The evolving landscape of breast cancer care

The evolving landscape of breast cancer care: 10 observations across 2 regions

As The Creative Engagement Group supports Breast Cancer Awareness Month, our Axiom teams across North America and the United Kingdom have provided their perspectives on the evolving landscape of breast cancer care.

Read on, as our tale of two regions reveals ten observations from both sides of the pond…

The US Story: Scientific Leaps and Equity Struggles

 

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The astonishing rate of progress

The continuing pace of growth and change in the breast cancer treatment landscape continues to be extraordinary. Each major oncology congress this year has brought the announcement of paradigm-shifting clinical trial results:

  • EMERALD (1), presented at the Miami Breast Cancer Conference in March, reported the clinical benefit of oral selective estrogen receptor degrader (elacestrant) in patients with ER+/HER2– metastatic breast cancer who had previously received CDK4/6 inhibitors
  • DESTINY-Breast04 (2), presented at the American Society of Clinical Oncology (ASCO) Annual Meeting in June, reported the clinically meaningful benefit of Enhertu® for patients with HER2-low metastatic breast cancer
  • TROPiCS-02 (3), presented at the European Society for Medical Oncology (ESMO) Congress in September, reported an overall survival benefit in heavily pretreated patients with HR+/HER2– metastatic breast cancer treated with Trodelvy®


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Early access is becoming more common

While approvals usually occur after successful phase III studies, they may occur earlier when there are very few treatment options, sometimes described as “high medical need.” These decisions can be influenced by urgency. Some of the data releases above were swiftly followed by regulatory decisions from the United States Food and Drug Administration authorizing use of the treatments based on the clinical trial results presented, while others still await regulatory decisions. 

 

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Precision treatment is gaining traction

These examples highlight how as the treatment landscape for breast cancer evolves, clinical trials are investigating more niche patient populations, defined by narrow biomarker requirements and/or specific prior treatment history. In a marketplace offering relatively abundant choice for certain patients, the dominant conversation is that clinicians are able to find the right drug for the right patient at the right time, knowing many patients will progress through several therapies during the course of their disease. While for other cancers this is not yet an option, in breast cancer the conversations are fervently increasing. 

 

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Health inequity is an ongoing challenge

With the potential for such highly individualized care to ensure the best possible outcome for each patient, pharmaceutical companies have an increased responsibility to foster equity in access to the latest therapeutic innovations for all patients. Health inequity – where there are differences in health status or in the distribution of health resources – is a pervasive problem in the United States and around the world. Access to treatment can also vary based on socioeconomic status and healthcare professionals' perception of race. The treatment of breast cancer is no exception.

In the United States, Medicare traditionally has not been able to negotiate prices for cancer medications, meaning that the pricing has been driven by pharmaceutical companies. However, change is coming with the introduction of the Inflation Reduction Act. In addition to this, the health insurance structure in the United States means that many people are not able to afford the care they need. It is important to remember that the high cost of novel treatments could lead to widening disparities in access to treatment – if efforts are not made to close the gap.

While achieving health equity will require dedication from both public and private sectors, ensuring fair access to novel treatments begins with education, and this is where the pharmaceutical industry can influence positive change. The COVID-19 pandemic forced the pharmaceutical industry to evaluate its playbook for physician interactions and consider how to adapt in the “new normal.”

 

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Digital engagement is starting to shine

Physician priorities, preferences for interaction types, and institutional accessibility have all shifted, yet the need for physician education remains. In the United States, these shifts have resulted in a hybrid approach to physician-representative interactions with an increased role for digital solutions and virtual meetings. It has also meant being more personalized and intentional with information shared, as meetings may be shorter and/or less frequent than in the pre-COVID-19 era. In a complex and rapidly changing treatment landscape like breast cancer, agility is essential for physicians. The pharmaceutical industry has a continuing role in providing physicians with tools and knowledge to get the right treatment to the right patient, at the right time.

 

The UK Story: Fast Changes and Past Learnings

 

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Fast track approvals make a huge impact

In recent years, biomarker testing has facilitated big steps forward in the global treatment of breast cancer which has enabled treatments developed by pharmaceutical companies to become more targeted. In the United Kingdom, this has led to approval this year of alpelisib, which in June became the 100th cancer drug fast-tracked to patients under the NHS Cancer Drugs Fund (CDF). The availability of alpelisib, used in combination with hormone therapy, is anticipated to benefit up to 3,000 people in the United Kingdom per year (4).

