at home?
George W. Sledge Jr., MD: Yes. As I recall, they have a contracted visiting nurse who gives it.
Adam M. Brufsky, MD, PhD: Do they have to be chemotherapy certified, I'm assuming, to give it, or can a general nurse give it?
George W. Sledge Jr., MD: That I do not know. One would imagine they have to have some sort of certification.
Adam M. Brufsky, MD, PhD: Lee, are you doing the same thing? I am curious.
Lee S. Schwartzberg, MD, FACP: We have not done it at home yet. We want to make sure that the custody of care and delivery is right. In the office, we are doing it. I know that my colleagues in hematology are doing it a lot with rituximab now, which has subcutaneous technology, as well as Darzalex [daratumumab]. These are drugs that take hours and hours, and anti-HER2 antibodies are the same.
Adam M. Brufsky, MD, PhD: I will take the last 15 minutes to talk about specific agents that we have now have seen both at ESMO [the European Society for Medical Oncology Virtual Congress 2020] and San Antonio Breast Cancer Virtual Symposium 2020, as well as at San Antonio in 2019.
I want to talk a bit about the concept of toxicity. Do you believe that it is a Cmax [peak plasma concentration] sort of thing? Is it a peak that determines toxicity to the agents, or is it more chronic? I am curious to hear what both of you think about that topic. It influences oral agents, right? I do not know if that is true, but supposedly, oral agents are more chronic, so you do not get as high of a Cmax. I am curious to hear what you think about that.
George W. Sledge Jr., MD: It depends on the drug, and it depends on the toxicity. For most agents we are talking about a Cmax sort of thing. But if I think of something like taxane neuropathy, weekly low-dose paclitaxel does not have a lower rate of taxane neuropathy than every 3 week taxane.
Adam M. Brufsky, MD, PhD: Yes.
George W. Sledge Jr., MD: That is clearly not a Cmax issue. It is probably more of a time above threshold issue.
Adam M. Brufsky, MD, PhD: Fair enough. Same thing, Lee? Do you think it is the same kind of thing?
Lee S. Schwartzberg, MD, FACP: Yes, I agree. It is specific for the types of toxicity that you are looking at.
Transcript Edited for Clarity