Role of Multidisciplinary Team in the Management of Patients with HER2+ BC and CNS Metastases

Vijayakrishna Gadi, MD, PhD: I fully appreciate those who are neurooncologists and neuroradiation oncologists, but I can’t play one on TV. When we take care of these patients, it is absolutely critical that we reach out to those colleagues to understand what the best combination of the therapy are. Certainly, if a neuroradiation oncologist, for example, says, “Hey, I think I can get those 3 lesions, otherwise, the CNS [central nervous system] looks really good,” I want to know that. I want to be able to offer that therapy. If they’re looking at it and say, “Hey, this is hard. It’s really got to be systemic therapy or even whole brain radiation,” that’s a different discussion, and we need to pursue therapies more in line with that.

The other thing that’s worth noting is that some patients will not just have central nervous system with visceral metastases in the brain, but they’ll also have what we call leptomeningeal disease. That’s a much more aggressive form or presentation of CNS-based disease. Those patients were excluded on all of these studies we’ve been talking about today. We’ve still got to deeply consult with our neurooncologists and our neuroradiation oncologists about what the best strategy is for those [patients]. It’s not that we might not use these molecules. Certainly, there’s some evidence to try that, but it’s not as well-proven. That is a scenario where we have to have a deeper conversation.

In an ideal situation, when we’re looking at these patients who have CNS metastasis, having the availability of a multidisciplinary conversation is critical. Engage them early before you start doing the treatment because the last thing you want to do is something that compromises their ability to help. Have that conversation very early in the process and then keep visiting with them. Maybe those patients continue to follow-up even if there hasn’t been a treatment to make sure that they’re also tracking the disease. It always strikes me as interesting that when a neurooncologist looks at a brain MRI of a patient with cancer. They’re looking at it a lot more carefully than a regular radiologist. You might get some additional insight by having them continue to follow the patient. Maybe they even give you advice on how the disease is monitored. There’s a lot of value to having them involved.

Of course, that’s a luxury [of] big cities [and] big cancer centers. Having that multidisciplinary option in smaller, more rural places might not be as easy to do. Through the pandemic, we’ve had the ability to get people virtual visits and so forth, and if that’s a possibility, certainly we should be exploring that, but if it’s really not possible to get that insight from a multidisciplinary neuroradiation oncologist or a neurooncologist, then I think we’re stuck having to make our decisions based on the evidence we have from the trials we’ve already done. In that case, especially if patients have CNS metastases, I think the option that makes the most sense [with the] robustness of the data is combinations including tucatinib.

Transcript has been edited for clarity.