Treating HER2+ Metastatic Breast Cancer: Caitlin’s Story - Episode 9

Adhering to Oral Therapy for HER2+ Metastatic Breast Cancer

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Caitlin Flanagan, a patient with HER2+ metastatic breast cancer, discusses the learning curve of taking an oral medication, tucatinib, in combination with chemotherapy, and Sara A. Hurvitz, M.D., reviews methods for medication adherence.

Sara A. Hurvitz, M.D.: Have you had any difficulty remembering to take your pills or adhering to it? Are there any tricks that you’ve found, because you’re having to do pills twice a day?

Caitlin Flanagan: I don’t have any tricks, but I need some tricks. I need to get a pill box and put them in. Because they have to be in separate pill boxes—it had said not to put the two pills together in a pill box for some reason—I never got around to it. I’ve definitely had times when it’s 11 at night and I’d think, “I have to get up and eat some bread and take that medicine,” because I’d forget it.

Sara A. Hurvitz, M.D.: Right. That’s something, I’m lucky enough to have nurse practitioners in my practice who are able to help with teaching patients. You’re a veteran patient, so maybe you didn’t get as much coaching from them, and that would be bad on us. To assume that you don’t need coaching when you’re going on a new regimen is not proper on the clinician’s side. I do think patient education and making sure you bring in your medications to appointments is important. Sometimes we’ll have patients bring in their bottles so that we can count and see, and make sure they are where they should be, if they have too many pills left, etc. When you’re not on a clinical trial and we’re not managing pills at that level, adherence to the medication can certainly affect outcome.

Caitlin Flanagan: It was very scary to have it at home. It was like, “I’m responsible?” I was used to going to the suite, infusion, nurses and blood work. I didn’t have to actively do anything except show up for my appointments. So it was a little anxiety-producing that the chemotherapy drugs are here in my house. It’s not like an antibiotic you have to take. You have to stay with that. That was an adjustment, but a wonderful adjustment, too, because you’re not in the infusion suite all the time and being reminded of your situation that way.

Sara A. Hurvitz, M.D.: Right. To go over the side effects a little bit with this particular regimen, tucatinib, capecitabine, which is the oral chemotherapy drug known as Xeloda, and trastuzumab are given together as a triplet therapy. The trastuzumab is IV [given intravenously] every three weeks, but the pills are given twice a day. It can be a little confusing because the Xeloda is given two weeks on, one week off, where the tucatinib is given continuously. It is a bit tricky. The side effects, based on the clinical trial evidence we’ve seen, can include diarrhea, as Caitlin described. Everyone needs to be coached to have Imodium on hand at home and to call if it’s getting really bothersome. Fatigue is very common. Even though it’s oral and not making hair fall out, it does make people feel tired. Some people can get dry, cracked palms and soles or mouth sores from the Xeloda.

It’s important to be seen every three weeks in the beginning, every month at least, and have blood work done. Occasionally, patients can have their liver enzymes go up. That’s not liver failure per se, but abnormalities in that, so that needs to be followed as well. But in the scheme of all the regimens we give, this is one of the better tolerated ones. I tend to start with a lower dose of the Xeloda and titrate up, rather than starting at the level that we’re supposed to get to.

Caitlin Flanagan: That would have been very depressing to start that high.

Sara A. Hurvitz, M.D.: Yes, I didn’t want you to run away screaming after the first cycle.

Caitlin Flanagan: Forget it.

Sara A. Hurvitz, M.D.: Exactly.

Transcript edited for clarity.