Adam M. Brufsky, MD, PhD: A lot of patients who come to us have chemotherapy first. For these patients that come to us with a very large, low-grade advanced tumor—a woman will come in, her breasts will be really red or she will have a really big tumor in her breast—the issue becomes, what do you do? What I usually tell people is, “We could do a mastectomy on you now, but we’d probably have to give you chemotherapy afterwards. So, why don’t we just do it first to see if it shrinks?” That’s kind of how you explain this neoadjuvant therapy to people.
Lynn Acierno, BSN, RN, OCN, RN-BC: Right.
Adam M. Brufsky, MD, PhD: I’m curious to hear your opinion on this. A lot of people will go, “I don’t want to leave my cancer in my breast. It’s going to spread all over my body.” What do people say to you when that happens? Do they say that to you at all?
Lynn Acierno, BSN, RN, OCN, RN-BC: Well, often the surgeon is involved from the very beginning.
Adam M. Brufsky, MD, PhD: Correct.
Lynn Acierno, BSN, RN, OCN, RN-BC: So, they’re not only hearing that from us. I have not really had many patients express that concern. I also think that because we’re treating them while it’s there, it’s very encouraging for them to know that, as we continue to monitor that tumor, it’s shrinking.
Adam M. Brufsky, MD, PhD: Right, they love that. I think patients really like knowing that and having that choice.
Lynn Acierno, BSN, RN, OCN, RN-BC: Yes. I’ve only had, maybe, a handful of patients that express concern on that.
Adam M. Brufsky, MD, PhD: Good. The other thing that’s really important is that a certain percentage of those patients who need chemotherapy first, as neoadjuvant chemotherapy, are HER2-positive. I explain to them, “You’re 1 of the 1 out of 5 people whose cancer has the HER2 gene in it. It makes your cancer very sensitive to chemotherapy.”
When we give chemotherapy with Herceptin (trastuzumab), it will shrink the tumor a lot, generally, and it’ll be very quick when that happens. I think people like that. We really have come a long way in the last 15 or 20 years with drugs like Herceptin (trastuzumab) and things like that. Do people ever ask you about that at all? “What is this Herceptin stuff?” “What is this pertuzumab stuff?”
Lynn Acierno, BSN, RN, OCN, RN-BC: I think that people are savvy enough now. A lot of people go on the computer and they want to know what targeted therapy is.
Adam M. Brufsky, MD, PhD: Yes.
Lynn Acierno, BSN, RN, OCN, RN-BC: We explain that their cancer expresses certain characteristics that we can target with this chemotherapy or, actually, targeted therapy. I explain the difference between how systemic chemotherapy works as opposed to targeted therapy. I also explain that the traditional systemic chemotherapy doesn’t know the difference between a healthy cell or an abnormal cell, but the targeted therapy goes right to that tumor. So, by using a regimen such as TCHP (docetaxel, carboplatin, trastuzumab, pertuzumab), we’re getting it from all angles. Even though it is a pretty heavy-duty regimen, it gives great results.
Adam M. Brufsky, MD, PhD: It does. A lot of people do really well. A lot of people have what’s called a complete pathological response, which means there’s no cancer left. In fact, if you come in and your cancer is negative for the estrogen receptor or HER2, and we give you neoadjuvant TCHP, the complete response rate—because there’s no cancer left when we do surgery—is about 70% to 75%. It’s really cool when it happens. But it is a pretty heavy-duty regimen. I agree.
Lynn Acierno, BSN, RN, OCN, RN-BC: And part of the nursing staff’s role, again, is managing the side effects that patients do experience with TCHP. We try to help patients through that. There’s a lot of gastrointestinal issues with TCHP.
Adam M. Brufsky, MD, PhD: What kind of gastrointestinal issues?
Lynn Acierno, BSN, RN, OCN, RN-BC: Many of our patients develop diarrhea. We try to manage that with over-the-counter Imodium. We have them follow the directions pretty faithfully to help keep that diarrhea as best controlled as we can. We encourage fluids. We tell them to make sure they let us know if they begin feeling like they’re getting behind and if they’re dehydrated. Then, we have them come in for fluids.
Adam M. Brufsky, MD, PhD: Right. In fact, we do that more than I thought. I think that we expect diarrhea from certain drugs, and I think that Herceptin [trastuzumab] has a little bit of diarrhea associated with it. And when adding pertuzumab to it—you see this as much as I do—I think we’re really getting more diarrhea. There are people in whom we’ve had to stop pertuzumab, especially somebody who is a little bit older; our patients who are in their 60s, late 60s, or early 70s.
We like to try to give everybody TCHP if we can. Sometimes, we just give THP if they can’t do the carboplatin. Or sometimes, we give antiparticle paclitaxel, or Abraxane, with Herceptin and pertuzumab, even though that’s not the standard of care. We try to do that to save them the steroids. But even with all of that, people come in and say, “I keep going to the bathroom, all the time.” We have to stop the pertuzumab. We have someone in our clinic, right now, who had TCHP and ended up in the hospital. Then, they got it in a reduced dose and ended up in the hospital. We said, “OK, let’s stop the carboplatin.” The patient still ended up in the hospital. Then we stopped the pertuzumab. The patient still had trouble.
Lynn Acierno, BSN, RN, OCN, RN-BC: That brings up a point. We have, again, a spectrum of responses. Some patients honestly can get through TCHP with little to no issues.
Adam M. Brufsky, MD, PhD: Right. Exactly.
Lynn Acierno, BSN, RN, OCN, RN-BC: Then we also have patients who really have problems with it. So, it’s hard for me, as a nurse, to say, “This is exactly how it’s going to be.” Everybody is different.
Adam M. Brufsky, MD, PhD: The weird thing is, there’s no way to know. It could be the most healthy, robust 45-year-old woman in the world, and she’ll be miserable. It could be a 75-year-old woman who does great.
Lynn Acierno, BSN, RN, OCN, RN-BC: As a matter of fact, in our initial teaching session, I say, “Your first cycle is a learning curve for all of us because we don’t know how you’re going to respond.”
Adam M. Brufsky, MD, PhD: Right. That’s really a cool way of saying it. I like that. I like that a lot.