Defining Value for the Treatment of Brain Metastases in Metastatic HER2-Positive Breast Cancer - Episode 4
Sarah Sammons, MD, and Bhavesh Shah, RPh, BCOP, discuss the increase in health care resource utilization associated with brain metastases for HER2-positive mBC.
Sarah Sammons, MD: Health care utilization in patients with breast cancer with brain metastases is increased compared with those who do not have brain metastases. We have a few studies looking at this that have shown that patients with brain metastases are more likely to have hospitalization and ICU [intensive care unit]–level health care stays toward the end of life. A few studies have also shown that early interventions with palliative care services and hospice can potentially help mitigate some of these effects. Patients with HER2 [human epidermal growth factor receptor 2]–positive brain metastases have a higher need: They need more physician visits, and they have more symptoms that may affect their quality of life. All of that needs to be thought about carefully in their treatment.
Bhavesh Shah, RPh, BCOP: Talking about HER2-positive metastatic breast cancer with brain metastasis, we know it’s the second most common brain metastasis that we see in practice next to non–small cell lung cancer. The difference between breast cancer brain metastasis for HER2-positive patients is that about 60% of patients will die from it. If we then look at the odds of developing CNS [central nervous system] metastasis, patients who are Hispanic, Black, or Latino and older patients are much higher odds of CNS disease in metastatic breast cancer or HER2-positive disease, so it is definitely an aggressive disease. We’ll talk about some of the agents that are promising and up and coming in this disease state.
The other thing is this: Compared with the first prominent malignancy that presents with brain metastasis, which is non–small cell lung cancer, the difference between brain metastasis of non–small cell lung cancer and breast cancer is that you have a more prominent number of brain lesions. You also have larger brain lesions, which means that you have patients who present with seizures and leptomeningeal disease. It’s definitely a more aggressive brain metastasis compared with what you see in non–small cell lung cancer.
For what the symptomatic burden from the brain metastases can be, the seizures are 1 of the biggest aspects, and some patients may require a long-term seizure prophylaxis. Then you have steroids. You have increasing intracranial pressure that could also affect patients’ quality of life. These patients are at substantial risk for VTE [venous thromboembolism]. They would be on anticoagulation, and you’re then thinking about the reverse of what happens to these patients in a setting of being anticoagulated and having brain metastases. There is definitely a competing risk that the patient has with having VTE, being anticoagulated, and having some CNS symptoms and brain metastases.
When then happens, the long-term effect is that there’s going to be neurocognitive decline. You have patients with difficulty in articulating words and changes in speech patterns. There is a lot of quality-of-life impact that they have. For many patients, in regard to health care utilization, we know it’s double the amount for a patient vs a patient who doesn’t have brain metastases and has breast cancer. There’s significant ICU utilization and hospitalization. As I had mentioned, there’s a health care disparity of who is affected. You have patients who are African American or Latino and older patients. You could imagine that there is even more utilization of health care resources in those patient populations because of it being affected more in that specific patient population.