Clinical Conversations Between an Oncology Nurse and Oncology Pharmacist During the Treatment of Patients With : A Focus on Oral Chemotherapeutic Formulations

© 2020. All rights reserved. No part of this report may be reproduced or distributed without the expressed written permission of PTCE. Faculty Information Chair Danielle Roman, PharmD, BCOP Manager, Clinical Pharmacy Services Allegheny Health Network Pittsburgh, Pennsylvania

Allison Butts, PharmD, BCOP Kandra Horne, DNP, APRN, WHNP-BC Clinical Coordinator, Oncology Pharmacy Women’s Health Care Nurse Practitioner UK HealthCare Breast and GYN Oncology: Medical Oncology Assistant Adjunct Professor Winship Cancer Institute: Emory Healthcare UK College of Pharmacy Atlanta, Georgia Lexington, Kentucky This activity is supported by an educational grant from Athenex. Educational Objectives

At the completion of this activity, participants will be able to: • Distinguish optimized treatment approaches for breast cancer based on disease- and patient-specific factors and potential places in therapy for oral formulations • Analyze the results of recent clinical trials with recently approved and emerging treatment options to inform the appropriate management of adverse effects and adherence for patients with breast cancer • Examine the benefits of multidisciplinary care across multiple practice environments for patients with breast cancer to optimize patient outcomes Evolving Oral Chemotherapeutic Opportunities in Breast Cancer Care Danielle Roman, PharmD, BCOP Manager, Clinical Pharmacy Services Allegheny Health Network Pittsburgh, Pennsylvania Pharmacologic Therapy for Breast Cancer

Hormonal Therapies Other Targeted Therapies CDK 4/6 inhibitors Tamoxifen mTOR inhibitors Aromatase inhibitors (AIs) PD-1/PD-L1 inhibitors Fulvestrant PARP inhibitors LHRH agonists PI3K inhibitor

HER2-Targeted Therapies Trastuzumab Pertuzumab Ado-trastuzumab emtansine Cytotoxic Fam-trastuzumab deruxtecan Neratinib Lapatinib

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer V.3.2020 © National Comprehensive Cancer Network, Inc 2020. Accessed 3/23/20. Chemotherapy for Metastatic Breast Cancer (MBC)

NCCN-preferred regimens Select NCCN “other recommended regimens” Other agents /liposomal doxorubicin Albumin-bound paclitaxel Doxorubicin/cyclophosphamide (AC) or Epirubicin/cyclophosphamide (EC) Cyclophosphamide// 5- (CMF) Green = commercially available oral agent Docetaxel/capecitabine Blue = oral agent in development

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer V.3.2020. © National Comprehensive Cancer Network, Inc. 2020. Accessed 3/23/20. Advantages of Oral Route of Administration

• Patient convenience • Home treatment • Minimize clinic/infusion visits • Removes the need for IV access and related complications (eg, infections) • Eliminates the risk of infusion-related hypersensitivity reactions related to formulation (eg, polyethoxylated castor oil [Cremophor]) • Removes need for hypersensitivity premedications (eg, corticosteroids)

Dai MS, et al. J Clin Oncol. 2019;37:no.15_suppl_abstr 1084. Ciruelos EM, et al. Eur J Cancer Care. 2019;28:e13164. Changes in Roles and Responsibilities

• Patient and/or caregiver • Health care providers • Must initiate therapy at the correct time • Establish a mechanism to track patients of day and at the correct dose on oral chemotherapy • Need to alert health care provider of • Longitudinal monitoring for AEs adverse effects (AEs) in a timely manner • Ensuring appropriate follow-up and labs • Increased responsibility for adherence throughout the course of treatment • May need to facilitate acquisition through a specialty pharmacy • Monitoring adherence with the regimen • Identify potential barriers to oral therapy (such as cost and access to medications) Select Oral Cytotoxic Agents in Breast Cancer

Capecitabine Cyclophosphamide Vinorelbine Dosing BID on days 1–14 every 21 Daily on days 1–21 or days 1–14 Daily once weekly days every 28 days Administration - Swallow whole -Swallow whole Prophylactic antiemetic - Take with water and -Prophylactic antiemetic for doses within 30 minutes after a ≥100 mg/m2/day meal -Increase oral hydration -Morning administration preferred Place in Monotherapy (adjuvant; Monotherapy (metastatic) Not in current guidelines therapy metastatic) Combination (neoadjuvant, Monotherapy (metastatic) Combination (metastatic) adjuvant, or metastatic) Combination (metastatic) FDA approved Yes Yes No for breast cancer?

