Advancements in Oncology, which took place on Saturday, June 1, the second day of the 2024 American Society of Clinical Oncology Annual Meeting, was co-hosted by Rohit Gosain, MD, and Rahul Gosain, MD, MBA, known as The Oncology Brothers. The panel-based event featured distinguished thought-leaders in breast, gastrointestinal, genitourinary, and lung cancers.
Margaret Gatti-Mays, MD, MPH, who specializes in breast cancer, delivered key insights on a plethora of breast cancer-related topics—from hormone receptor (HR)-positive disease and patients with HR-positive disease in the metastatic setting to patients with endocrine-resistant disease. She capped off her panel session by discussing advancements in HER2-positive and triple-negative breast cancer.
“With HER2-positive [disease] in the early stage, we proceed with surgery; in the adjuvant setting, [we proceed with chemo]; and in locally advanced [disease, we use] neoadjuvant chemotherapy, then surgery, and then, based on the residual disease, we proceed with a trastuzumab-based regimen or T-DM1,” said Dr. Rohit Gosain. “There has not been much data on early lines [from the annual meeting]. In advanced disease, we will be seeing what we know is THP followed by HP. Is eribulin adding any benefit with HP when compared with THP?”
On the topic of eribulin, Dr. Gatti-Mays said, “In the EMERALD study, eribulin with Herceptin and pertuzumab was noninferior to our standard CLEOPATRA regimen. It does become challenging when our patients have had chemotherapy in the neoadjuvant or adjuvant setting and have some neuropathy. We’ve been somewhat limited in terms of what options we have for chemo.” She noted EMERALD was a helpful study because it allows another option. “I would feel comfortable using [Eribulin with Herceptin and pertuzumab] as first line,” she said.
Next, Dr. Rohit Gosain posed a question about trastuzumab deruxtecan (T-DXd). “We have been utilizing T-DXd in the second line, but the thing that makes us question [that regimen] is brain metastasis. Should we be relying on T-DXd? [Can you share your] anecdotal experience and some of the data that were presented at [the annual meeting]?”
According to Dr. Gatti-Mays, “in general, people have favored the HER2CLIMB regimen for active brain metastasis because of the way the clinical trials were done. Anecdotally, when I’ve used Enhertu, I have seen some really nice responses in active brain metastasis.” She also noted a specific radiation-related risk. “When using Enhertu with active brain metastasis, be aware of the risk of radiation necrosis,” she cautioned. “If you’re using it after SRS, there’s a heightened risk of radiation necrosis for these patients. That’s the other question in terms of choosing between the therapies. If patients just received SRS, sometimes they’ll favor the HER2CLIMB regimen, because that risk of radiation necrosis is less.”
Returning to the idea of T-DXd, Dr. Rahul Gosain said, “We know it’s an active drug. We just have to be very careful in picking the right patient for this [therapy]”
The conversation then switched gears to triple-negative breast cancer. Dr. Rahul Gosain added that community oncologists are “seeing this all. In terms of the current landscape, not too much has changed. What was practice changing was the KEYNOTE-522 study saying that we should consider the right patient for perioperative immunotherapy, neoadjuvant chemotherapy, surgery, and then continue with immunotherapy for everyone.”
KEYNOTE-522 still remains the standard of care today, but Dr. Rahul Gosain noted that the bigger questions is “how much [immunotherapy] is playing a role, especially if you have PCR.”
Dr. Gatti-Mays expounded on the KEYNOTE-522 data. “We were all excited to see the survival benefit, especially in those patients with PCR. It’s important to note, though, that in some of the earlier data that were presented a few months ago, when they looked at PCR by EFS and the recurrence sites, even in those patients who have PCR, even in those patients who have an RCB-I, we are seeing first site of metastasis in not a ton of patients, but in some as brain.” She noted that PCR is a good indicator, but “it doesn’t necessarily mean the patient doesn’t have risk of recurrence. Immunotherapy may not necessarily improve or decrease the risk of brain metastases.”
Dr. Gatti-Mays then discussed the A-Brave trial and the importance of considering treatment toxicity, saying that “[this trial] included patients who got neoadjuvant chemo but no immunotherapy. Do we add on immunotherapy now in the adjuvant setting for those who had residual disease? In those patients who received adjuvant chemotherapy, we added on immunotherapy at that point.” She said she is looking forward to seeing the response.
Dr. Rohit Gosain noted “immunotherapy is really changing, especially when we talk about the toxicity. Everyone thinks, ‘Oh, it’s just immunotherapy,’ but the toxicity is real even if it’s minimal.”
He then concluded by summarizing the trio’s discussion: “From the triple-negative perspective, we have to keep an eye out for A-Brave. It will be questionable how the data will truly change the practice because we are already giving pembrolizumab in the neoadjuvant setting. In the HER2 space, it will be interesting to see how eribulin combined with HP versus THP is going to change the landscape for HR-positive disease. Watch for ribociclib approval, and pick the right patient for chemotherapy, especially when perimenopausal females are concerned. INNOVO, along with the CDK 4/6 inhibitor, is extremely important. There is a lot to look forward to.”
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