Forming Breast Cancer Treatment Strategies Amid Chemo Shortages

Maryam Lustberg, MD, MPH

Yale School of Medicine

Yale School of Medicine has implemented several strategies during the ongoing chemotherapy shortage, including creating an algorithm to help prioritize patients for treatment, determining which patients are eligible for clinical trials with alternative treatments, and even reducing platinum-based chemotherapy dosage, according to Maryam Lustberg, MD, MPH.

In a discussion with CancerNetwork^®, Lustberg, an associate professor of Internal Medicine, director of the Center for Breast Cancer, and chief of Breast Cancer Medical Oncology at Yale School of Medicine, discussed the importance of these curative therapies, especially in patients with aggressive diseases such as triple-negative breast cancer (TNBC).

“Neoadjuvant chemotherapy is quite important for stage II and stage III TNBC,” she explained. “We absolutely need to do up-front chemotherapy to gauge the responsiveness, and to be able to tailor our treatments on the back end. In our conversations here at Yale, as well as in conversations nationally with other physicians about this very relevant topic, I haven’t seen too much of a shift from neoadjuvant chemotherapy because, as a community, we feel that it’s so important to give some type of preoperative chemotherapy.”

CancerNetwork^®: How has the ongoing chemotherapy shortage impacted patient care from your perspective?

Lustberg: Over the last 6 to 9 months, this has been a topic that has been on our minds as we continue to hear alarming reports of drug shortages, particularly platinum [agents]. As a breast oncologist, we use this type of drug quite routinely for patients with our most aggressive type of breast cancer, [TNBCs]. There has been ongoing concern about whether we would have enough drugs to most effectively treat this subset of breast cancers and in other types of breast cancer, as well. But we have spent quite a bit of time discussing strategies in terms of how we would deal with this most current drug shortage issue.

Has this affected how patients with breast cancer are being treated?

What I’ve seen and heard about is a lot of substitutions where standard neoadjuvant chemotherapy [is substituted] with different drugs. What we’re sometimes doing is taking out the platinum and essentially giving less treatment with the hope that perhaps, for that particular patient, it might be just enough. And then we would gauge their responsiveness at the time of surgery and make additional decisions at the back end. Some creative ‘recipe changes’ [are] the most common approach that I’ve seen, but less for my experience shifting to surgery first.

Are there any other strategies that are being implemented at your institution to mitigate impact on patients?

One of the big decision points has been to look at the curative intent of therapy as a community of oncologists. We have tried to ration [in terms of] who would get platinum agents or not. This is obviously a very sensitive topic, where I do believe that every patient, regardless of their stage of disease, deserves to have the best care and the best treatment regimen. However, in pragmatic considerations, when there have been clear shortages within an institution, the priority has been to reserve the platinum drugs for patients with curative intent, and to use less of them in patients with more advanced disease.

In our institutions, our pharmacy leadership actually proposed an algorithm dividing patients into early stages vs more advanced stages and have really [examined] various specific scenarios. If a patient, for example, has early-stage TNBC, we want to perhaps prioritize those patients. If there is a clinical trial option that perhaps is not using platinum drugs, we make sure that we’re at least discussing those options, and just really being cognizant of different alternatives to therapy. This algorithm was vetted in our institution by multiple medical oncologists, and there was active discussion in terms of what made sense or not. There was a lot of heart that went into it so that we were not being robotic in terms of who gets the platinum.

As an example, there are very specific instances in advanced breast cancer settings where if the liver function is severely impaired, a platinum doublet is really the only regimen you can get. All of us were very supportive of this. [It] really pointed out that we can’t just be black and white about only [patients with] early-stage [disease] getting platinum therapy and [patients with] advanced [disease] not getting it. There are certain situations in the advanced setting where platinum drugs should absolutely be used. We put this in place so we could be proactive, and I think it had a good chance of at least giving some direction to things. But here’s what happened in our institution, and I think this highlights some of the confusing aspects of this drug shortage. It’s very regional, and it’s very patchy. In some ways, that is part of the reason that maybe there hasn’t been a greater mobilization by the oncology community.

We put these guidelines in place, and what happened is, for reasons I don’t fully understand, we had another supply come in. [Because of that] we essentially didn’t have to resort to this rationing type of algorithm at our institution, although in multiple national forums, I do hear from oncologists that they are actively making those decisions. Even [the question of] who is getting the drugs in different regions seems quite variable. That has perhaps dampened some of that advocacy where if you think about it as a true crisis, we can’t be talking about the next hottest drug in cancer when drugs that have been shown to improve cure rates and our tried-and-true drugs are not available. We have been, in some ways, fortunate in that we put some guardrails in place. But for now, we seem to be okay.

What should multidisciplinary breast cancer care teams know about this shortage?

The theme of multidisciplinary collaboration still stands here just the same. The best care in breast cancer is absolutely that close collaboration among the surgeons, radiation oncologist, and breast medical oncologist. The same applies here. If there is a situation where maybe the patient is in that borderline situation where you could do surgery first or are perhaps considering preoperative chemotherapy when the optimal drugs are not available, that’s the situation where perhaps surgery could be considered first. [It is important to] continue those types of multidisciplinary discussions and for surgeons to be aware that perhaps some of their regimens may be modified. There is a possibility that response rates may not be as high as what [we are] used to. Again, we will deal with additional considerations for more therapy at the back end. But [it’s important to have] awareness and continue discussions as a team in terms of how we can continue to deliver the best care that we can for each patient.

What are the implications of this shortage?

I’m sure [we] are all thinking about just what this all means because this is not just about platinum drugs. This is a recurring theme that continues to come up. There were saline shortages, [for example]. There continues to be themes of shortages that are happening, and I do worry [because] we’re kind of in this reactive mode. We need to really come together as a medical community to take stock of the root causes that are contributing to these crises and really think about all the supply chain issues and other aspects that may be contributing. I would welcome greater education and insight into that and how we can come together to try to prevent these situations in the future.