I moved, but the DS-8201 stays

That drug. This is the volatile adolescent relationship I never had. I’ve been dose reduced and dose delayed multiple times; I have no idea how much drug I’ve actually had. My new center started me over at Cycle 1, so now I’ve really lost track. But the thing still works! Even my brain is stable. The side effects are brutal, and I think not discussed openly because the drug works so well and is so new, but the nausea and fatigue are unbelievable. I’ve never thrown up from a drug before this. I’ve got a carefully curated four-drug combo designed to control the nausea, and it’s shocking to me that it really takes that much, and honestly I’m a little surprised that after a decade, I haven’t adapted to regular doses of poison.

Two milestones passed since I last wrote. June 6 was ten years from my original diagnosis. I was living in Switzerland. The doctor who diagnosed me was honestly the only Swiss I met who was kind to me, and more importantly, she got me diagnosed. I was lying on a table after a breast ultrasound while the radiologist fought with her in German on the phone, right in front of me, about whether to perform a biopsy. I was 25, right? It was impossible. He was pissed but hung up the phone and did the goddamn biopsy. A week later, sitting across from my doctor in her office, I remember what she said, so gently. “You will require more treatment.” Okay. She told me it was cancer. When I didn’t burst into tears, she said, with some surprise, “You were expecting this?” Yes. I’d known, I’d always known. She called my boyfriend for me to tell him, to bring him in and talk to him. I couldn’t do it. I’ve never been able to tell anyone; I have my husband do it, always. July 8 was the anniversary of my surgery. I remember that morning vividly. It was the first time I’d seen the thermometer that you just hold to your forehead. I thought it was so cool. My boyfriend, now husband, and aunt were with me. We watched Lady Gaga perform on the Today show on the TV in the corner of the room. She looked so amazing that I got a platinum blond wig like hers and wore it around NYC when my hair fell out. The last thing I said to my husband as they were wheeling me away was, “I wish this weren’t happening.” I woke up and didn’t feel that different.

I forgot the anniversaries of both of these days, though they’d been fading in and out of my memory for a few weeks. They were so long ago, and it’s all so different now.

We moved to Palo Alto in June, and despite working in finance and living in Berkeley over a decade ago, somehow I’d never been here before we pulled up to the front door of our rented house. I cannot believe such a paradise exists. I can see the sun every day. (A marvel after Boston, Indiana, Sweden and Switzerland.) I bought a bike, an adorable little mint green e-bike, that I love and am using to go back and forth between my house and the hospital. If you see me on the road, please don’t hit me. My brain’s been irradiated, and I don’t quite trust my balance. I’m hoping this won’t end with an OS event.

So here I am, in a standoff with my bone marrow and soaking up the sun, ten years out from a diagnosis of metastatic IBC and two weeks from my 36th birthday. I am SO OLD.

News from ASCO Abstract Day

We’ve been waiting for this all year, right, this bright spot in a sea of dread? Nothing perks me up like the latest in metastatic breast cancer research.

My abstract highlights – including new results on DS-8201, tucatinib, the accursed entinostat and a novel Pfizer ADC plus my predictions for late-breaking abstract results – after the break.

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Tucatinib Receives FDA Approval

Little tucatinib is all grown up! The TKI that started out at Array long, long ago has now been FDA approved in combination with Herceptin and Xeloda for the treatment of 2L+ HER2+ metastatic breast cancer. Additional international approvals could be imminent, as the submission was part of a concurrent review program between the FDA and worldwide regulatory authorities. This is fantastic news for everyone but the Kadcyla sales force, though Genentech will get a slice of the pie via some incremental Xeloda sales.

The approval was supported by data from the HER2CLIMB trial, which enrolled 612 subjects and randomized them 2:1 to tucatinib or placebo plus Herceptin and Xeloda. Subjects with brain mets at baseline comprised 47.5% of the study population. This is their story:

NEJM 2020

Among subjects with measurable disease at baseline, the confirmed objective response 40.6% in the tucatinib group and 22.8% in the placebo group. But look at those numbers! The brain mets patients didn’t do much worse than patients with visceral mets. Cascadian went in boldly by enrolling brain mets patients, and the gamble paid off. They have brain mets featured prominently in their labeling, and they’re an example for all the companies that have excluded brain mets patients from their trials for fear of muting response rates. But patients in the real world, in HER2+ breast cancer, have brain mets. I have brain mets. I’ve looked at a lot of eligibility criteria, and while we’ve seen brain mets exclusions gradually relax over the past decade, most trials that allow them still caution that they must be stable.

