Kelsey Martin, APRN, AOCNP, Discusses Frontline ADCs and Managing TNBC Care

In an era of rapid oncology advancements, targeted therapeutic agents and novel antibody-drug conjugates (ADCs) are redefining treatment paradigms for complex malignancies like metastatic triple-negative breast cancer. To explore these profound clinical shifts, Oncology Nursing News sat down with Kelsey Martin, APRN, AOCNP, of the Sarah Cannon Research Institute. Having recently moderated a case-based roundtable discussion on triple-negative breast cancer, Martin shared her clinical insights on navigating this rapidly evolving treatment landscape.

Martin highlighted how frontline ADCs have dramatically reshaped patient outcomes, offering more tolerable alternatives to standard frontline chemotherapy. However, these increasingly complex regimens bring unique toxicity management challenges. From differentiating chemotherapy-induced diarrhea from immunotherapy-related diarrhea to proactive monitoring of neuropathy, vomiting, and neutropenia, Martin emphasized that infusion and triage nurses remain the critical frontline defense in maintaining treatment safety and dose appropriateness.

Beyond patient monitoring, Martin underscored the importance of tailored therapeutic sequencing, noting there is no official, one-size-fits-all sequencing guideline when navigating disease progression, HER2 expression variations, or prior therapeutic lines.

What were some of your big takeaways from that from the case-based roundtable?

It was a great, really fruitful discussion with some other APPs in the area. We talked about frontline ADCs for our newly diagnosed metastatic triple-negative patients. Previously, a lot of those patients really just got standard chemotherapy, and so just having more ADCs available in that area is really helpful for patients.

We talked with the other APPs a lot about people who are seeing very tolerable side effects. [There were] ADCs that had a lot of nausea in some of the studies, or had a lot of diarrhea or neutropenia. We all talked about how even with those side effects, we're finding ways to manage it really easily, and give the patient the treatment, which is obviously the most important thing.

We see that a lot in our clinic, particularly, but being able to collaborate with other colleagues in the area to reemphasize that patients all across middle Tennessee where we live are having good tolerability for these first-line treatments, and that these treatments are letting patients get standard chemo later in line instead of having that front line. So hopefully, that helps those patients have more tolerability overall.

With chemoimmunotherapy now firmly established in both the neoadjuvant/adjuvant and metastatic triple-negative breast cancer settings, what frontline toxicity management strategies should APPs and bedside nurses prioritize to mitigate severe side effects?

When we add in immunotherapy with an ADC or chemo, obviously something like diarrhea can certainly come into play for those patients. And so, really, one important thing is trying to differentiate a chemo-type diarrhea and immunotherapy-type diarrhea, and so one of the things that we talked about at that discussion was really figuring out does something like loperamide help the diarrhea? Does it not help the diarrhea? And so, making sure that both us as APPs and then our infusion and triage nurses are able to kind of help figure out what the patient's actually experiencing, and being able to kind of get them to tell us more about does this help calm it down? Does this not help calm it down? Are you able to eat anything? Those sorts of things. But I think diarrhea, particularly, is something that's a challenge that we have to figure out what's the cause, so we know what's the best treatment. With adding in the immunotherapy, we don't necessarily see a big increase in nausea or neutropenia, anemia, those sorts of things, but I think keeping our nurses and our APPs well versed in trying to get the patient to tell us how they're experiencing it and what helps and what doesn't help will help us manage them easier.

ADCs have dramatically reshaped the treatment paradigm for pre-treated metastatic triple-negative breast cancer. From a clinical practice perspective, what key updates or practical tips should nurses keep in mind regarding dosing prophylaxis and active management of ADC-specific toxicities?

An important thing that nurses can particularly help us with is some of the ADCs are dosed Day 1 and Day 8, and not every 3 weeks. It just depends on the schedule, and each one is a little bit different, but if there's ever a time where a patient’s coming in, saying, “My neuropathy is way worse,” or, “I haven't been able to keep down any food. I'm just vomiting,” but they didn't maybe tell the provider that for some reason, that's something certainly we want the nurses to help us know about.

Every ADC is a little bit different with what side effects we may look for, and a lot of us as APPs and other providers, our physicians will help ask certain questions about their side effects. But if there's something that a patient chooses to not tell us for some reason or another, nurses are our next line of defense before they administer the drug, and so them being able to say, “Did you tell the doctor that?” or, “Did you talk about that in your visit?” or if they're there for just a Day 8 visit and they say, “Anything changing?” making sure they let us know so that we can decide, is this dose appropriate or not, any big change from their baseline where we might want to hold the drug, or give more supportive care, or even if we decide to give the drug, but add in a lab check and a supportive care check that next week or something, they're definitely a really important part of the team to be able to make sure the patient's getting the right treatment and the right care.

As more targeted agents and novel combinations enter the clinical pipeline, sequencing therapies can become increasingly complex. What are some of the main takeaways from the case discussion regarding how to sequence ADCs, PARP inhibitors, or standard chemo after progression on initial lines of therapy?

Our big takeaway was really there's no official sequencing that everyone follows. Each physician and group does things differently, and even with my physician that I work with, we don't always go A, B, and C. We can just really tailor it to the patient. If someone's truly triple negative with no HER2 positivity at all, then we may do something differently than if we do see a HER2 low or HER2 positive. And then obviously we're going to look at based on the patient's comorbidities or their side effects they've had, whether it's this last treatment that they had or something else. There's no one size fits all. In some ways that'd be easier so that we could have some continuity, but really, obviously every patient's different, and so we just tailor each treatment choice based on what's right for that patient at that time, based on what they'll tolerate well, based on what we think they'll get a good benefit from.

From talking to the other APPs in in the area, people do things differently. Which, again, I think most people are trying to tailor things to the patients, which obviously is, at the end of the day, probably what's best for them. But it's interesting. Who knows if one day we'll have a very linear process, this is what everyone does, but it's not really the case right now. And maybe that's just how it will be, and that's OK.