@TumorBoardTues @DrSGraff @CharlesMilrod 1/18 #TumorBoardTuesday #OncTwitter
44 yo👩🏾
Stage 1 triple neg #BreastCancer #TNBC
✂️right lumpectomy
adj ACx4
radiation ☢️
8⃣🗓️months later
New R breast mass, ⬆️fatigue x3 mos
🩻CT many small 🫁 nodules & 4cm liver mass
🔬Breast & Liver ➡️ breast ca ER0% PR0% HER2 1+
Now?
44 yo👩🏾
Stage 1 triple neg #BreastCancer #TNBC
✂️right lumpectomy
adj ACx4
radiation ☢️
8⃣🗓️months later
New R breast mass, ⬆️fatigue x3 mos
🩻CT many small 🫁 nodules & 4cm liver mass
🔬Breast & Liver ➡️ breast ca ER0% PR0% HER2 1+
Now?
@TumorBoardTues @DrSGraff @CharlesMilrod 2/18 #TumorBoardTuesday
Closer look at the biopsies:
🔬Breast: Invasive Ductal Carcinoma w/dense lymphocytic infiltrate, G3, ER 0% PR 0% HER2 1+
🔬Liver: met carcinoma c/w breast primary, ER staining absent
❓What additional testing?
🤨Would it differ with ER+ #BreastCancer?
Closer look at the biopsies:
🔬Breast: Invasive Ductal Carcinoma w/dense lymphocytic infiltrate, G3, ER 0% PR 0% HER2 1+
🔬Liver: met carcinoma c/w breast primary, ER staining absent
❓What additional testing?
🤨Would it differ with ER+ #BreastCancer?
@TumorBoardTues @DrSGraff @CharlesMilrod 3/18 #TumorBoardTuesday #BreastCancer
📌For metastatic #TNBC
📍Germline BRCA1/2 (gBRCApv) and PD-L1 are 🔑 in early decision making📍
🤔What if she were 3L or beyond?
❓What factors–clinical, genomic–impact decisions?
📌For metastatic #TNBC
📍Germline BRCA1/2 (gBRCApv) and PD-L1 are 🔑 in early decision making📍
🤔What if she were 3L or beyond?
❓What factors–clinical, genomic–impact decisions?
@TumorBoardTues @DrSGraff @CharlesMilrod 4/18 #TumorBoardTuesday
👩👩👦 Mini tweetorial 1
📌Role of local therapy in MBC
There are 4️⃣trials shown here:
3⃣:🚫benefit ✂️surgery
1⃣:⬇️QoL with ✂️surgery
🧐 Only favorable study? Required responding ds, unbalanced arms 🤨
📍For us, surgery in MBC = "almost never"
👩👩👦 Mini tweetorial 1
📌Role of local therapy in MBC
There are 4️⃣trials shown here:
3⃣:🚫benefit ✂️surgery
1⃣:⬇️QoL with ✂️surgery
🧐 Only favorable study? Required responding ds, unbalanced arms 🤨
📍For us, surgery in MBC = "almost never"
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur 5/18 #TumorBoardTuesday #BreastCancer
👩👩👦 Mini tweetorial 2
📌Additional testing!
With a new or suspected diagnosis of mTNBC:
2️⃣🔑tests:
🫧PD-L1
🫧germline BRCA status
📍These 2 🧩 are the foundation for the algorithm that’ll build🔨 your road map🗺️ through treatment!📍
👩👩👦 Mini tweetorial 2
📌Additional testing!
With a new or suspected diagnosis of mTNBC:
2️⃣🔑tests:
🫧PD-L1
🫧germline BRCA status
📍These 2 🧩 are the foundation for the algorithm that’ll build🔨 your road map🗺️ through treatment!📍
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein 6/18 #TumorBoardTuesday
👩👩👦 Mini tweetorial 3
We know ✨KEYNOTE-355 @JavierCortesMD @NEJM showed patients with mTNBC got the most bang 💥 with pembrolizumab with CPS≥10 (those others groups are 👎!)
