Chapter 1: The Evolving Frontline mTNBC Landscape

Watch Chapter 2 here.

Katie Newlin: Hi everyone. My name is Katie Newlin. I'm a nurse practitioner at Washington University in St. Louis, and I'm here today with some of my colleagues, and we are talking about metastatic triple-negative breast cancer and where we are today in the scheme of things.

Sanita Burgic: Good morning. My name is Sanita Burgic, and I'm a nurse practitioner at Washington University in St. Louis as well.

Ashley Martinez: Hi, I'm Ashley Martinez. I'm also a nurse practitioner at UTMD Anderson Cancer Center.

Amanda Brink: And I'm Amanda Brink. I'm a nurse practitioner in Sarah Cannon Research Institute's Drug Development Unit in Denver.

Katie Newlin: Wonderful. Thank you all so much for being here with us today. So we just really wanted to get started and see where we are right now with metastatic triple-negative breast cancer. So, for anyone who hasn't been keeping up with metastatic triple-negative breast cancer over the last year, I just wanted to talk about what the foundation looks like and the new changes that have been happening this past year.

Ashley Martinez: Thanks so much, Katie. So, I think, it's good for us to just start with the unmet need of metastatic triple-negative breast cancer and the burden that currently exists in that field.

So with triple negative breast cancer, we know that it represents approximately 15% of all breast cancers, and it's disproportionately diagnosed in younger women and in African American women, who unfortunately have poor outcomes when you compare them to their white counterparts. Metastatic triple negative breast cancer, we know historically has a very aggressive nature with a median overall survival rate with chemotherapy-based regimens of less than 18 months in the first-line setting. So, really advanced practice providers often serve as the primary person, the primary clinical contact for our triple negative breast cancer patients, which makes their fluency in the current field of triple negative breast cancer and new treatment options so very important.

Sanita Burgic: Yeah. With that being said, we should discuss that the guidelines have shifted recently. So this is what APPs need to know that the National Comprehensive Cancer Network, NCCN Breast Cancer Guideline, now includes an antibody drug conjugate, or ADC, that targets TROP2 as a category preferred one option in the first line metastatic triple negative breast cancer. And critically, this guideline addresses both the PD-L1-positive and PD-L1-negative patient populations, meaning the therapeutic decision-making framework has expanded to the full metastatic triple-negative population, not just the biomarker-selected subset.

Katie Newlin: All right. So, could each of you describe the practice setting that you all work in? So, for instance, I work in an academic setting, but over the past several years, I would say probably the last six years, we have satellite offices in St. Louis that are adjunct to our academic setting. And so we're able to go out into the community and reach every single population without them having to go to a big academic center, while still providing the same care. And so I would say I come from an academic background, and we also utilize a community-based setting. So, are all of you? If you could just share where you are in your practice.

Sanita Burgic: Yeah. In a larger academic center like Washington University's Siteman Cancer Center, I feel that APPs are usually exposed to these guideline updates early on through our tumor boards, national meetings, and pharmaceutical educational events. And I feel like that's a good way to get updates on the new treatments and guidelines.

Ashley Martinez: Yeah, absolutely agree with Sanita. I'm also in an academic-type setting, and APPs are really at the forefront of receiving these updates. And we practice similarly to Katie, with a large academic cancer center, but we also have satellite hospitals throughout the community. But when you compare the APPs that work in the community versus those on our main campus, there really is no difference in how we receive our education and updates. It is very uniform across the cancer center and the community's satellite sites.

Katie Newlin: Amanda, how about you?

Amanda Brink: I'm a little bit of a hybrid between academic and community, I think. We're very academically focused, as we conduct early-phase clinical trials, but we also serve the Denver community and surrounding communities.

Katie Newlin: Okay, great. Great. So it sounds like we all have very similar backgrounds or academic settings in which we practice. But based on your experience, do you think that there is a lag time between the guidelines that come out and then how we interpret them and put them into clinical practice? Do you see lag times? And if you do, what do you think that those lag times are from?

Sanita Burgic: I feel that, even with all this exposure, it sometimes takes months for NCCN guidelines recommendations to become routine in everyday clinic practice. But I feel that with all the exposure and with our big, robust APP group, we're able to share information amongst ourselves and stay up to date.

Ashley Martinez: Absolutely. Completely agree with you, Sanita. A lot of times, APPs and even other practitioners in oncology receive regular email updates from NCCN, ASCO, and other major institutes that set these guidelines. So, while the lag time I feel can be a couple of months, just while everybody updates themselves and maybe even develops a consensus within their practice area, the lag time, maybe a couple of months, but I don't think it's too long.

Sanita Burgic: I don't feel that it affects patient care.

Katie Newlin: Yeah. For sure.

Ashley Martinez: Absolutely.

Amanda Brink: And I think as ADCs become more integrated into oncology practice, overall awareness is definitely increasing.

Katie Newlin: Yeah, definitely. So what does guideline-coordinated care look like in your everyday practice? How would you say?

Sanita Burgic: Yeah. In our practice, I think we do a good job following the routine to get biomarker testing done early and help us choose the most appropriate treatment based on the NCN guidelines.

Ashley Martinez: Yeah, and I think, following guidelines and establishing guideline concordant care starts with staying up to date with this type of information.

Katie Newlin: Yeah. Amanda.

Amanda Brink: And I think one of the main reasons there are delays in adopting new guidelines is just how quickly the TNBC landscape is evolving. Academic centers are closer to clinical trial data, so there's naturally greater comfort with novel agents among providers in this setting. Community rural settings tend to struggle with high patient volumes, limited resources, and fewer subspecialty supports, which can lead to some lag in guideline uptake. But I think that's where APPs play a huge role. We can advocate for more appropriate testing as needed for our patients, broader NGS panels, integration of future treatment options, and notes when we see patients and toxicity management.

Katie Newlin: Yeah. And I know we really haven't been able to talk about rural much since most of us are based in academic and community settings, but I agree. I think it's important, even for rural APPs, nurse practitioners, or providers, to stay up to date by resourcing themselves, networking with others outside their community, attending conferences, completing CEUs, and similar activities.

Sanita Burgic: And I take responsibility for teaching our nurse coordinators and other nurses in our institution, because they may not have the same access to these exposure updates as we do as APPs. So I always try to update my nurse coordinators as well.

Katie Newlin: Yeah. Well, thank you for talking with me and going through some of these important things.