Treating HER2+ Metastatic Breast Cancer During the COVID-19 Pandemic


Caitlin Flanagan, a patient with HER2+ metastatic breast cancer, and Sara A. Hurvitz, M.D., discuss treatment approaches and modifications during the COVID-19 pandemic.

Sara A. Hurvitz, M.D.: We’re getting ready to close this out in the next 10 minutes. One of the next things that we want to discuss is how cancer treatment has changed during the COVID-19 era. It’s really interesting. In the beginning, back in March and April [of 2020] when everything shut down, we remained open, but we opened up video visits and telehealth, which previously was not really something we were able to do. It’s fascinating to me that things that we thought we couldn’t do because of legal implications and HIPAA [Health Insurance Portability and Accountability Act] concerns, all of sudden—within a month—all the lawyers and everybody figured out how to make it happen. Now we have telehealth and video visits available to us, which has made it great for patients who haven’t wanted to leave the home.

There’s been a lot more uptake of the use of oral therapies, and subcutaneous Herceptin and Perjeta and home health visits have become more common to keep people out of doctor’s offices. Can you describe how things changed for you, how your perception of going into the office changed, and what your experience was during this crazy pandemic?

Caitlin Flanagan: In the beginning, I was really frightened that I would get COVID-19. Remember when we were wiping off our groceries and you felt like it was everywhere? It was super easy to catch it, and I knew with my compromised lungs, it would be a very serious situation. I had that fear. I’m 59 [years old], and I’ve never had my government tell me so many different things that contradict each other. I was born in the 1960s, we have public health together. It’s like, “What happened?” That was really scary.

It’s great to be on the oral medication, and now I’m on the Herceptin that you get at home. That was also great. I have to go in for my blood work and Xeloda. I feel sad when I see patients who are getting a heavier chemotherapy [regimen]. They can’t have a loved one with them, and I feel like it’s hard for them. I also see it’s a burden for the nurses who are great about it but have to do much more emotional labor of comforting and calming people, which in my experience, would have been handled by my husband, my friend or my sister. I also see that everybody’s being extremely careful and extremely thoughtful. I’m aware of it, but less frightened about getting it than I was.

Sara A. Hurvitz, M.D.: Yes, and hopefully everybody will be vaccinated shortly. In the next month, there’s a move, at least out here in Los Angeles, to start vaccinating patients who have chronic conditions. We need to get the vaccine into everybody.

Let’s now look to the future. This is a quite exciting time in the field of HER2 [human epidermal growth factor receptor 2]-positive breast cancer treatment. There are a number of new agents, in addition to the ones that have all been approved very recently. We have a number of new targeted therapies and lots of clinical trials. At UCLA [University of California, Los Angeles Health], we have five or six clinical trials that are looking at new drugs that target HER2. It’s a very exciting time. Moreover, a lot of these therapies, like tucatinib and TDXd [trastuzumab deruxtecan], are being looked at in early stage disease, so the curative setting; stage 1, 2 and 3. We may be seeing these drugs move up into earlier-line settings, our goal being to prevent metastatic occurrences from even happening. I think that in the next five years we’re going to even see bigger changes occur.

There are also a number of drugs that are looking at how to best treat patients who have brain metastases. Fortunately, you do not. The hope is that the tucatinib is providing you a layer of protection, so that you avoid that from happening. But we do have a number of agents being looked at in clinical trials to deal with that when that happens as well.

In my own practice, I’m using tucatinib in patients who have had at least two prior lines of therapy in the metastatic setting. I’m using it just like I’m using it in Caitlin, but we also have a clinical trial where tucatinib is being combined with TDM1 [trastuzumab emtansine] in patients in the first- or second-line setting to see if that’s a safe and active combination.

It’s a really exciting time. I see nothing but hope ahead of us. I know Caitlin has her goals of good quality of life and keeping the disease at bay, but my goal would be that she live out a long life and die of something totally different at the age of 95.

Caitlin Flanagan: I like that. By then, you will have found a cure to that problem, too. I might never get out of here.

Sara A. Hurvitz, M.D.: How do these advances make you feel? Have you been keeping track of all the changes in this field?

Caitlin Flanagan: You always tell me there are so many more things. I had never heard the word armamentarium, and I love that word. It’s a great word. You would always say there’s more and more, and more things are being approved, so I’ve always had a upbeat feeing that it won’t be like, “Well, we only have one thing to try, and then you’re going to be in bad shape.” I feel like, “OK, there’s a fight to be fought. There are things out there.”

Sara A. Hurvitz, M.D.: That’s great. In closing, can you give some sage advice to patients who may find themselves in your shoes at this point? What would you say to them?

Caitlin Flanagan: As having metastatic recurrence? I would just say that in our minds, and with most other cancers, with stage 4, there’s no stage 5. That’s the end. That’s the scary one. That’s the metastatic disease. But it’s not that way for us. We can treat it for a long time as a chronic disease, and we all know people with chronic diseases. Their lives are more challenging, whether it’s diabetes, fibromyalgia, or one of those things. But it’s not unusual for someone to have a chronic illness that they’re managing all the time. When I think of it that way, then my terror goes away altogether. And, until I hear otherwise, I am going to think of it that way.

Sara A. Hurvitz, M.D.: That’s an amazing way to end. Very hopeful.

Transcript edited for clarity.

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