Mohammad Jahanzeb, MD: If we look at consideration of sequential neratinib after dual anti-HER2 antibody treatment with trastuzumab/pertuzumab, the first thing we have to say is that there are no data. The data are only in sequential trastuzumab followed by neratinib, and there are separate data showing superiority of doublet therapy of adding pertuzumab to trastuzumab in the APHINITY trial, only in the high-risk patients. So, if we have a young patient who is very high risk, we have to have an honest conversation with them and say that we don’t have the data, but there’s no reason to believe that we cannot improve their chances further by giving them a year of neratinib, particularly in the hormone receptor—positive subset of patients. So, it’ll be a discussion with the patient about the pros and cons; of course, cost factors into the discussion. And in this day and age, payers are increasingly intervening to tell us what we are allowed to do and not allowed to do.

When it comes to cost, it’s increasingly becoming an important consideration with the rising cost of healthcare being on everybody’s radar, especially if the costs are no longer trivial. All the new drugs are super expensive, and there has been a consolidation of healthcare, with more and more practices merging with each other to form large conglomerates or with hospital centers and academic centers. The concept of the old solo practice of oncology has become a dinosaur. There are still a few people who are solo practitioners, but that’s uncommon.

So, I think when consolidation happens, there are opportunities to have pathways. Increasingly, guidelines are no longer the 50-lane highway that we can use. It’s narrowed down to 2 or 3 lanes by pathways that we are increasingly being asked to use. And then I think there will be formularies, there will be contracts, and there will be contractual discounts. All of those will keep making this shifting sands—type of arena. So, I don’t think that cost enters as much into an individual patient discussion as it perhaps should. And ASCO recommends that it should enter that discussion.

But we increasingly follow the guidelines, and the NCCN has very current guidelines. ASCO just published its guidelines on May 22, not too long ago, so that people can read closely about what ASCO recommends for HER2-positive patients in the adjuvant setting. So, I would recommend an evidence-based, guideline-compliant, pathway-driven approach to treatment.

Transcript Edited for Clarity