Cheers to you, Cascadian/SeaGen.

Immunomedics’ P3 Halted for Efficacy

After a slow-enrolling trial, a failed acquisition, an FDA Complete Response Letter, years of unspecified manufacturing issues and about eleven different management teams, Immunomedics finally had some good news last week: their phase 3 ASCENT trial was halted for efficacy. Wait, not just efficacy, compelling efficacy. (That’s a new one for me.) And since Immunomedics’ leadership roles are rented, not owned, there was naturally a concurrent announcement that they’ve appointed a new CEO.

The 529 subjects enrolled in ASCENT were randomized 1:1 to receive either sacituzumab (a TROP-2-directed ADC with an irinotecan metabolite payload) or standard of care chemo. Patients had to have had at least two prior lines of therapy in the metastatic setting, including a taxane, so the single-agent chemo options allowed by the trial are not particularly exciting and set sacituzumab up well on the efficacy endpoints: eribulin, capecitabine, gemcitabine, or vinorelbine. The primary endpoint is PFS, with secondary endpoints including OS and duration of response.

I do think sacituzumab will be approved under its current accelerated designation, which means the full analyses will have to be delivered at some point. A full approval could still be a year out, but I don’t think that’s the only reason behind what I expect to be a lack of fanfare come PDUFA day in June. This drug just isn’t going to be a blockbuster. It addresses a small market (TNBC patients number about 10-15% of the breast cancer population), and this “targeted” therapy brings with it some heinous toxicities that remind us it’s closer to a chemo reformulation than a Kadcyla, which I know has lost its luster but really felt like a game-changer circa 2010. And while a Kadcyla comparison isn’t apples-to-apples, as it’s HER2+ targeted and addresses a larger, likely healthier market, we’ll reference it here because, practically, there aren’t that many other ADCs kicking around to reference.

One of the benefits of ADCs is you take a supremely toxic payload and, by targeting it to a protein, minimize the adverse events and make the drug tolerable. Kadcyla did this with maytansine, which is a tubulin binder with side effects too severe to be clinically useful. Link it to Herceptin, and poof! Problem solved. 

Even with the TROP-2 “targeting”, which I’ve always found suspect given the high reported AE rates (TROP-2 is thought to be expressed in many solid tumors but only minimally in normal tissue – so is the issue the antibody or the linker?), sacituzumab is a difficult drug to tolerate. In the phase 1/2 study, 41% of subjects experienced adverse events of grade 3 or higher, with 39% experiencing grade 3 or higher neutropenia. It did knock diarrhea, which is the biggest issue with irinotecan, down to 59% overall and 13% grade 3 or higher, which is … better. On the less deadly side, about half of patients lost their hair. Targeted, you say? EMILIA, Kadcyla’s P3, demonstrated a serious adverse event rate of 18%. That’s what an ADC can do. That’s how you improve quality, not just quantity, of life. Anyone can go on, and likely stay on, Kadcyla with a minimum of surveillance and intervention, though, in general, HER2+ patients are easier to manage and are more likely to be healthier at baseline. That’s what TNBC needs and what immunotherapy is trying to deliver, however modest the results have been so far. There are a lot of drugs out there, so when do we get quality and not just “options”?  

In fairness, sacituzumab rates as an option. Immunomedics has been parading the early efficacy data around for so long that I nearly have it memorized: it’s about a 30% response rate and 6 months of PFS, right? That kind of response rate is good in TNBC; I’d expect standard of care to be 15-20%, worse as you move further away from first-line treatment, and PFS to be closer to 4 months. As for how that predicts the outcome of the study and the FDA decision, the AEs will be worse in the treatment group, but it’s going to get approved. The question is what kind of market is waiting for it. We haven’t seen much excitement from anyone not on Immunomedics’ payroll, but we know that at least as of 2017, Seattle Genetics was … less than enthused with their antics. I’m with Seattle. TNBC is a truly underserved population that needs better, but this drug has real limits.

