New Frontiers in Breast Cancer: Updates and Advances in Treatment - Episode 6
Following their discussion on the OlympiA and monarchE trials in breast cancer, experts consider when they would use olaparib or abemaciclib in the adjuvant setting.
Joyce A. O’Shaughnessy, MD: Sarah, here’s a tough question for you. For a young woman, 14 positive nodes despite preoperative chemotherapy, you’re going to optimize her endocrine therapy. But let’s say she’s a germline BRCA2, and you’ve got a choice for the patient. How are you thinking through abemaciclib versus olaparib for a patient who is eligible for both trials?
Sara A. Hurvitz, MD: When the BRCA mutation is there, I tend to feel that the PARP inhibitor is the one to be prioritized. Now that we have overall survival data, that underscores that thinking. Believe it or not, I thought this was one of those hypotheticals I would never see in practice, but I’ve had 3 patients in the last 6 months who fall into this category. I have used olaparib first, with the plan to utilize abemaciclib after, even though we’re not following the monarchE and starting the abemaciclib on time. I feel that if it’s beneficial and there’s micrometastatic disease to be managed, then using it after should theoretically still work. In those very high-risk patients who have both a BRCA2 mutation and qualify for abemaciclib, I’m doing PARP inhibitor first followed by abemaciclib, with the caveat that this has not been tested in a clinical trial. It’s the art of medicine. I’m definitely not using the 2 drugs together, of course, which is really important for people to know.
Joyce A. O’Shaughnessy, MD: Yes, because the OlympiA trial was a very substantial improvement, 8.8% in IDFS [invasive disease-free survival], but unfortunately, there was still recurrences. There were still recurrences in these patients, and some of this breast cancer can be ER [estrogen receptor]-driven even though its germline BRCA. The CDK4/6 inhibitors can also potentially be used. But I totally agree, given the choice between the two, I am also prioritizing the PARP inhibitor for the germline BRCA patients whose breast cancer is HR [hormone receptor]-positive. The exquisite synthetic lethality with a PARP inhibitor in the context of a germline mutation is one of the most effective things we’ve got in all of breast cancer. I also agree that the survival data are critically important that have come out from the OlympiA trial. I’m also prioritizing that as my first go-to for these high-risk patients.
Transcript edited for clarity.