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer V.3.2020. © National Comprehensive Cancer Network, Inc. 2020. Accessed 3/23/20; Capecitabine. Lexicomp. Wolters Kluwer, Inc. Accessed 3/23/20. online.lexi.com; Cyclophosphamide. Lexicomp. Wolters Kluwer, Inc. Accessed 3/23/20. online.lexi.com; Steger GG, et al. Clin Breast Cancer. 2018;18:e41-e47; Aapro M, Finek J. Cancer Treat Rev. 2012;38:120-126. Oral Etoposide in MBC

• Retrospective review of 110 patients with previously treated MBC • Median number of previous chemotherapy lines = 5 • Received oral etoposide 50 mg/day x 20 days in 28-day cycles • Results Response or Median stable disease duration on Median survival Tumor response = 6.4% lasting >6 therapy = 4 = 10.6 months months: 18.2% months

• Well-tolerated with only 2 patients discontinuing treatment due to toxicity

Giannone G, et al. Breast. 2018;38:160-164. Barriers to the Development of Oral Chemotherapy Formulations • Active excretion of drug by efflux transporters • P-glycoprotein (P-gp) in the intestinal cells • Breast cancer-resistant protein (BCRP) • Limited aqueous solubility • Acid hydrolysis in the stomach • Susceptibility to cytochrome P450 • Poor permeability across the gastrointestinal (GI) tract

Mazzaferro S, et al. Drug Discovery Today. 2013;18:25-34. Mazzaferro S, et al. Drug Discovery Today. 2013;18:93-98. Mazzaferro S, et al. Drug Discovery Today. 2013;18:99-104. Circumventing the Barriers

• Drug delivery systems • Addition of micelles, liposomes, micro- and nanocapsules, dendrimers, emulsions, microemulsions, nano-emulsions, and cyclodextrins • Use of mucoadhesive drug delivery system • Coadministration with CYP450 inhibitors • Coadministration with P-gp inhibitors • Prodrugs

Mazzaferro S, et al. Drug Discovery Today. 2013;18:25-34. Mazzaferro S, et al. Drug Discovery Today. 2013;18:93-98. Mazzaferro S, et al. Drug Discovery Today. 2013;18:99-104. P-gp Inhibitors

• Enable the oral absorption of anticancer drugs that are substrates of P-gp • Ideal agent has minimal oral absorption, which allows for localized activity in the GI tract • Examples of first-generation inhibitors include verapamil, cyclosporine A, ketoconazole, and erythromycin • Encequidar (HM30181A) is being studied in ongoing clinical trials with several chemotherapy agents Phase 1 Preparing for phase 2 Phase 3

• Eribulin • Docetaxel • Paclitaxel • Topotecan •

Mazzaferro S, et al. Drug Discovery Today. 2013;18:99-104. Orascovery platform. Accessed 3/21/20. athenex.com/pipeline/orascovery-platform Prodrugs

• Inactive compounds that are converted in vivo to active cytotoxic compounds • Benefits of the prodrug design • Improve solubility and chemical stability • Increase oral or local absorption and brain permeability • Modify presystemic metabolism • Reduce toxicity • Capecitabine is a third-generation fluoropyrimidine • Rapidly and almost completely absorbed from the intestine • Converted into fluorouracil in a 3-stage mechanism • Higher levels of fluorouracil produced in tumors with minimal exposure of healthy tissue

Mazzaferro S, et al. Drug Discovery Today. 2013;18:93-98. Delahousse J, et al. Cancer Chemother Pharmacol. 2019;84:937-958. Questions for Panel Discussion

• In your experience, what is the patient’s perspective on the use of oral chemotherapy compared with IV agents? • What is the biggest challenge that you have faced with the increasing use of oral chemotherapy in patients with breast cancer? • Historically, novel oral formulations of cytotoxic agents have not played a big role in the treatment of breast cancer. Why do you think we aren’t seeing more of these agents used in practice? Evolving Treatment Options in Breast Cancer: Optimizing Outcomes in the Clinic

Allison Butts, PharmD, BCOP Clinical Coordinator, Oncology Pharmacy UK HealthCare Assistant Adjunct Professor UK College of Pharmacy Lexington, Kentucky Commonly Used Oral Agents in Breast Cancer