Cancer and Covid-19: Patient Registries Open

This is exciting: ASCO is funding a registry on how cancer patients are managed during the Covid-19 pandemic, seeking to capture 12-month outcomes on patients included in the all-comers cohort (the study is agnostic on tumor types, whether the patient is cancer-free or metastatic, and treatment modality). The full list of objectives and outcomes is available here, but they’re capturing everything from baseline status to treatment modifications to symptom severity to cancer and virus outcomes in Covid-confirmed patients. The meaty CRF is here. I love it.

Of course, everyone is using a registry for everything now, and there’s a potential competitor in place from the “Covid-19 and Cancer Consortium”. While ASCO put most of their protocol information online, the Consortium’s page highlights their participating institutions, and … it’s a good mix of sites, representing both Big Cancer and smaller community networks (I’m really curious to see a breakout of patient management by center size and geography in the analyses). On their website, ASCO differentiates their registry by noting that it’s more holistically focused on patient outcomes rather than Covid-specific treatment outcomes, so it would be great if centers could participate in both … but no one wants to fill out CRFs twice, even when they’re not strained by a pandemic. It would be a shame to miss out on the data ASCO is looking to capture. This is not the time for RCTs, and I’m happy to see that Covid-19 patients are being treated the way I think (advanced) cancer patients should be treated all the time: dole out chloroquine, remdesivir, losartan, cell therapies, whatever you’ve got. We know there’s no data. We don’t know what works. So let’s watch and learn.

Cancer in the Time of Coronavirus

I’m a cancer-riddled germophobe with one neutrophil, so I’ve been preparing for this for the past ten years. Purell? Stocked. Lysol wipes? Come to my house, and I will hook you up. Masks, ranging from simple surgical masks to the slightly fancier Respokare models? In stock. I’ve also worked from home since 2008, which is its own quarantine. But now you’re all like me!

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Brain Mets at One Year

The one thing I said I would never do is whole brain radiation. Never, ever. That was the line. I was too scared of cognitive decline, that I wouldn’t be able to write, talk, walk or remember, and there is so much good stuff to remember.

I was diagnosed after going to the ER with a seizure that could be more gently characterized as episodes of visual changes. At intake, it was about 9 p.m. I insisted to the nurses and everyone who came by that I almost certainly had brain mets, but I still had to wait until after 3 a.m. for retinal detachment to be ruled out before they would put me on the list for an MRI. The ER was mobbed, and I spent the night on a stretcher in a hallway, using my coat as a blanket. I had an MRI the next morning, and while I was on the scanner I missed a call from my boss. Good remote employee that I am, this caused my heart to pound more than the impending test results. I kept muting and unmuting myself so he wouldn’t hear the sounds of the ER around me. This was actually the most surreal part of the day. The brain mets were known, as far as I was concerned; I didn’t know how I was going to explain them.

After the scan, they moved me out of a hallway and into an exam room, and some poor innocent ER resident came in and pulled my MRI up on a computer. I could see a handful of lesions, pretty big ones, but I couldn’t get a good look because the guy was clearly accustomed to looking at X-rays of fractures and lungs and not to scrolling through slices. So I didn’t see any of the other slices, but it seemed like the size of at least one of the lesions was pushing what could be managed with SRS, which as a treatment modality of course seemed comparably benign, and I’d have no objection to using it. I didn’t have a death wish with the brain mets, just an aversion to WBR.

They topped me up with Ativan and a massive dose of steroids and instructed me to go to my clinic, go straight there, right now, and I agreed. We stopped at the house so I could take a shower and put on makeup and change into nice clothes because I wasn’t facing The Institute looking like I’d just suffered a few hours of intermittent seizure activity then spent the night in a hallway before being told I had multiple brain mets.

The main thing I learned from that first meeting was that it was a lot more than three lesions. It was probably closer to a dozen. Hopefully that ER guy has since learned to scroll. When we were alone again, I told my husband that if they wouldn’t do SRS there, and we couldn’t find another institution to do it, and I couldn’t get tucatinib, that would be it. I was calling it.

I was ready for all of this, because I’d been having symptoms. The main one being confusion with bright lights at night; I couldn’t seem to see dimension when there were headlights and streetlamps competing for attention.

