Q1

Fran: Welcome back to Australia Fatima. It’s fantastic to have you here and what I’m keen to know about is some of the work you have been doing in advocacy for women with metastatic breast cancer. It’s an area where women in Australia face lots of challenges and you have a worldwide perspective on that, can you tell us what you have been discovering?

Fatima: 

• Lack of specific support for women with metastatic breast cancer – worldwide
• Their needs are very different
• Teaching physicians and nurses how to communicate is key
• We are fighting the stigma of cancer, specifically metastatic cancer
• Changed focus – increasing advocacy through ABC global alliance
• Platform for everyone who is developing projects dedicated to metastatic disease

Q2 

Fran: And as you’ve been familiar with, of course breast cancer in men is much less common but also can occur as metastatic disease. Can you tell us a little about the work you’ve done to bring together information and support for men with metastatic breast cancer?

Fatima:

• Created international program for male breast cancer
• Only 1% of breast cancer, with metastatic even rarer
• Men excluded from drug trials until now, so we don’t know the treatment
• We have a lot to learn, to understand if it’s the same as female breast cancer
• Can we treat it by extrapolating from female breast cancer?

Q3 & 4

Fran: Many men will come from families with BRCA mutations so they may in fact share some of the features. Can you comment on any new treatment advances for people who’ve got metastatic disease or BRCA mutations?

Fran: And that’s a drug that will be available in Australia probably by later this year, specifically for people who have those mutations. It will be something for woman to ask their oncologists if they haven’t been tested if it’s appropriate.

Fatima: 

• First breakthrough: olaparib showed a benefit with BRCA mutations
• Also showing interesting results overseas with BRCA-related ovarian cancer

Q5

Fran: So the other group of drugs we are hearing about in Australia and been involved with testing and clinical trials are called CDK inhibitors, and palbociclib and ribociclib are gradually making their way through the approval process here and have received a fair amount of attention and hype. Do you think they really represent a significant advance?

Fatima: 

• Optimistic about CDK inhibitors: palbociclib and ribociclib
• Still waiting for survival results, but they are very well tolerated
• Tolerance important- can be taken over a long period
• These drugs can stabilise metastatic disease for two years or more
• No concurrent chemotherapy required

Q6

Fran: Takes time out of the clinic, time out of the hospital…

Fatima: 

• Oral treatment
• All oral options are well tolerated
• Allow a long period without chemo
• If clinical trials show an improved survival rate , we could have a breakthrough for men and women with metastatic cancer

Q7

Fran: That’s right, and more people potentially could gain and the challenge really in Australia at least is getting funding for them through the PBAC so the oncologists and BCNA have been working together to try and secure that and we are hoping to hear some positive news perhaps by the end of the year it’s also the case I think avoiding the tied down aspect of having intravenous chemotherapy that allows people to work, travel and get on with their normal lives may well be a big advantage.. So for woman with hormonal breast cancer it’s something they should be asking their oncologist about?

Fatima:

• Women with hormonal breast cancer should also ask about the CDK drugs
• Need to do cost effectiveness studies to show benefit of these drugs
• Not just the cost of drug, it’s savings in travel, nursing, hospital time
• BCNA women should keep applying pressure for correct cost analysis

Q8

Fran: and you mentioned just now that the HER2-positive breast cancer which we see in about 15% of women with MBC really does seem to have taken a big leap forward in the last couple of years and we are now very fortunate working together with BCNA we have been able to ensure a good range of HER2-positive drugs are available to women in Australia but what do you think we are going to be seeing as the next step forward for people with HER2-positive disease?

Fatima:

• Working out the best sequencing for using HER2 positive drugs
• New treatments are in trials right now
• Women with HER2 positive breast cancer are living ten years
• So we need to options and treatments to extend that
• Exciting time for the development of breast cancer treatment

Q9

Fran: Again, if you have HER2 positive breast cancer a good option might be to talk to your oncologist about whether there are trials available because if you receive a drug as part of your clinical trial it means you haven’t lost one of your other options and you still have that up your sleeve so…

Fatima: 

• Encourage women to participate in clinical trials
• Doesn’t remove other treatment options
• Opportunity to help shape future management of HER2positive breast cancer

Q10 

Fran: Exactly and you’ll be learning at the same time. So we haven’t talked about triple negative breast cancer except to say that it does sometimes link with BRCA mutations, what about for those women do you think we have the optimal chemotherapy yet or do you think there is more to come?

Fatima: 

• At least 7-10 subtypes within the triple negative
• Could be seven different diseases, so need to define them and specify treatments
• Promising drug trial stopped because of change of manufacturer
• Oral drug, well tolerated, good solution – hope that trials will restart
• Optimising chemotherapy not easy – already very good

Q11

Fran: There has been a lot of interest in Australia in immunotherapy because in the melanoma world of course immunotherapy has really transformed the lives of many people with metastatic disease and of course Australia has been very involved in those trials, what is your take on some of the roles of immunotherapies in metastatic breast cancer?

Fatima: 

• Not a huge fan of immunotherapy for breast cancer: a lot of hype
• Breast cancer more complex and tumours often hidden deeper than melanoma
• Good research in Australia into helping immune system identify tumours
• Clinical trials are good, but caution use of immune therapy outside of clinical trials

Q12

Fran: Certainly would be my impression with them treating my patients with melanoma with them that there is no free lunch and these are drugs that can have significant side effects when you turn on the immune system and get angry at the cancer and it often gets angry at other things as well and they certainly need to be administered by people who are very experienced for looking after they very different side effects from chemo… so as we are going to wrap up here Fatima, what about supportive care you mentioned that at the outset the things that women should be asking their oncologist to help them with in terms of their supportive care?

Fatima: 

• Lot of confusion worldwide about supportive care and palliative care
• Supportive care is not an end of life discussion
• Allows all of our treatments, but also improves quality of life
• New treatments for nausea, scalp-cooling
• Complexity of required emotional support not recognised
• Families and psycho-oncologists need to be in the treatment team
• Communication vital: voice your preferences, fears, information needs
• Be clear: how do you want to be treated?

Q13

Fran: there was a very provocative study presented at ASCO this year about a system that would allow patients to send in and connect their symptoms and there side-effects experiencing that are just waiting for them on consultation time to come up and that would allow the nurse to get action happening if they had back pain issues or vomiting or whatever it was and not surprisingly of course that meant that patients felt better but what was a bit surprising perhaps was that they also lived longer and I think that really underlines the importance  of supportive care that if someone manages your pain well then you will get up and out of bed and get moving and be interested in coming in for more treatment and if your pain is totally out of control and your disappearing out of yourself

Fatima: 

• Study confirms importance of supportive care in survival
• Depression under-diagnosed and under-managed; negative influence on treatment
• Study will open people’s eyes – quality supportive care is critical