Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: For our panelists as we come to a close today, I want to ask everyone 2 main questions. No. 1, what are some key areas of education that you would provide for anyone—payers, patients, FDA, pharmacy, and whoever is running these clinical trials? What would be an area that you would like education to be focused or improved upon, as well as what are you looking forward to in this CDK [cyclin-dependent kinases] space or at least this patient population?Heather [McArthur], I’ll start with you and we’ll go this way.

Heather McArthur, MD: I probably speak for all of us in that we’re all looking forward to seeing this NATALEE [NCT03701334] data. As we pointed out earlier, we’ve seen a positive press release, but the devil is always in the detail, so I’m looking forward to those specific analyses. And currently, education in the adjuvant setting, as pointed out by Sarah [Sammons] and others has really focused on 1 drug recently, abemaciclib. Later today that conversation may change and there could be a very different educational need if we’re comparing 2 different opportunities for potentially overlapping patient populations.I think another space that we really need to desperately attend to is the issue of sequencing. We brought up the MAINTAIN study [NCT02632045], which looked at the transition to ribociclib after prior CDK exposure, but the vast majority of those patients had prior palbociclib, only a handful of them had ribociclib, and almost no patients had prior abemaciclib. So these incredibly high-risk patients who will progress either on their adjuvant therapy or after completion of adjuvant therapy, we have no data to inform really how to treat progressors after adjuvant abemaciclib and maybe potentially ribociclib, so that’s a definite area of unmet need. So my education asks would be to invest heavily in understanding how to treat that high-risk population.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Excellent. Sam [Samyukta Mullangi]?

Samyukta Mullangi, MD, MBA: I would say that we are in a very happy place. We have really great survivorship and even the invasive disease-free survival, I think, with the adjuvant abemaciclib increase from 80 mg to 85 mg. We’re doing really well in breast cancer, just chipping away, trying to get even better, so I think we’re interested in such a great place. I am looking forward to seeing whether or not the NATALEE data are positive and then we have another adjuvant option on the market. I’m curious to see what happens in terms of access and pricing to democratize this for more patients.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Excellent. Sarah [Sammons], how about you?

Sarah Sammons, MD: I’m excited to see what adherence to these adjuvant CDKs will be. I do think these are higher-risk patients that are more motivated. However, we do know from the endocrine therapy data that nearly 40% to 50% of patients do not complete 5 years. And now we’re adding more drugs with more toxicity. I think monitoring compliance, optimizing compliance, optimizing toxicity management, and more research into supportive care mechanisms to help patients stay on these drugs so that they can benefit from them—I’d like to see more of that.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: And Jay [Andersen]?

Jay Andersen, MD: I agree with everything. They stole what I was going to say. But another space I really like is the new adjuvant setting. When you have an adjuvant setting, you have to wait for outcomes, whereas, in a neoadjuvant, you can get immediate response rates, biomarkers, interrogation, and correlation. I think that is the wave to help design future trials, to get signals of creative combinations based upon interrogating the tumor, not just ER [estrogen receptor], PR [progesterone receptor], HER-2 [human epidermal growth factor receptor 2], but a laundry list of other mutations or alterations that may be a niche for that particular patient. A big plug in that space as well.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: I can’t thank you all enough for this rich and informative discussion. Before we wrap up and conclude for the day, any final remarks from you all, round robin, anything that we haven’t covered? I know we talked about this being a very specific subset of this breast cancer patient population. We’ve talked about having 1 limited FDA approval right now, and that’s really been the experience for most, but there’s some information we can adopt from our experiences with the patients in the metastatic setting. And then at ASCO [the American Society of Clinical Oncology Annual Meeting], there’s going to be some exciting things happening over the next several months as well. Jay [Andersen], maybe I’ll start with you. [Do you have] any final remarks?

Jay Andersen, MD: Just a global remark. I’ll just echo what Sam [Samyukta Mullangi] said. It’s super exciting. I’ve been doing this now [for] 20 years and every year [it] gets more complicated in a good way and [it’s] super exciting, and I’m just fascinated by it. I love what I do, and I love to deliver new therapies to patients.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Excellent. Sarah [Sammons]?

Sarah Sammons, MD: I agree. For the first time in 30 years, we have new adjuvant regimens. We’ve seen so many drugs fail in this space—aspirin, metformin, everolimus, palbociclib—and now we do have drugs that are impacting outcomes and I’m excited to see the NATALEE data. I’m excited to see what toxicity looks like with the lower dose and how patients will tolerate it. And it’s a good time to be alive in treating these patients.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: We went from aspirin to CDK4/6, right? Sam [Samyukta Mullangi], how about you?

Samyukta Mullangi, MD, MBA: I’d say I’m the youngest here. I’m still in fellowship. I would say that I feel very privileged to be entering cancer care at this time when there are such phenomenal advances in therapeutics. I’m also really grateful to have met all of you, and I’ve learned a lot just by being on this peer exchange.

Sarah Sammons, MD: I learned a lot about value-based care from you.

Jay Andersen, MD: That’s great.

Heather McArthur, MD: Absolutely.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Heather [McArthur]?

Heather McArthur, MD: I’ll share an anecdote. My mother in the 1970s went to [Memorial] Sloan Kettering [Cancer Center] to be an expert in oncology, which was a 2-week course. So it’s remarkable to me that in 1 generation we’ve come so far, and I think you’ve heard very consistently that it’s a time of tremendous optimism to be treating breast cancer with an unprecedented number of FDA approvals that are translating into clinically important improvements in outcome, improvements in survival, improvements in cure rate. And now the challenge amongst us is really what Jay [Andersen] described, which is tailoring treatment recommendations, and who derives benefit from specific treatment recommendations so that we can minimize a lot of the toxicity that’s currently incurred.

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Absolutely. Again, to our panel, I can’t thank you all enough. I think this was an exceptional discussion. Thank you, again. And to our viewing audience, we hope you found this AJMC Peer Exchange to be useful and informative. Thank you.

Transcript edited for clarity.