Danielle Roman, PharmD, BCOP

Panelists discuss how evaluating quality of life in patients on CDK4/6 inhibitors requires asking open-ended questions beyond just adverse effects to assess social functioning, work capacity, and emotional well-being (with quality of life data showing these agents maintain rather than significantly improve outcomes), and how multidisciplinary care can be optimized through nurse navigators for additional patient touchpoints, coordination with subspecialty colleagues like pulmonology and cardio-oncology for rare toxicities, and utilizing learners and standardized workflows to manage the high patient volume despite limited pharmacist resources.

Panelists discuss how treatment sequencing in early-stage breast cancer requires a stepwise approach, adding one therapy at a time (typically radiation, then hormonal therapy, then CDK4/6 inhibitors, with special considerations for BRCA-positive patients receiving olaparib first), while in metastatic settings the sequencing is more straightforward with first-line CDK4/6 inhibitors plus endocrine therapy, and how patient adherence can be optimized through shared decision-making, detailed toxicity education with graded explanations, frequent health care team touchpoints especially during the challenging first 90 days, and addressing the unique adherence challenges in early-stage patients who are asymptomatic compared to metastatic patients.

Panelists discuss how analysis from the Miami Breast Cancer Conference showing 60% of eligible early breast cancer patients are not receiving CDK4/6 inhibitors reflects disparities between academic and community settings, particularly affecting older patients and those with fewer lymph nodes, while identifying remaining unmet needs including better management of quality-of-life impacting adverse effects like fatigue and diarrhea, reducing the burden of frequent laboratory monitoring, and addressing financial toxicity and administrative barriers that affect both patients and health care staff.

Panelists discuss how they are excited about future CDK4/6 inhibitor data including oral SERDs to replace fulvestrant injections, triplet combinations with newer agents, expansion into HER2-positive settings, and the potential role of ctDNA monitoring, while emphasizing key patient education points such as explaining mechanism of action differences from chemotherapy, managing expectations about common adverse effects, setting parameters for when to contact the care team, and providing resources like ChemoCare while also educating health care teams through primary literature and electronic health record care plans.

Panelists discuss how pharmacists play a crucial role in toxicity management and monitoring for CDK4/6 inhibitors (including proper QTc calculations, lab monitoring thresholds, and diarrhea mitigation strategies), how they incorporate NCCN guideline recommendations into clinical practice while identifying patients who might fall through the cracks (especially those not receiving chemotherapy), and how they consider sequencing CDK4/6 inhibitors based on postMONARCH trial data for patients with soft progression or low tumor burden without actionable mutations.

Panelists discuss how treatment selection between CDK4/6 inhibitors in early-stage breast cancer is primarily driven by trial eligibility criteria with abemaciclib being preferred when qualified, while in metastatic settings ribociclib is often favored due to overall survival data, and how adverse event profiles differ significantly among the 3 agents (neutropenia with palbociclib/ribociclib, QTc prolongation and drug interactions with ribociclib, and early-onset diarrhea with abemaciclib that typically improves with supportive care management).

Panelists discuss how CDK4/6 inhibitors can be considered for patients with visceral crisis based on limited data from the RIGHT Choice trial (though historically chemotherapy has been preferred), and how the number of positive lymph nodes in early-stage breast cancer drives treatment selection based on the specific inclusion criteria from the monarchE and NATALEE trials, with dual-eligible patients requiring consideration adverse effect profiles and patient-specific factors.

Panelists discuss how FDA-approved CDK4/6 inhibitors are used in early breast cancer (abemaciclib and ribociclib with different trial designs and dosing regimens) and metastatic breast cancer (palbociclib, ribociclib, and abemaciclib showing approximately 2-year progression-free survival advantages in various combination therapies).