📚nejm.org/doi/full/10.10…
👩👩👦 Mini tweetorial 3
We know ✨KEYNOTE-355 @JavierCortesMD @NEJM showed patients with mTNBC got the most bang 💥 with pembrolizumab with CPS≥10 (those others groups are 👎!)
📚nejm.org/doi/full/10.10…
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab 7/18 #TumorBoardTuesday
👩👩👦 Mini tweetorial 4
But is CPS≥10 the best marker? 🤷♀️
In early-TNBC,🚫 PDL1/CPS should NOT drive decision making!
⚡️All TNBC benefit⚡️
🔮In early TNBC ⬆️ Tumor-infiltrating lymphocytes (TILS) strongly correlate with DFS!
📚ascopubs.org/doi/10.1200/JC…
👩👩👦 Mini tweetorial 4
But is CPS≥10 the best marker? 🤷♀️
In early-TNBC,🚫 PDL1/CPS should NOT drive decision making!
⚡️All TNBC benefit⚡️
🔮In early TNBC ⬆️ Tumor-infiltrating lymphocytes (TILS) strongly correlate with DFS!
📚ascopubs.org/doi/10.1200/JC…
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD 8/18 #TumorBoardTuesday
👩👩👦Mini tweetorial 5
🤔Will PDL1 be🎯for our 👩🏾?
📍PDL1 expressed ~50% of breast ca, esp TNBC & high grade tumors
🤯but 0% normal breast tissue!
💡CPS is critical‼️🟰 PDL1+ tumor cells, lymphs, macrophages ➗tumor cells x100
⬆️immune cells🟰⬆️CPS!
👩👩👦Mini tweetorial 5
🤔Will PDL1 be🎯for our 👩🏾?
📍PDL1 expressed ~50% of breast ca, esp TNBC & high grade tumors
🤯but 0% normal breast tissue!
💡CPS is critical‼️🟰 PDL1+ tumor cells, lymphs, macrophages ➗tumor cells x100
⬆️immune cells🟰⬆️CPS!
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD 9/18 #TumorBoardTuesday
👩👩👦 Mini tweetorial 6
WEALTH OF RICHES!? 💰
What if pt is BOTH gBRCApv & PD-L1?🎯🎯
#TumorBoardTuesday friends, @ArielleMedford @dradityabardia covered this!
Hit the bookmark 🔖tab down there ↘️ & come back to review their🔥lesson:
twitter.com/i/events/15548…
👩👩👦 Mini tweetorial 6
WEALTH OF RICHES!? 💰
What if pt is BOTH gBRCApv & PD-L1?🎯🎯
#TumorBoardTuesday friends, @ArielleMedford @dradityabardia covered this!
Hit the bookmark 🔖tab down there ↘️ & come back to review their🔥lesson:
twitter.com/i/events/15548…
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia 10/18 #TumorBoardTuesday #BCSM
👩👩👦 Mini tweetorial 7
💫Recap💫
MBC: No breast surgery 🚫✂️
mTNBC Step 1 🟰
🧬germline BRCA testing
🔬tumor testing for PD-L1 CPS
Driving first line treatment decision:
🔹Pembro + Chemo
🔹PARP inhibitor
🔹Chemo alone
👩👩👦 Mini tweetorial 7
💫Recap💫
MBC: No breast surgery 🚫✂️
mTNBC Step 1 🟰
🧬germline BRCA testing
🔬tumor testing for PD-L1 CPS
Driving first line treatment decision:
🔹Pembro + Chemo
🔹PARP inhibitor
🔹Chemo alone
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia 11/18 #TumorBoardTuesday
Back to our case🔎
Our 👩🏾patient’s results:
🧪 gBRCA wild-type and PD-L1 CPS≥10
👩🏾started pembrolizumab + chemo & had partial response
🩻After being on treatment for 8 months, disease demonstrated progression☹️
🤔What might we need to know now?❓🔬
Back to our case🔎
Our 👩🏾patient’s results:
🧪 gBRCA wild-type and PD-L1 CPS≥10
👩🏾started pembrolizumab + chemo & had partial response
🩻After being on treatment for 8 months, disease demonstrated progression☹️
🤔What might we need to know now?❓🔬
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia 12/18 #TumorBoardTuesday #BCSM
🌟We are now in the realm of ADCs!