ER/PR+ HER2+ ER/PR/HER2-

CDK4/6 inhibitors Capecitabine^ PI3K inhibitor Tyrosine kinase inhibitors mTOR inhibitor PARP inhibitors* PARP inhibitors*

*BRCA mutation. ^Can also be used in ER/PR+ or HER2+ disease. Identifying Patients Likely to Achieve Clinical Benefit • Extent and site of disease • Pathology and targetable mutations • Comorbidities • Performance status • Response to prior treatments • Tolerability of prior treatments • Demonstrated adherence Anticipated Benefit Based on Site of Disease Example: Tucatinib

Total population (+) Brain metastases N = 320 N = 148 TUCATINIB PLACEBO TUCATINIB PLACEBO 1-year PFS 33.1% 12.3% 24.9% 0% Median PFS 7.8 months 5.6 months 7.6 months 5.4 months Median OS 21.9 months 17.4 months • Bottom Line • Tucatinib was FDA approved in 2020 for patients with unresectable or metastatic HER2+ breast cancer, including brain metastases, who have received ≥1 prior anti-HER2 regimen in the metastatic setting • Its efficacy in patients with brain metastases in particular may impact its place in therapy

HER2CLIMB: trastuzumab + capecitabine ± tucatinib

Murthy RK, et al. N Engl J Med. 2020;382(7):597-609. Tucatinib Safety and Monitoring Monitoring parameter Frequency • Most common AEs AST/ALT/Tbili Every 3 weeks during treatment • Diarrhea Adverse effect Management • Hand-foot syndrome Diarrhea Antidiarrheals prn • Nausea/vomiting HOLD for grade 3 and ↓ dose • Stomatitis Hepatotoxicity HOLD for grade 2 bilirubin • AST/ALT elevations HOLD for grade 3 LFTs and ↓ dose • Discontinuation rate: 5.7%

LFT, liver function test.

Murthy RK, et al. N Engl J Med. 2020;382(7):597-609. Tukysa. Prescribing information. Seattle Genetics. 2020. Anticipated Benefit Based on Pathology Example: Neratinib

Neratinib (N = 1420) Placebo (N = 1420) Total population HR+ HR- Total population HR+ HR- 2-year IDFS 93.9% 95.4% 92% 91.6% 91.2% 92.2% 2-year DDFS 95.1% 93.7%

• Bottom Line • Neratinib was approved in 2017 for the extended adjuvant treatment of patients with early-stage HER2+ breast cancer, following adjuvant trastuzumab-based therapy • Its limited efficacy in patients with HR-/HER2+ breast cancer may limit its use in that population

ExteNET: neratinib vs placebo IDFS, invasive disease-free survival; DDFS, distant disease-free survival. Chan A, et al. Lancet Oncol. 2016;17(3):367-377. Neratinib in the Metastatic Setting

NERATINIB + capecitabine LAPATINIB + capecitabine N = 307 N = 314 1-year PFS 28.8% 14.8% Mean PFS 8.8 months 6.6 months 1-year OS 72.5% 66.7% Mean OS 24.0 months 22.2 months • Bottom Line • Neratinib was approved in 2020 for patients with advanced or metastatic HER2+ breast cancer who received ≥2 prior anti-HER2–based regimens in the metastatic setting • This trial showed a significant reduction in risk of progression or death in patients with HR-/HER2+ breast cancer (HR, 0.42), in contrast to the ExteNET results NALA: neratinib + capecitabine vs lapatinib + capecitabine

Saura C, et al. 2019 ASCO oral abstract #1002. Neratinib Safety and Monitoring

• Most common AEs Monitoring parameter Frequency • Diarrhea Liver function tests Q1 month for the first 3 • Nausea/vomiting months, then Q3 months • Abdominal pain AE Management • Rash Diarrhea Increase antidiarrheal regimen • Anorexia Diet modification Increase fluids • Discontinuation rate: 11%-17% May dose-reduce depending on • Antidiarrheal prophylaxis with duration loperamide is recommended during the Hepato- HOLD for grade 3 then ↓ dose first 2 cycles toxicity

Chan A, et al. Lancet Oncol. 2016;17(3):367-377. Nerlynx. Prescribing information. Puma Biotechnologi, Inc. 2020. Anticipated Benefit Based on Comorbidities Example:

PIK3CA-mutated PIK3CA-wt Fulvestrant + Fulvestrant + Fulvestrant + Fulvestrant + ALPELISIB PLACEBO ALPELISIB PLACEBO (N = 169) (N = 172) (N = 115) (N = 116) Median PFS 11.0 months 5.7 months 7.4 months 5.6 months ORR 26.6% 12.8% Dose interruptions 74.0% 32.2% Grade 3 32.7% 0.3% Hyperglycemia • Bottom Line • Alpelisib was approved in 2019 for patients with HR+/HER2-, PIK3CA-mutated advanced or metastatic breast cancer following progression on an endocrine-based regimen • Patients with type 1 diabetes and uncontrolled type 2 diabetes were excluded from the trial

SOLAR-1: fulvestrant ± alpelisib Andre F, et al. N Engl J Med. 2019;380(20):1929-1940. Alpelisib Safety and Monitoring • Most common AEs Monitoring Frequency • Hyperglycemia parameter • Diarrhea Fasting plasma Q1 week x 2 weeks, then • Nausea/vomiting glucose (FPG) Q4 weeks • Anorexia A1C Q3 months • Rash AE Management • Weight loss Diarrhea HOLD for grade 2-4 • Stomatitis ↓ dose for G3-4 • Fatigue • Asthenia Rash Topical corticosteroids Oral antihistamines • Alopecia Systemic corticosteroids • Discontinuation rate: 6.3% HOLD for grade 3

Andre F, et al. N Engl J Med. 2019;380(20):1929-1940. Piqray. Prescribing information. Novartis; 2019. Alpelisib Safety and Monitoring

Blood glucose value Initial management Subsequent management Grade 1 Initiate or intensify antihyerglycemic None FPG > ULN-160 mg/dL Grade 2 Initiate or further intensify If not reduced to grade 1 within 21 days, reduce FPG >160-250 mg/dL antihyperglycemic alpelisib dose Grade 3 - Interrupt alpelisib - If FPG decreases to grade 1 within 3-5 days, reduce FPG >250-500 mg/dL - Initiate or further intensify alpelisib dose antihyperglycemic - If FPG does not decrease to grade 1 within 3-5 days, - Administer IV hydration and consider consult a specialist for further glucose management additional treatment - If FPG does not decrease to grade 1 within 21 days, permanently discontinue Grade 4 - If FPG ≤500 in 1 day, follow grade 3 FPG >500 mg/dL recommendations - If FPG remains >500 in 1 day, permanently d/c

Piqray. Prescribing information. Novartis; 2019. Oral Drugs in the Pipeline:

Taxane Formulation Half-life (hours) Major toxicity Paclitaxel (DHP107) Oral 15.3 Diarrhea, neutropenia Tesetaxel Oral 167 Leukopenia, GI Docetaxel (ModraDoc001) Oral Not reported Diarrhea, fatigue, dehydration IV and oral 6.9 Leukopenia, GI Milataxel IV and oral 178 Leukopenia BMS-275183 Oral 26 Peripheral neuropathy, leukopenia

Flores JP, Saif MW. Clin Investig. 2013;3(4):333-341. Phase 1: Oral Paclitaxel + P-gp Inhibitor

Pharmacokinetics (PK) Multicenter, single-arm, assessed at weeks 1 and 4 open-label HM30181A (encequidar) 15 mg PO N = 28 patients Paclitaxel 205 mg/m2 PO (oraxol) • MBC Given 3 consecutive days weekly for • 26 patients received up to 16 weeks multiple previous chemotherapy regimens Tumor response measured at weeks 8 and 16 • Achieved paclitaxel exposure similar to that of weekly IV paclitaxel 80 mg/m2, with lower peak exposure • 26 evaluable patients • 42.3% partial response • 46.2% stable disease • 3 patients experienced treatment-related AEs (grade ≥3 neutropenia)

Dai MS, et al. J Clin Oncol. 2019;37(suppl 15):abstr 1084. Phase 3: Oral vs IV Paclitaxel 2:1 N = 265 Open-label R OPE: N = 360 A Paclitaxel 205 mg/m2 PO x 3 consecutive days every week x 3 • MBC • ECOG 0-1 N weeks (each capsule = 30 mg solubilized paclitaxel) • CNS mets D Encequidar 15 mg PO prior to each dose of paclitaxel were O 6 cycles excluded • Allowed M prior I N = 137 2 if Z Paclitaxel 175 mg /m IV every x 3 weeks >1 year 6 cycles prior E

