Oncologists Discuss Optimizing the Use of Elacestrant in Breast Cancer

Oral selective estrogen receptor degraders (SERDs) have become more popular for use in patients with hormone receptor–positive, HER2-low metastatic breast cancer following progression on prior therapy. During a virtual Case-Based Roundtable event for oncologists in Georgia and Virginia, Claudine Isaacs, MD, professor of medicine and oncology, associate director of Clinical Research, and leader of the Clinical Breast Cancer Program at the Georgetown Lombardi Comprehensive Cancer Center, and the medical director of the Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, discussed the use of elacestrant (Orserdu) in this setting. Participants shared their experience with adverse events (AEs) and management strategies.

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DISCUSSION QUESTIONS

• What have been your experiences with elacestrant?
• How do you manage gastrointestinal toxicity and other AEs?

Claudine Isaacs, MD: What's your experience been in terms of patient tolerability or how they view their tolerance to elacestrant, or if you had other oral SERDs that you've used?

Ghada M. Kunter, MD: I think it's very tolerable. I have not personally seen a lot of AEs. A lot of my patients end up using it for at least a year before they progress, but it's fairly tolerable with no major AEs, maybe gastrointestinal but nothing major. Blood counts stay stable. So overall, I would say it's pretty tolerable.

Rao Moravineni, MD: I agree, it is fairly tolerable. But I guess the issue comes to who are the best patients? Those with bone-only metastases and a long prior, CDK4/6 exposure; for the rest of the patients, I think it's a question mark. To look for other options and then come to decision, as opposed to elacestrant only, what else [checks] the other boxes. But for these 2 boxes clearly, elacestrant [checks] regardless of the mutation. And it is fairly well tolerated.

Isaacs: Although the subgroup analysis suggested that the benefit was very similar if they had visceral disease, so there was benefit regardless of sites of disease with elacestrant.

Moravineni: However, the magnitude is quite different for bone only vs [other sites].

Isaacs: On subset, it was still pretty similar. Lung or liver was 7.3 vs 9.1 months [with bone metastases].¹ It was a pretty similar benefit for this.

Soren Caffey, MD: Do you check the cholesterol profile when you start the elacestrant, and if you do, how frequently do you do that?

Isaacs: I tend to do it fairly frequently, just because then I don't forget. I do it at the beginning, and I do it for a couple of months, and then I do it at the time of scans.

Soren Caffey, MD: I've not seen that much of a worsening in the low-density lipoprotein, but in your patients, you see a lot more than me when it comes to breast cancer. Have you seen something scary in that department?

Isaacs: I haven't seen anything scary, but I have seen them get mildly elevated.

There was a real-world study looking at the median PFS benefit from elacestrant. It showed the median real-world PFS, and it is in similar range to the clinical trial. Are you routinely using prophylactic antiemetics if you're starting patients on elacestrant?

Caffey: I always have it as a backup, personally speaking. It all depends on the patient's threshold as well. I've seen some patients say some nausea is not a big deal. But yes, I routinely prescribe that as a backup, just in case. But whether they use it routinely or not, I want to say a vast majority of them say it was OK. It was a couple hours or a few hours of some mild gastrointestinal symptoms, and they did well, so they never end up taking it. But I just prescribe it automatically when this starts. Zofran is called to the pharmacy as well just in case.

Isaacs: So people aren't using it. You’re giving it to patients but not telling them to take it.

Caffey: That is correct. I do not tell them to routinely take it. Do you do that routinely?

Isaacs: I send it in, but I tell them they can take it if they need it. Most already have it.

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_{DISCLOSURES: Isaacs previously reported consulting role for Arvinas, AstraZeneca, Genentech, Novartis, Pfizer, Gilead Sciences, Merck, and Seattle Genetics, and receiving royalties from Wolters Kluwer (UptoDate), and McGraw-Hill (Goodman and Gillman).}

_References:

_{1. Bardia A, Cortés J, Bidard FC, et al. Elacestrant in ER+, HER2- metastatic breast cancer with esr1-mutated tumors: subgroup analyses from the phase III EMERALD trial by prior duration of endocrine therapy plus CDK4/6 inhibitor and in clinical subgroups. Clin Cancer Res. 2024;30(19):4299-4309. doi:10.1158/1078-0432.CCR-24-1073}