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New Treatment Guidelines for Aggressive Breast Cancer

ASCO experts address HER2-positive disease and brain metastases

The American Society of Clinical Oncology (ASCO) has released two sets of guidelines for treating patients with an aggressive form of breast cancer.

In the first set of guidelines, published online May 5, researchers provide evidence-based recommendations to practicing oncologists and others on systemic therapy for patients with human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer.

ASCO convened a panel of medical oncology, radiation oncology, guideline implementation, and advocacy experts, who conducted a literature review from January 2009 to October 2012. A total of 16 studies met the review criteria.

The CLEOPATRA trial found survival and progression-free survival (PFS) benefits for docetaxel, trastuzumab, and pertuzumab in first-line treatment, and the EMILIA trial found survival and PFS benefits for trastuzumab emtansine (T-DM1) in second-line treatment. T-DM1 also showed a third-line PFS benefit. One trial reported on the duration of HER2-targeted therapy, and three others reported on endocrine therapy for patients with HER-positive advanced breast cancer.

Based on these findings, the experts recommend HER2-targeted therapy for patients with HER2-positive advanced breast cancer, except for those with clinical congestive heart failure or a significantly compromised left ventricular ejection fraction, who should be evaluated on a case-by-case basis. The authors further recommend trastuzumab, pertuzumab, and taxane for first-line treatment and T-DM1 for second-line treatment. In the third-line setting, clinicians should offer other HER2-targeted therapy combinations or T-DM1 (if not previously administered). They may also offer pertuzumab, if the patient has not previously received it.

The experts state that the optimal duration of chemotherapy is at least 4 to 6 months or until maximal response, depending on toxicity and in the absence of progression. HER2-targeted therapy can continue until the time of progression or unacceptable toxicities.

For patients with HER2-positive and estrogen receptor–positive/progesterone receptor–positive breast cancer, clinicians may recommend either standard first-line therapy or, for selected patients, endocrine therapy plus HER2-targeted therapy or endocrine therapy alone. In the second set of guidelines, also published online May 5, the authors provide formal expert consensus-based recommendations to practicing oncologists and others on the management of brain metastases in patients with HER2-positive advanced breast cancer.

The experts recommend that patients with brain metastases should receive appropriate local and systemic therapy, if indicated. Local therapies include surgery, whole-brain radiotherapy, and stereotactic radiosurgery. The treatments depend on factors such as the patient’s prognosis, the presence of symptoms, resectability, the number and size of metastases, prior therapy, and whether the metastases are diffuse.

Other treatment options include systemic therapy, best supportive care, enrollment into a clinical trial, and/or palliative care.

According to the authors, clinicians should not perform routine magnetic resonance imaging (MRI) to screen for brain metastases, but rather should have a low threshold for MRI of the brain because of the high incidence of brain metastases among patients with HER2-positive advanced breast cancer.

Sources: ASCO: HER2 Disease; May 5, 2014; and ASCO: Brain Metastases; May 5, 2014.

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