Understanding the Journey of Survivorship in Metastatic Breast Cancer: The Asia-Pacific Experience
19 Jun 2024
In Southeast Asia, breast cancer survival
rates have seen a sustained upward trajectory for the last four decades mainly due
to a host of factors including early detection and advances in multimodal
treatment.1 Along with this came the increase in population of
breast cancer survivors whose plight was highlighted in a recent scientific
symposium entitled “Breast Cancer Congress Philippines”.
In partnership with the Philippine Society of Medical Oncology, Novartis Philippines conducted the scientific symposium with the theme “Understanding the Journey of Survivorship in Metastatic Breast Cancer: The Asia-Pacific Experience”. It featured esteemed Medical Oncologists from around the Region led by Session Chair Dr Maria Luisa A. Tiambeng, Medical Director of the Cardinal Santos Memorial Medical Center and Chair of the Section of Medical Oncology at the same institution. She was joined by the symposium moderator, Dr Arthur Gregory A. Lui, Vice Chief of Training and Medical Oncologist at the Metro Davao Medical and Research Center together with foreign speakers Dr Anita Archwamety, Faculty Member of the Division of Medical Oncology, Siriraj Hospital, Mahidol University in Bangkok Thailand and Dr Mastura Md Yusof, Medical Oncologist at the Cancer Institute of Pantai Hospital, Kuala Lumpur, Malaysia. Dr Josephine P. Contreras-Magno, President of the Philippine Society of Medical Oncology (PSMO), graced the event and expressed the society’s gratitude for the strong stakeholder collaboration in advancing the advocacy for cancer awareness and its management.
Metavivors
Sadly, not all breast cancer survivors receive the advanced quality of comprehensive care tailored to their specific needs. In her opening presentation, Dr Tiambeng highlighted the unique challenges of survivors of metastatic disease who call themselves “metavivors”.2 From being excluded from commonly used definitions of survivors and the experience of living with an incurable disease, to the issues associated with prolonged survivorship including distress, financial toxicity, and poor quality of life, metavivors are indeed on a journey that is poorly understood outside of their circle.2 Dr Tiambeng advocated for a better understanding of the survivorship journey through the 3P model where the identified predisposing, precipitating and perpetuating factors present as foci of interventions to improve survivorship outcomes.2,3
CDK4/6 Inhibitors and Its Impact on the 3Ps of Survivorship Journey
Predisposing factors
To highlight the impact of cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) on predisposing factors, Dr Tiambeng presented a case where ribociclib and letrozole were administered in an elderly hormone receptor (HR) positive, human epidermal growth factor 2 (HER2) negative metastatic breast cancer patient. As can be expected in the patient’s age group, the working diagnosis was complicated by comorbidities, advanced age, apprehension to receive potential toxicities from chemotherapy, high burden of disease and the need to achieve optimal response.4 Ribociclib and letrozole were chosen by the patient from the treatment options presented, with improved outcomes and expected safety profile consistent with published clinical evidence of ribociclib use in elderly population.5
The case presented by Dr Tiambeng had a high burden of disease with pulmonary, nodal, skin and bone metastases, ER/PR+, HER2- with an ECOG 1 score. The choice of ribociclib and letrozole treatment for this case was informed by robust clinical evidence of ribociclib + ET in patients with clinically aggressive HR+/HER2- advanced breast cancer. The series of MONALEESA (ML) trials have shown that the combination improves the rates of progression-free survival (PFS), median overall survival (OS) and the median time to adjuvant chemotherapy (TTC) across all elderly age group segments. Safety data showed adverse effects were manageable using existing dose adjustment guidelines.5,6
The results of the CompLEEment-17 study were consistent with the results on the combination’s safety and efficacy seen in the ML series. Indeed, ribociclib and letrozole combination can positively impact the predisposing and precipitating factors in the 3P model of survivorship especially in elderly patients.8 The management approach, however, must be highly individualized with shared decision making and collaboration with the patient, the caregivers, and a multi-disciplinary team.9
Precipitating factors