• OPE regimen: fast for 4 hours before taking encequidar followed 1 hour later by paclitaxel (≈11 capsules) followed by 4 hours of fasting • Primary end points: response rate by week 19 and safety and tolerability • Secondary end points: PFS and OS Umanzor G, et al. San Antonio Breast Cancer Symposium 2019. Abstract G26-01. Accessed 4/20/20. ECOG, Eastern Cooperative www.abstractsonline.com/pp8/#!/7946/presentation/2050; Oncology Group. DePolo J. Accessed 3/23/20. breastcancer.org/research-news/oral-vs-iv-paclitaxel-for-mbc Results: Oral vs IV Paclitaxel

Efficacy end points OPE (N = 235 ) IV paclitaxel (N = 125 ) Response rate 40.4% 25.6% P = 0.005 PFS 9.3 months 8.3 months P = 0.077 OS 27.9 months 16.9 months P = 0.035 Safety end points OPE (N = 264) IV paclitaxel (N = 135) Neuropathy (grade ≥2) 7.6% 31.1% -- Alopecia (grade 2) 28.8% 48.1% -- Neutropenia (grade ≥3) 29.9% 28.1% -- • Bottom Line • Oral paclitaxel may be a promising alternative to the IV formulation in terms of both efficacy and tolerability for patients with breast cancer • Adherence and patient acceptance are concerns based on complicated administration Umanzor G, et al. San Antonio Breast Cancer Symposium 2019. Abstract G26-01. Accessed 4/20/20. www.abstractsonline.com/pp8/#!/7946/presentation/2050 Phase 2: Oral Tesetaxel Primary end point: ORR Tesetaxel 27 mg/m2 day Single-arm, open-label Every 3 weeks N = 38 patients • HR+/HER2- MBC Escalation to 35 mg/m2 in • ECOG 0-1 subsequent cycles based on • Prior taxane allowed Secondary end points: tolerability PFS • ORR: 45% Disease control rate • 44% in patients who did not have prior taxane exposure • 45% in patients who received prior taxane • Median PFS: 5.4 months • Median duration of response: 10.9 months • Most common AE: neutropenia (grade 3 or 4 in 13%)

Seidman AD, et al. J Clin Oncol. 2018; 36 (suppl); abstr 10442. Phase 3: Oral Tesetaxel 1:1 Tesetaxel 27 mg/m2 D1 R Capecitabine 1650 mg/m2 D1-14 A Every 3 weeks N N = 600 patients D • HR+/HER2- O • Prior (neo)adjuvant M taxane Capecitabine 2500 mg/m2 D1-14 • Patients with CNS mets I Every 3 weeks included Z E

• Enrollment began in December 2017 (enrollment closed for CONTESSA) • Primary end point: PFS • Secondary end points: OS, ORR, and disease control rate • CONTESSA 2 and CONTESSA TRIO are open to enrollment CONTESSA: Tesetaxel + capecitabine vs capecitabine O’Shaughnessy J, et al. J Clin Oncol. 2019;37(suppl; abstr TPS1107). Select Oral Drugs in the Pipeline for Breast Cancer Drug class Agents VEGF Inhibitors Apatinib Sorafenib Lucatinib HDAC Inhibitors mTOR Inhibitors Ridaforolimus/deforolimus Anti- Vinorelbine Anti-progesterone Telapristone PI3K Inhibitor Pictilisib Buparlisib Others PMD-026 Reparixin Mesupron Clinicaltrials.gov. Accessed May 1, 2020. Questions for Panel Discussion

• Assuming FDA approval, how do you foresee the role for oral paclitaxel evolving in the treatment of metastatic breast cancer? • What do you think will be the greatest challenges with the use of this agent? • Does your practice start antidiabetic medications prior to alpelisib initiation? • How often do you follow up with these patients? • Where does tucatinib fall in your treatment algorithm for HER2- positive metastatic breast cancer? Taking a Multidisciplinary Proactive Approach to Treatment-Related Adverse Effects and Adherence: What to Expect Kandra Horne, DNP, APRN, WHNP-BC Women’s Health Care Nurse Practitioner Breast and GYN Oncology: Medical Oncology Winship Cancer Institute: Emory Healthcare Multidisciplinary Proactive Approach to Treatment