Because our 👩🏾 was:
🧬gBRCA wild type
🔬Her2 1+
🔥#ProTip
👉🏽This is when I would send off genomic profiling if I hadn’t already. Then I have it. If I have a 🦄, I am ready to consider those agents in 3rd Line
🌟We are now in the realm of ADCs!
Because our 👩🏾 was:
🧬gBRCA wild type
🔬Her2 1+
🔥#ProTip
👉🏽This is when I would send off genomic profiling if I hadn’t already. Then I have it. If I have a 🦄, I am ready to consider those agents in 3rd Line
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett 13/18 #TumorBoardTuesday
💉What would you choose?💉
📊What is your plan in 2L treatment after progression on adjuvant, then pembro+chemo 1LmTNBC in gBRCAwt patients?
✍️Tell us in reply
🤔Do all #TNBC need carbo?
🤔How many lines of chemo before ADC?
🤔What's the right ADC seq?
💉What would you choose?💉
📊What is your plan in 2L treatment after progression on adjuvant, then pembro+chemo 1LmTNBC in gBRCAwt patients?
✍️Tell us in reply
🤔Do all #TNBC need carbo?
🤔How many lines of chemo before ADC?
🤔What's the right ADC seq?
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett 14/18 #TumorBoardTuesday #BCSM
👩👩👦 Mini tweetorial 8
Sequence for T-DXd & SG =❓🤷🏻♀️
💥But ADC>ADC can work!
✨TROPION-Breast01
🥔Datopotamab deruxtecan (DatoDXd) a Trop-2 ADC🎯 like SG, incld 30% of pts prev treated w/SG
👉🏻In that subset ORR=52% 📉
📖abstractsonline.com/pp8/#!/10462/p…
👩👩👦 Mini tweetorial 8
Sequence for T-DXd & SG =❓🤷🏻♀️
💥But ADC>ADC can work!
✨TROPION-Breast01
🥔Datopotamab deruxtecan (DatoDXd) a Trop-2 ADC🎯 like SG, incld 30% of pts prev treated w/SG
👉🏻In that subset ORR=52% 📉
📖abstractsonline.com/pp8/#!/10462/p…
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett 15/18 #TumorBoardTuesday #TNBC
👩👩👦 Mini tweetorial 9
✨ASCENT✨
📍ph3 trial of 529 patients w/ mTNBC
💉Sacituzumab Govitecan (SG)
📍~10% had treated 🧠mets
📍3 median prior therapies (up to 16🤯)
📍⬆️PFS 3.9 months
👩👩👦 Mini tweetorial 9
✨ASCENT✨
📍ph3 trial of 529 patients w/ mTNBC
💉Sacituzumab Govitecan (SG)
📍~10% had treated 🧠mets
📍3 median prior therapies (up to 16🤯)
📍⬆️PFS 3.9 months
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett @RICKLIN4TH @ProfWishart @ProfAMThompson @antonyruggeri @Liz_ORiordan @FilipaLynce @rafa_p10 16/18 #TumorBoardTuesday #TNBC
👩👩👦 Mini tweetorial 10
✨DestinyBreast04
📍ph3 trial of 557 pts, ONLY 63 were “TNBC” Her2-low
💉Trastuzumab deruxtecan (TDXd)
📍~5% had treated🧠mets
📍3 median prior therapies (up to 9🤯)
📍⬆️PFS 4.8 mon
📍Ex analysis in TNBC-Her2low⬆️PFS 5.6 mon
👩👩👦 Mini tweetorial 10
✨DestinyBreast04
📍ph3 trial of 557 pts, ONLY 63 were “TNBC” Her2-low
💉Trastuzumab deruxtecan (TDXd)
📍~5% had treated🧠mets
📍3 median prior therapies (up to 9🤯)
📍⬆️PFS 4.8 mon
📍Ex analysis in TNBC-Her2low⬆️PFS 5.6 mon
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett @RICKLIN4TH @ProfWishart @ProfAMThompson @antonyruggeri @Liz_ORiordan @FilipaLynce @rafa_p10 17/18 #TumorBoardTuesday #BreastCancer
Back to our case 🔎
Wrap up review 🔁
👩🏾 & her 👩🏻⚕️ engaged in
🤝#SharedDecision Making🤝
👩🏾+👩🏻⚕️ discussed
Dosing🗓️
Potential side effects
Current symptoms
💰
+more
📬They also sent genomic profile for 🔮 future.