The talk by Dr Archwamety highlighted a case of breast cancer disease that progressed despite ongoing first-line therapy. The choice of ribociclib in combination with letrozole was supported by data from the RIGHT CHOICE study, that showed better progression-free survival (PFS), time to failure and 3-month treatment failure rates over combination chemotherapy.10 Most notable was the result in the subgroup analysis, with the Asian subpopulation showing significantly better response and survival rates.11 The study also showed safety data consistent with the results of the ML trials. The phase II RIGHT CHOICE trial showed clinically significant PFS longer than that of the currently indicated combination chemotherapy, with lower rates of adverse events.10 These studies helped drive a reinterpretation of the concept of metastasis among the metavivors, realizing that metastatic cancer can become chronic, and that chemotherapy can affect their lives the most because of the physical impact and how long it can last. And this further emphasized the need for innovative first-line treatment options like ribociclib in combination with letrozole that can positively impact the survivorship journey.10,12
Perpetuating factors
Dr Mastura highlighted data from the MAINTAIN study on metastatic breast cancer patients who experienced disease progression despite being on endocrine therapy and CDK4/6is.13 Ribociclib, together with switch endocrine therapy, showed significant reduction of progression or death and longer survival across subgroups. Data from pooled ML post-progression has demonstrated that patients given CDK4/6i after first-line RIB had the longest OS.14 Dr Mastura presented 3 clinical cases that prove the efficacy and safety of the treatment combination for these cases. This data on disease progression on a prior CDK4/6i has redrawn the boundaries of living with metastatic cancer. The new battle cry of “living life” highlights integration of chronic illness into one’s life experience emphasizing emotional resolution and acceptance of their lived experiences that are beyond their control. This is in contrast with the “war metaphors” that had been used to inspire metavivors before, but many times bred despair and disappointment.15-17
Panel discussion: Survivorship Beyond Progression
The speakers and the participants engaged in a highly interactive discussion following the presentations. The considerations in choosing ribociclib in actual practice piqued the audience's interest to which the speakers shared the disease phenotypes, previous treatment, therapy goals and affordability, especially in the local setting, are important to look at. Caution in the elderly remains to be paramount especially with the high probability of comorbidities and polypharmacy. The speakers shared their observed quick response times to ribociclib in combination with letrozole in patients with visceral crisis but may be delayed in some patients. The cost of ribociclib treatment was an important point of discussion with the speakers emphasizing on focusing on the benefits, time taken off work, medical insurance coverage and external sources of financial support that varies according to patient needs and resources. The symposium participants were very appreciative of the learning session and responded with very positive feedback, with 88% being very satisfied overall and 88% stating that the educational program resulted to much improvement of their knowledge on the topic. Also, 75% of the audience found the learnings from the sessions to be very impactful.18
Conclusion
The symposium highlighted the efficacy and safety of ribociclib in combination with endocrine therapy in the management of hormone-receptor (HR) positive, human epidermal growth factor 2 (HER2) negative metastatic breast cancer with significant impact on the predisposing, precipitating and perpetuating factors of the journey of metavivors that can potentially redefine their lived experiences.
In partnership with the Philippine Society of Medical Oncology, Novartis Philippines conducted the scientific symposium with the theme “Understanding the Journey of Survivorship in Metastatic Breast Cancer: The Asia-Pacific Experience”. It featured esteemed Medical Oncologists from around the Region led by Session Chair Dr Maria Luisa A. Tiambeng, Medical Director of the Cardinal Santos Memorial Medical Center and Chair of the Section of Medical Oncology at the same institution. She was joined by the symposium moderator, Dr Arthur Gregory A. Lui, Vice Chief of Training and Medical Oncologist at the Metro Davao Medical and Research Center together with foreign speakers Dr Anita Archwamety, Faculty Member of the Division of Medical Oncology, Siriraj Hospital, Mahidol University in Bangkok Thailand and Dr Mastura Md Yusof, Medical Oncologist at the Cancer Institute of Pantai Hospital, Kuala Lumpur, Malaysia. Dr Josephine P. Contreras-Magno, President of the Philippine Society of Medical Oncology (PSMO), graced the event and expressed the society’s gratitude for the strong stakeholder collaboration in advancing the advocacy for cancer awareness and its management.
