ESMO Breast Cancer Roundtable: Episode 5

— An oncologist's role in managing overall health and risk factors

MedpageToday

At the recent ESMO Congress 2019 in Barcelona, Hope Rugo, MD, Jennifer Litton, MD, and Michelle Melisko, MD, gathered to discuss new and potentially practice-changing data from the meeting on advanced hormone receptor-positive breast cancer.

With ASCO and ESMO recently placing new emphasis on the need to manage cancer patients' overall health and risk factors -- such as obesity, diabetes, physical activity, and stress -- the last of five exclusive MedPage Today episodes asks: what is the oncologist's role in this aspect of patient care?

Episode 1: What role does genomic testing play in HR+ breast cancer?

Episode 2: CDK4/6 inhibitors improve overall survival in advanced breast cancer

Episode 3: How do we sequence therapy in patients who have advanced disease?

Episode 4: Next steps in treatment following progression on a CDK4/6 inhibitor

Following is a transcript of their remarks:

Hope Rugo, MD: We've talked about some really exciting treatments. One area that we haven't talked about yet and is, I think, really important and I know certainly near and dear to both of your hearts is there's a lot of interesting lifestyle modifications and how they help patients with early- and late-stage disease. ASCO and ESMO put a lot of emphasis on this that we really need to manage overall health. A lot of times when people have cancer, they're seeing us. They're not seeing their primary care doctors. Obesity, diabetes, exercise, and of course, stress, to some degree, probably the hardest. Michelle, what do you tell your patients?

Michelle Melisko, MD: I think I have always had an interest in managing endocrinopathies and diabetes having family members with diabetes and trying to make sure I don't get it myself. I feel very comfortable monitoring patients' hemoglobin A1C. Certainly, patients we know the mTOR inhibitors can cause hyperglycemia, so we need to be super diligent about that along with looking at patients' lipids. I personally feel comfortable starting people on metformin and starting people on a statin, but I know other oncologists don't really want to play that role.

I do encourage patients. I sort of, in some ways, bribe them and say, "You need to be really as proactive as you can about your exercise, caloric restriction," not fasting, but caloric restriction to try to maintain weight because they may be excluded from trials in the future if their cholesterol is too high or if their blood sugars are too high. I'm pretty proactive with these lifestyle changes that would hopefully contribute to control of their lipids and their blood sugars and their weight. I always make a plug in early-stage disease for the benefits of physical activity. I think it's harder in the metastatic setting. Certainly, there's so many confounders that I don't think we'll ever even have any sort of retrospective data or observational data that patients that exercise in the metastatic setting are going to live longer. But I think if they exercise, they're going to feel better and that's what I do.

Dr. Rugo: The BWEL trial is certainly addressing that in early-stage disease.

Jennifer Litton, MD: No, I completely agree. I think, though, when we look at all the ways that our metastatic patients are having fatigue and everything and we think we're going to give this drug or this drug or steroids, the thing that it keeps coming down to is regular, moderate exercise. Everyone wants that perfect cancer diet, right? They're all like, "Tell me exactly what foods to eat." I get it because when you're in such... yes, when you're in this totally uncontrollable situation, you want to control some of those things that you can. I don't think there's a perfect cancer diet. I think it's a diet we all know we should do, which is the no processed foods, the lean meats.

I think there's some intriguing data and I'm not in any way endorsing this right now. I'm just saying it's intriguing studying some of this low glycemic index and keto-like diets and how that's changing some of the microbiome especially with immuno. It's all very intriguing. I think I'm all for we're going to put a lot of effort into this side of the treatment that we've put aside for a long time. For my metastatic patients, again, I'm really fortunate to have a very aggressive supportive care group at our institution.

One of the biggest things I think has helped my patients is I will get them involved usually around visit one or two if you have metastatic cancer so it's not down the road. I really feel those patients who have their symptoms under better control during the totality are going to do better during the treatment. If you have a supportive care group, a palliative care group, that is available, the earlier you get them involved I think has been one of the biggest lessons for my career.

Dr. Rugo: I think that's a really, really important point that getting patients involved in symptom management or palliative care program early, but also helping them understand that doesn't mean we're writing them off.

Dr. Litton: Absolutely.

Dr. Rugo: It's really helpful and it can really be a lifeline for many people. Managing glucose and weight is incredibly important, too, particularly as we're using alpelisib more and seeing hyperglycemia and insulin spikes. I think we're all going to have to be able to treat at least some degree of sugar increases and also be able to use prophylaxis for rash with antihistamines for alpelisib, a lot of these different areas where we're sort of incorporating supportive care and management of general health as well. I think the symptom management groups can also help with some of the stress of diagnosis of metastatic disease and the enormous stress of each scan coming up.

Dr. Litton: Absolutely, and it's not their oncologists and it's not their family member. It's another person that can be much more objective and outside of those relationships I think is really helpful.

Dr. Rugo: Which is great, yeah. I think this is a great area and really, really important. I know there's a lot more focus on it, and we all are needing to be able to be involved and think about the non-oncologic issues that plague our patients and contribute to both their outcome quality of life and their tolerance of therapy, so interesting times. Thank you very much.