Back to our case 🔎
Wrap up review 🔁
👩🏾 & her 👩🏻⚕️ engaged in
🤝#SharedDecision Making🤝
👩🏾+👩🏻⚕️ discussed
Dosing🗓️
Potential side effects
Current symptoms
💰
+more
📬They also sent genomic profile for 🔮 future.
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett @RICKLIN4TH @ProfWishart @ProfAMThompson @antonyruggeri @Liz_ORiordan @FilipaLynce @rafa_p10 18/18 #TumorBoardTuesday #BreastCancer
Case outcome🥁
Let's say 👩🏾👩🏻⚕️chose how you voted! 🗳️
6️⃣months later👩🏾is going 💪on treatment, disease is responding 🎉
👩🏾attending #SABCS22 @SABCSSanAntonio for first time as a #PatientAdvocate - look forward to seeing you there!
Case outcome🥁
Let's say 👩🏾👩🏻⚕️chose how you voted! 🗳️
6️⃣months later👩🏾is going 💪on treatment, disease is responding 🎉
👩🏾attending #SABCS22 @SABCSSanAntonio for first time as a #PatientAdvocate - look forward to seeing you there!
@TumorBoardTues @DrSGraff @CharlesMilrod @drsadafch @NicoleKuderer @KiranManjee @LuisBlancoJrMD @LurieCancer @NagiSaghir @hmcarthur @DrLauraEsserman @tmprowell @genperisi @RitaNandaMD @drteplinsky @nicholasklemen @ErikaHamilton9 @hoperugo @naborala @DrHBurstein @JavierCortesMD @NEJM @Dr_Ivanoncologo @Nicole_O_W @donnashort @nlinmd @elmayermd @barrosolab @JCO_ASCO @JaniceTNBCmets @MridulaGeorgeMD @ArielleMedford @dradityabardia @ZainabFatima100 @travelingholls @prat_aleix @SorenBentzen @RebeccaDSing @cwilliamszf @ElisaAgostinett @RICKLIN4TH @ProfWishart @ProfAMThompson @antonyruggeri @Liz_ORiordan @FilipaLynce @rafa_p10 #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽#CME Eval🔗integrityce.com/tbtEval
👉🏽ALL🔗integrityce.com/tbt
🤔@DrSGraff @LauraSalamaMD @CharlesMilrod taught us mTNBC tx, test your🧠
🧐What tx for PD-L1+ (CPS =14), local adv TNBC recurrent after ✂️ & adj chemo (ddAC) x 8 mos prev?
👉🏽#CME Eval🔗integrityce.com/tbtEval
👉🏽ALL🔗integrityce.com/tbt
🤔@DrSGraff @LauraSalamaMD @CharlesMilrod taught us mTNBC tx, test your🧠
🧐What tx for PD-L1+ (CPS =14), local adv TNBC recurrent after ✂️ & adj chemo (ddAC) x 8 mos prev?
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