Metavivors
Sadly, not all breast cancer survivors receive the advanced quality of comprehensive care tailored to their specific needs. In her opening presentation, Dr Tiambeng highlighted the unique challenges of survivors of metastatic disease who call themselves “metavivors”.2 From being excluded from commonly used definitions of survivors and the experience of living with an incurable disease, to the issues associated with prolonged survivorship including distress, financial toxicity, and poor quality of life, metavivors are indeed on a journey that is poorly understood outside of their circle.2 Dr Tiambeng advocated for a better understanding of the survivorship journey through the 3P model where the identified predisposing, precipitating and perpetuating factors present as foci of interventions to improve survivorship outcomes.2,3
CDK4/6 Inhibitors and Its Impact on the 3Ps of Survivorship Journey
Predisposing factors
To highlight the impact of cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) on predisposing factors, Dr Tiambeng presented a case where ribociclib and letrozole were administered in an elderly hormone receptor (HR) positive, human epidermal growth factor 2 (HER2) negative metastatic breast cancer patient. As can be expected in the patient’s age group, the working diagnosis was complicated by comorbidities, advanced age, apprehension to receive potential toxicities from chemotherapy, high burden of disease and the need to achieve optimal response.4 Ribociclib and letrozole were chosen by the patient from the treatment options presented, with improved outcomes and expected safety profile consistent with published clinical evidence of ribociclib use in elderly population.5
The case presented by Dr Tiambeng had a high burden of disease with pulmonary, nodal, skin and bone metastases, ER/PR+, HER2- with an ECOG 1 score. The choice of ribociclib and letrozole treatment for this case was informed by robust clinical evidence of ribociclib + ET in patients with clinically aggressive HR+/HER2- advanced breast cancer. The series of MONALEESA (ML) trials have shown that the combination improves the rates of progression-free survival (PFS), median overall survival (OS) and the median time to adjuvant chemotherapy (TTC) across all elderly age group segments. Safety data showed adverse effects were manageable using existing dose adjustment guidelines.5,6
The results of the CompLEEment-17 study were consistent with the results on the combination’s safety and efficacy seen in the ML series. Indeed, ribociclib and letrozole combination can positively impact the predisposing and precipitating factors in the 3P model of survivorship especially in elderly patients.8 The management approach, however, must be highly individualized with shared decision making and collaboration with the patient, the caregivers, and a multi-disciplinary team.9
Precipitating factors
The talk by Dr Archwamety highlighted a case of breast cancer disease that progressed despite ongoing first-line therapy. The choice of ribociclib in combination with letrozole was supported by data from the RIGHT CHOICE study, that showed better progression-free survival (PFS), time to failure and 3-month treatment failure rates over combination chemotherapy.10 Most notable was the result in the subgroup analysis, with the Asian subpopulation showing significantly better response and survival rates.11 The study also showed safety data consistent with the results of the ML trials. The phase II RIGHT CHOICE trial showed clinically significant PFS longer than that of the currently indicated combination chemotherapy, with lower rates of adverse events.10 These studies helped drive a reinterpretation of the concept of metastasis among the metavivors, realizing that metastatic cancer can become chronic, and that chemotherapy can affect their lives the most because of the physical impact and how long it can last. And this further emphasized the need for innovative first-line treatment options like ribociclib in combination with letrozole that can positively impact the survivorship journey.10,12
Perpetuating factors
Dr Mastura highlighted data from the MAINTAIN study on metastatic breast cancer patients who experienced disease progression despite being on endocrine therapy and CDK4/6is.13 Ribociclib, together with switch endocrine therapy, showed significant reduction of progression or death and longer survival across subgroups. Data from pooled ML post-progression has demonstrated that patients given CDK4/6i after first-line RIB had the longest OS.14 Dr Mastura presented 3 clinical cases that prove the efficacy and safety of the treatment combination for these cases. This data on disease progression on a prior CDK4/6i has redrawn the boundaries of living with metastatic cancer. The new battle cry of “living life” highlights integration of chronic illness into one’s life experience emphasizing emotional resolution and acceptance of their lived experiences that are beyond their control. This is in contrast with the “war metaphors” that had been used to inspire metavivors before, but many times bred despair and disappointment.15-17
Panel discussion: Survivorship Beyond Progression
The speakers and the participants engaged in a highly interactive discussion following the presentations. The considerations in choosing ribociclib in actual practice piqued the audience's interest to which the speakers shared the disease phenotypes, previous treatment, therapy goals and affordability, especially in the local setting, are important to look at. Caution in the elderly remains to be paramount especially with the high probability of comorbidities and polypharmacy. The speakers shared their observed quick response times to ribociclib in combination with letrozole in patients with visceral crisis but may be delayed in some patients. The cost of ribociclib treatment was an important point of discussion with the speakers emphasizing on focusing on the benefits, time taken off work, medical insurance coverage and external sources of financial support that varies according to patient needs and resources. The symposium participants were very appreciative of the learning session and responded with very positive feedback, with 88% being very satisfied overall and 88% stating that the educational program resulted to much improvement of their knowledge on the topic. Also, 75% of the audience found the learnings from the sessions to be very impactful.18
Conclusion
The symposium highlighted the efficacy and safety of ribociclib in combination with endocrine therapy in the management of hormone-receptor (HR) positive, human epidermal growth factor 2 (HER2) negative metastatic breast cancer with significant impact on the predisposing, precipitating and perpetuating factors of the journey of metavivors that can potentially redefine their lived experiences.