• Center of breast cancer care Physician • Cancer care is complex • Holistic view Nurse practitioner Patient navigator Patient • Optimize patient outcomes

Nurse Pharmacist Social worker

Denton E, Conron M. J Multidiscip Healthc. 2016;9:137-144; Kane HL, et al. CA Cancer J Clin. 2014;64:377-388; Fecher LA, et al. Oncologist. 2013;18:733-743. Multidisciplinary Management of Patients with Breast Cancer

ONCOLOGY NURSES AND ONCOLOGY PHARMACISTS

VITAL ROLES TO ENHANCE COLLABORATION AMONG ONCOLOGY TEAM MEMBERS

PARTICIPATE IN AND DEVELOP EDUCATIONAL ACTIVITIES

PROMOTE THE SAFE USE OF MEDICATIONS Best Practices for Implementing Oral Oncolytic Therapy

• Establish the critical role of oral chemotherapy agents • Review drug and food interactions in disease management • Address common adverse effects and • Set clear expectations of duration and goals of the strategies to manage treatment • Communicate important storage and • Empower the patient to own their care delivery handling requirements • Discuss the consequences of nonadherence and • Requires a multidisciplinary approach methods to enhance adherence • Automated reminders • Pillboxes • Lifestyle triggers • Symptom logs

Lambourne T, et al. J Cancer Educ. 2019;34(5):1024-1030. Optimizing Dose and Scheduling The patient is ultimately in control of their dose and schedule, so we must do everything we can to set them up for success.

Patient counseling Ensuring medication • Including adherence access tools

Supportive care Close follow-up for • Preventive measures toxicity and adherence • Toxicity management checks

Simplifying regimen Monitoring AEs instructions and pill burden, when possible

Mackler E, et al. J Oncol Pract. 2019;15(4):e346-e355. Reasons for Nonadherence

• Complexity of treatment regimens • Poor communication with health care providers or dissatisfaction with care • Out-of-pocket cost • Medication access delays • Toxicity • Forgetfulness • Misunderstanding of dosing instructions • Difficulty swallowing • Misperceptions of importance of PO formulations compared with IV

Lambourne T, et al. J Cancer Educ. 2019;34(5):1024-1030. Early Recognition of Adverse Effects

Patient Education Is Can Empower Improve Adherence Most Effective when Patients in Their to Therapy and Provided Before Care Outcomes Treatment Initiation

Jacobs JM, et al. J Oncol Pract, 2017;13(5):e474-e485. Holistic View of Patient

Patient Factors and Integrated Care Social Systems Comorbidities

Ng ZX, et al. Breast cancer: exploring the facts and holistic needs during and beyond treatment. In: Healthcare. 2017;5(2):26. Multidisciplinary Digital Publishing Institute. Facilitating Access to Oral Chemotherapeutics

Cost Questions for Panel Discussion

• How is oral chemotherapy different from IV chemotherapy from a team resource perspective? • How does initiating an oral drug change needs for treatment planning? • What strategies has your clinic used to enhance adherence? • What are the roles of the pharmacist and the nurse in initiation and management of oral chemotherapy patients at your practice site? • Who completes symptom and adherence assessments? Who documents? Where? When? • How do you evaluate specialty medication access (coverage, financial assistance, which specialty pharmacy)? Summary and Conclusions

• Oral chemotherapy offers advantages over parenteral agents, which may improve quality of life for patients. • Barriers exist that may limit the development of oral preparations such as acid hydrolysis in the stomach, low aqueous solubility, drug efflux pumps, poor GI permeability, and CYP450 interactions. • Use of novel drug delivery systems, P-gp inhibitors, and CYP450 inhibitors may help to overcome these barriers. • Oral oncolytics are part of all treatment algorithms for different subtypes of breast cancer including HR+, HER2+, and TNBC. • Multidisciplinary teams are critical for ensuring success of oral therapies in patients with breast cancer. Additional Resources

Oral chemotherapy education sheets: oralchemoedsheets.com

Mackler E, et al. 2018 Hematology/Oncology Pharmacist Association best practices for the management of oral oncolytic therapy: pharmacy practice standard. J Oncol Pract. 2019;15(4):e346-e355.

Dillmon M, et al. Patient-centered standards for medically integrated dispensing: ASCO/NCODA standards. J Clin Oncol. 2020;38(6):633-644.