ASCO Clinical Practice Guidelines Updates in Advanced HER2-Positive Breast Cancer
Posted: Monday, September 24, 2018
In the updates of the 2018 American Society of Clinical Oncology (ASCO) clinical practice guidelines for therapy and management of advanced HER2-positive breast cancer and brain metastases, few substantive changes from the guidelines published in 2014 were required, according to reports published in the Journal of Clinical Oncology. The recommendations were determined by a panel of experts who identified and reviewed 622 relevant publications. Both reports focused on overall survival, progression-free survival, and adverse events.
According to Sharon H. Giordano, MD, of The University of Texas MD Anderson Cancer Center, and colleagues, patients with HER2-positive advanced breast cancer should receive HER2-targeted therapy. However, those with clinical congestive heart failure or a compromised left-ventricular ejection fraction should be evaluated individually. Recommended first-line treatments include trastuzumab, pertuzumab, and a taxane. Ado-trastuzumab emtansine is advised for second-line treatments. For third-line treatments, clinicians may offer ado-trastuzumab emtansine or pertuzumab if not previously administered.
A separate report by Naren Ramakrishna, MD, of the University of Florida Health Cancer Center, and others suggests that patients with HER2-positive breast cancer and brain metastases be treated appropriately with local and systemic therapies. For those with a favorable prognosis and a single brain metastasis, surgery with postoperative radiation, stereotactic radiosurgery, whole-brain radiotherapy, and fractionated stereotactic radiotherapy are treatment options. For patients with a poor prognosis, treatment options include whole-brain radiotherapy, best supportive care, and/or palliative care.
The choice of treatment should depend on factors such as patient prognosis, presence of symptoms, resectability, number and size of metastases, prior therapy, and whether metastases are diffuse. Routine magnetic resonance imaging (MRI) should not be performed; however, clinicians should maintain a low threshold for conducting MRI of the brain based on the high incidence of brain metastases among this patient population.
Additional information on the guidelines may be found at www.asco.org/breast-cancer-guidelines.