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Dr. Harbeck: 
This is CME on ReachMD, and I'm Dr. Nadia Harbeck. Joining me today is Dr. Hope Rugo. We know that medication adherence and persistence can be challenging in some patients with HR-positive, HER2-negative, early breast cancer.

Hope, what are some of the factors that influence this?

Dr. Rugo: 
Hi, Nadia. Thank you so much for highlighting this issue, as it's incredibly important. We really do need to ensure in our work that we work hard on adherence to medications that can impact patient's life and risk of distant recurrence of early-stage, hormone receptor-positive, HER2-negative disease.

And we see that there are significant issues with medication adherence among different populations of patients that we treat. I think, really, it's just taking the time to explain information to patients and with very close follow-up; that plays a huge difference.

We also know that as patients get older, they may have some issues with comorbidities that impact symptoms from treatment, and that impacts adherence. In our younger patients, there can be big issues with adherence in terms of the treatment we give for hormone receptor-positive disease, where we use ovarian function suppression as a sort of standard for higher-risk hormone receptor-positive disease with aromatase inhibitors or tamoxifen. And that can really result in significant issues, both psychological as well as physical. And of course, issues with delayed childbearing, as well, the immediate menopause effects.

So these issues all play a huge role for patients. And now we're running into issues when we're dealing with trying to add on CDK4/6 inhibitor like abemaciclib in patients who have higher-risk disease, that I get feedback from many of our community colleagues that these patients are saying, “Well, wait a minute, I've already done all this treatment, and I don't really want to take anything more. It's expensive. It has more toxicity, and I don't want to deal with the issues relating to treatment.” And we work very closely with our patients to manage the side effects, to give them control of when they hold medications for side effects, and also resources in order to manage as well as early dose reduction. That plays a huge role.

And what we saw was in patient-reported outcomes from monarchE, that patients actually maintained their quality of life in terms of factors, with the exception of having more diarrhea, which we can generally control now that we're more knowledgeable about it. And that was quite intriguing, even in our older population. I think we do see some issues with PROs, where the patients who drop off treatment in the first 3 or 6 months because of side effects are not included in the longer-term PROs, of course. And so what we really want to do is help patients in that early time frame get through their treatment. And for endocrine therapy, it's really continuing to follow patients and taking their concerns seriously and managing this over time.

Dr. Harbeck: 
I think the other thing is, for this shared decision-making, is that we sort of split the time into different decision points. So we have the first decision point, whether to give chemotherapy or just endocrine therapy. Then the second decision point whether to add CDK4/6 and some patients also a PARP inhibitor. And I think we sort of need to tell the patients step by step that there will be more therapies coming, depending on all the information we get, and then ensure that they're okay with that.

And with regard to the management, where we're working a lot with the eHealth topics and with CANKADO, where we showed in the metastatic setting that actually that an autonomous eHealth program that helps patients to sort of to alert them if there is something going wrong with the side effects, that they’re to come see their doctor earlier, that that actually helps them to have less severe side effects and also improves quality of life. So I think that's something for the future.

Dr. Rugo: 
It's such a good point. And I really did love that electronic system where you could send in side effects. So I do think that that's the future, and we'll be able to use AI, I think, more and more, to kind of modify the alerts and also to provide, for example, immediate information back to patients about how to manage little side effects, right, that you don't need a person to actually interact with, whereas the more significant side effects will alert for them.

With the HER, now we have computers in our room. I can actually show patients the data and what happens over time and that this early treatment will impact outcome over the long term, both endocrine therapy and now CDK4/6 inhibitors. And I think that plays a huge role. And then you just have to also negotiate with what's important to the patient, because what's important to us may not be as important to the patient and vice versa.

Dr. Harbeck: 
Yeah, I completely agree. I'm a big fan of the autonomous eHealth tools, because I don't think we have time and staff to sit there and look at what patients send in. So the system that we work in, the system tells the patient this is a severe side effect, you've got to see your doctor early. And patients actually love that, because they sort of always feel they're burdening us with coming in, but if the system tells them that that they should come in, they feel sort of relieved.

I think in the future, we'll have more effective tools to help manage our patients. But I think, as always, the discussion with the patients and listening to the patients is the most important thing.

So always a nice discussion with you, Hope. Thank you very much, and thank you to our audience for tuning in.

Dr. Rugo: 
Thank you.

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