Dosing and Safety Implications for Oncologists When Administering Everolimus to Patients With Hormone Receptor-Positive Breast Cancer

Aberrations in the phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin pathway are common abnormalities in breast cancer and are associated with the development of resistance to endocrine- and human epidermal growth factor receptor (HER)2-targeted therapies. Because of the significant improvement in progression-free survival for everolimus plus exemestane compared with exemestane plus placebo, everolimus, an mTOR inhibitor, was approved in the United States for the treatment of patients with hormone receptor-positive (HR+), HER-negative, advanced breast cancer whose disease had progressed while receiving letrozole or anastrozole. To provide optimal prevention and management strategies, it is crucial that clinicians are aware of the adverse events (AEs) associated with mTOR inhibition. Understanding the appropriate dose modifications will help reduce toxicity and improve drug tolerance, thus achieving the optimal benefit from everolimus. Analyses of data from the Breast Cancer Trials of Oral Everolimus 2 trial have shown that, despite a greater frequency of AEs in the everolimus plus exemestane treatment arm, the AEs were effectively managed with temporary dose reductions or interruptions. In some cases, the full dose of everolimus could be resumed. Despite a lower mean dose and duration of exposure in patients aged ≥ 70 versus < 70 years, everolimus plus exemestane was similarly efficacious, suggesting that appropriate dose reductions for toxicity will not adversely impact efficacy. Appropriate modification of the everolimus dose and dose delay according to the severity of AEs, with resumption of the optimal dose of everolimus when toxicity has improved, will positively affect patient outcomes in HR+ advanced breast cancer.