Why didn’t I say anything? Because it felt like only brain mets could, ahem, bring me down. I wasn’t having it.

Months earlier, I had bought ELO tickets for me and my father. My dad shaped my deep love for oldies and classic rock from when I was an infant, and I remember listening to Face the Music on his turntable when I was 8 or 9. He saw them live a couple of times in the 70s, but anyone who knows the band knows that Jeff Lynne’s not a never-ending tour guy, and I didn’t think I’d get a chance to see him in my lifetime. I was happy to take more or bigger mets in exchange for that night. What was I going to do, get a scan and start treatment and jeopardize the concert? I waited 10 years for the brain mets, but I’d been waiting for Jeff Lynne all my life.

It was so worth it. It was one of the best nights of my life. I think my dad feels the same. Of course I never told him that I was waiting out brain mets so we could have that time together.

This is going somewhere, as much as any of my anecdotes go anywhere. When I met my radiation oncologist, he told me WBR was my best option. Number of lesions aside, the size of the lesions alone was likely to cause so much fibrosis that I may suffer more symptoms than I was having already, and it would make follow-up challenging. All I asked about was the risk of cognitive decline. His answers were good, all of them. He had stories about patients who had better outcomes than I imagined to be possible. I started to consider WBR. He seemed worried that I wasn’t processing the rest of it, like the fact I had a little army of brain mets capsizing some essential brain function. You’ll lose your hair, he warned. He showed me the Paul Brown papers on hippocampal-sparing WBR in combination with memantine. WBR became the reasonable option.

It raised a question I’d never asked before in course of my treatment, because I was always so sure I would do well: what if I didn’t deteriorate?

I didn’t. A year out, and it’s like nothing happened. I compromised everywhere here, from when I reported the brain mets symptoms to the treatment itself. Maybe it cost me, and it could cost me more later (I’ve likely exhausted most options for further brain radiation). But I did what I wanted, and my brain and mobility and independence are intact. It reassures me whenever I think about it that I’m capable of staying true to myself when it counts.

This is not the kind of blog I usually write. Drugs and science are really the only things I want to talk about. But I wanted to tell this story so that other patients know good outcomes are possible. Think about where we were with HER2+ brain mets when I started, when even without the brain mets, I felt like I was on a precipice, always pushing up against the limits of treatment. There was no space for risk. Waiting to see if Tykerb and Xeloda would be effective was one of the only times I ever felt like a patient. I didn’t know then how many rules I’d have to break to stay myself, to get what I needed.

Now it’s 2020, and I can’t even count the lines of therapy I’ve had. I just started DS-8201. We’ll check in on the HER2+ pipeline in a future entry.

Tucatinib Meets Primary Endpoint in HER2CLIMB

Joining DS-8201 as a likely FDA approval in early 2020 is tucatinib, a HER2-targeted small molecule TKI that I’ve been fangirling for years. If this keeps up, I’m going to be able to treat my cancer with actual new medicine and not just mental fortitude.

Not to malign the Herceptin-plus-X paradigm that’s bridged me all this time, but it’s been a while since the T-DM1 and Perjeta launches of 2013. In metastatic cancer years, it’s a real long while.

Onto the successes of HER2CLIMB, Cascadian Therapeutics’ (now Seattle Genetics’) phase III trial comparing tucatinib + Herceptin + Xeloda to placebo + Herceptin + Xeloda. The trial enrolled 612 subjects and was randomized 2:1, and subjects had been previously treated with Herceptin, Perjeta and T-DM1. The press release notes that 47% of subjects had brain mets at the time of enrollment. A classic placebo-controlled RCT in a tough crowd? Yes, please. What’s not to like about these guys?

We don’t know a lot yet, with actual numbers to be presented at San Antonio. But to pull the highlights from the press release:

  • Tucatinib + H/Xeloda combo met its primary PFS endpoint, with a 46% reduction in risk of PD or death compared to placebo + H/Xeloda
  • Among secondary endpoints, OS was superior for the tucatinib arm versus placebo + H/Xeloda, with a 34% reduction in risk of death
  • For patients with brain mets at baseline, tucatinib + H/Xeloda offered a 52 percent reduction in the risk of PD or death compared to placebo + H/Xeloda

Not a bad teaser, right? Congrats, Cascadian.