 

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There is hope even in advanced disease

The National Institute for Health and Care Excellence (NICE) has a technological appraisal process designed to provide recommendations on the use of new and existing medicines, products and treatments within the NHS. Since April 2017, there has been a directive in place whereby the NHS must pay for drugs and other treatments recommended by NICE in its technological appraisal programme. In 2022 alone, technological appraisals have seen more drugs than ever before become available to those living with breast cancer, positively impacting treatment options, especially for those with metastatic or recurrent breast cancer. Along with alpelisib, we have also seen new or updated appraisals on (5): 

  • Sacituzumab govitecan for treating unresectable, triple-negative, locally advanced or metastatic breast cancer in adults after two or more systemic therapies, at least one of which was for advanced disease
  • Abemaciclib with endocrine therapy for adjuvant treatment of hormone receptor-positive, HER2-negative, node-positive early breast cancer at high risk of recurrence in adults
  • Pembrolizumab plus chemotherapy for untreated, triple-negative, locally recurrent unresectable or metastatic breast cancer
  • Tucatinib with trastuzumab and capecitabine for treating HER2+ advanced breast cancer after two or more anti-HER2 therapies
 

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COVID still casts a long shadow

Despite these huge strides in the availability of more targeted treatments, the past few years have been clouded by the impact of the COVID-19 pandemic on cancer services across the United Kingdom. Breast cancer screenings were paused during the pandemic, and there are estimations that close to 1.5 million people had their screenings delayed by around 2–7 months between July 2020 and June 2021 (6). This means people who would have been screened and diagnosed with early stage cancer may now be presenting with later stage cancer, which is harder to treat and anticipated to impact on cancer services and the healthcare system as a whole over the coming years. 

 

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NPOs and COVID learnings push progress

Despite recent challenges, charities such as Macmillan Cancer Support continue to champion those living with cancer in the United Kingdom. In the wake of the pandemic, Macmillan launched a campaign to make sure that cancer didn’t become #theforgottenC (7), and along with other charities are advocating to fight health inequalities in breast cancer care and treatment access across the UK. Breast Cancer Now (8) have also funded new research this year, with researchers in the UK looking at lessons learnt from COVID-19 vaccines. Scientists will be using mRNA – a molecule that provides temporary instructions for protein creation in cells – to target breast cancer cells with high levels of p5310. This is similar to the approach taken by scientists from Moderna and Pfizer, where mRNA was used in the development of their COVID-19 vaccines.

 

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Patient advocacy is a growing priority for pharma

While the pandemic has been a disruption to cancer screening and care, it has also enabled pharmaceutical companies to reconsider their approach across the sector. In the United Kingdom, we have seen more collaboration between pharmaceutical companies, people living with cancer, and patient advocacy groups, with pharma taking the time to really understand the unmet needs of those living with breast cancer as well as the impacts of treatment. Sanofi’s Future of Advocacy Partnerships (9) report is an example of setting a vision for advocacy now and in the future. This is especially valuable at a time when – due to more screening, earlier detection and targeted treatments – breast cancer is pivoting from a terminal disease to one that physicians are beginning to manage as a chronic condition.

 

References

  1. Bardia A, et al. Cancer Res 2022;82(Suppl 4):GS2–02
  2. Modi S, et al. J Clin Oncol 2022;40(Suppl 17):LBA3–LBA3
  3.  Rugo HS, et al. Ann Oncol 2022;33(Suppl 7):S808–S869 (Abstr LBA76)
  4. NHS England. Thousands of patients to benefit as NHS marks 100th fast-tracked cancer drug. Available at: https://www.england.nhs.uk/2022/07/thousands-of-patients-to-benefit-as-nhs-marks-100th-fast-tracked-cancer-drug/. Last accessed 30 September 2022
  5. National Institute for Health and Care Excellence. Technological appraisals breast cancer. Available at: https://www.nice.org.uk/guidance/conditions-and-diseases/cancer/breast-cancer/products?GuidanceProgramme=TA. Last accessed 30 September 2022
  6. Duffy SW, et al. Br J Cancer 2022;126:1355–1361
  7. Macmillan Cancer Support. Stop cancer becoming the forgotten ‘C’. Available at: https://www.macmillan.org.uk/get-involved/campaigns/the-forgotten-c. Last accessed 30 September 2022
  8. Breast Cancer Now. Breast Cancer Now funds search for new treatments inspired by COVID-19 vaccine innovation. Available at: https://breastcancernow.org/about-us/media/press-releases/breast-cancer-now-funds-search-new-treatments-inspired-covid-19-vaccine-innovation. Last accessed 30 September 2022
  9. Sanofi. Future of Advocacy Partnerships. Available at: https://www.sanofi.co.uk/dam/jcr:17a0e42f-a4e6-45c2-9748-ba95aaa10f16/Sanofi-Future-of-Advocacy-Partnerships.pdf. Last accessed 30 September 2022

 

 

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