Managing Patients With Breast Cancer Receiving Targeted Therapies

Dr. Stricker is an oncology nurse practitioner within the Hematology/Oncology Division of the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, where she has teaching as well as clinical responsibilities. Active within the Oncology Nursing Society (ONS), she participates in the Nursing Research Special Interest Group and the Nurse Practitioner Special Interest Group. Dr. Stricker has authored and co-authored a number of peer-reviewed articles in journals such as Cancer Practice, Blood, Oncology Nursing Forum, and Clinical Journal of Oncology Nursing.

Carrie Tompkins Stricker, PhD, RN, reported a financial interest/relationship or affiliation in the form of: Speakers’ Bureau, Merck & Company, Inc., and Roche, Inc; Contracted Research, Merck & Company, Inc.

Treatment Overview: The Therapeutic Landscape for Breast Cancer

Breast cancer is the most common type of cancer in women. Over 200,000 new cases will be diagnosed in the United States in 2007, and an estimated 40,910 deaths will be attributed to this disease. Fortunately, an explosion of new therapies has improved the outlook for the millions of women living with breast cancer. Some of the most exciting developments during the past few years have included the introduction and expansion of targeted therapies in both the adjuvant and metastatic treatment settings. Targeted therapies, which use drugs or other substances to identify and attack specific cancer cells while minimizing harm to normal cells, include trastuzumab, a monoclonal antibody against the HER2 oncogene, lapatinib, an oral dual tyrosine kinase inhibitor targeting HER1 and HER2, and bevacizumab, a monoclonal antibody targeting angiogenesis. Targeted therapies are increasingly being employed both independently and in conjunction with chemotherapy and/or hormonal therapy to improve outcomes for women with breast cancer.

Workshop: Model Algorithm for Assessing and Managing Cardiotoxicity

Consistent with their novel mechanisms of action, targeted therapies present unique challenges to oncology nurses in terms of their methods of administration and toxicity profiles; some side effects, such as cardiotoxicity, have the potential to be life threatening. This presentation will address the rationale for the use of targeted therapies, provide an overview of evolving clinical trial data, and highlight toxicity issues in the context of a case study.

Dr. Romond is professor of medicine at the University of Kentucky College of Medicine and Markey Cancer Center. He is the study chair for the National Surgical Adjuvant Breast and Bowel Project (NSABP) and principal investigator on the NSABP B-31 trial, a recently reported pivotal trial for the treatment of women with HER2-positive primary breast cancer.

Edward H. Romond, MD, reported a financial interest/relationship or affiliation in the form of: Consultant, Genentech BioOncology.

Clinical Trials Update: Practical Applications for Oncology Nurses

The introduction of the monoclonal antibody trastuzumab 10 years ago significantly improved outcomes for women with HER2-positive metastatic breast cancer and reaffirmed the value of targeting specific key cellular proteins as an effective means of controlling disease. This has led to the development of a plethora of new agents targeting not only important steps of the HER2 pathway but also other critical elements of tumor biology such as angiogenesis. Multikinase inhibitors have changed the treatment of some traditionally chemotherapy-resistant malignancies such as renal cell carcinoma; these agents are also finding their place in the management of breast cancer. Lapatinib is a small molecule that targets both HER1 and HER2 and works intracellularly on the ATP binding site of HER molecules. Bevacizumab is a monoclonal antibody that blocks the activity of vascular endothelial growth factor; the addition of the agent to first-line paclitaxel chemotherapy has doubled progression-free survival. The combination of targeted therapies with each other and with traditional chemotherapy agents has already started to change and improve the natural history of breast cancer. However, many of these targeted therapies have toxicity profiles distinct from those of traditional chemotherapy agents, requiring oncologists and oncology nurses to be cognizant of their differences in order to provide optimal patient care.

The addition of trastuzumab to chemotherapy for the adjuvant treatment of HER2-positive breast cancer has resulted in a marked improvement in early outcome for patients and has produced absolute increases in disease-free survival at 3 years, ranging from 5% to almost 13% in various trials. The corresponding relative reductions in disease recurrence range from 33% to 52%, and statistically significant improvements in patient survival have been seen in all the large adjuvant trials. In view of these impressive benefits, a major challenge is the selection of chemotherapy regimens that minimize the well-recognized cardiac risk of trastuzumab/chemotherapy combinations while achieving the highest possible anticancer efficacy. Upcoming clinical trials, including some testing combinations of targeted agents as well as others evaluating preoperative therapies, are extremely promising and deserve wholehearted support from the oncology community as we approach the possibility of cure for HER2-positive breast cancer.

Dr. Craft is an oncology clinical nurse specialist at Breast Imaging of Oklahoma in Edmond, Oklahoma, and is a clinical instructor at the University of Oklahoma College of Medicine in Oklahoma City, Oklahoma. She received her master’s degree in nursing from the University of Oklahoma and doctorate in nursing from Texas Women’s University in Denton, Texas. Dr. Craft has presented lectures and authored numerous journal articles on breast cancer risk factors and treatment. She is a founding member of the Oklahoma Association of Clinical Nurse Specialists and a member of the Oncology Nursing Society and American Nurses’ Association.

Melissa Craft, RN, PhD, AOCN^®, reported no areas of conflict.

Workshop: Model Algorithms for Assessing and Managing Toxicities in Patients With Breast Cancer

Targeted therapies are becoming standard treatment for advanced breast cancer and early stage disease. This presentation focuses on the most frequent and serious toxicities of targeted therapies used in breast cancer, with recommendations for recognition, prevention, and management. The agents that will be discussed are bevacizumab, sunitinib, and sorafenib.

Approximately 25% of newly developed drugs for cancer are oral agents. Adherence to oral regimens has been studied in many chronic diseases, including hypertension, diabetes, and arthritis. Studies suggest that adherence rates in cancer treatment may be as low as 20%. Management of patients receiving oral therapies presents complex issues, including assessment of adherence and identification of complications without the benefit of frequent office visits. Achieving agreed-upon treatment goals and adherence to treatment (concordance) involves patient education, appropriate side-effect management, and personalization of therapy. Strategies for achieving success with oral therapies will be presented.