Systemic Treatment of Patients With Metastatic Breast Cancer
Key Points
Key Points
- Palliative care needs should be addressed for all patients at presentation of metastatic breast cancer (MBC), including situations in which no antineoplastic interventions are accessible.
- Patients who are premenopausal can receive aromatase inhibitors only if accompanied by ovarian ablation or ovarian suppression.
- Clinicians should recommend treatment according to pathological and biomarker features when quality (following established guidelines) testing results are available.
- Cases should be discussed using a multidisciplinary approach with the core team including the surgeon, pathologist, oncologist, and radiation oncologist.
Table 1. Framework of Resource Stratification
| Setting | |
|---|---|
| Basic | Core resources or fundamental services that are absolutely necessary for any public health/primary health care system to function; basic-level services typically are applied in a single clinical interaction. Vaccination is feasible for highest need populations. |
| Limited | Second-tier resources or services that are intended to produce major improvements in outcome such as incidence and cost-effectiveness and are attainable with limited financial means and modest infrastructure; limited-level services may involve single or multiple interactions. Universal public health interventions feasible for greater percentage of population than primary target group. |
| Enhanced | Third-tier resources or services that are optional but important; enhanced-level resources should produce further improvements in outcome and increase the number and quality of options and individual choice. (Perhaps ability to track patients and links to registries). |
| Maximal | May use high-resource settings’ guidelines. High-level/state-of-the-art resources or services that may be used/available in some high-resource countries and/or may be recommended by high-resource setting guidelines that do not adapt to resource constraints but that nonetheless should be considered a lower priority than those resources or services listed in the other categories on the basis of extreme cost and/or impracticality for broad use in a resource-limited environment. |
Treatment
...eatment...
...Diagnosis, Staging, and Treatment Capacities by S...
...rst-line
...one receptor-positive (HR-positive)...
...-positive...
...negative...
...econd-li...
...sitive...
...HER2-...
...positive, BRCA1/2 mutations...
...ative...
...rd-line...
...R2-positive...
...e-negative...
Table 3. First-Line Systemic Metastatic...
...tings, the recommendations presume that n...
...R-Positive, HER2-Ne...
1.1.1
...fen, palliative,* and best supportive ca...
...uential hormone therapy** Aromatase inhibitors...
...ential hormone therapy** (, , , )1048203...
....1.2
...c Tamoxifen Palliative* and best s...
...le-agent chemotherapy Combination r...
...hanced Single-agent chemotherapy...
....1.3
...ic Tamoxifen Palliative* and be...
...Single-agent chemotherapy Combinatio...
...ed Single-agent chemotherapy Combination regim...
1.1.4
Basic Tamoxifen (, , , )1048203
...Tamoxifen (Nonsteroidal AI if availab...
...ed A nonsteroidal AI** and a CDK4/...
....1.5
...oxifen Bilateral oophorectomy (, , , )10...
...amoxifen or alternate hormone therapy Surgi...
...hanced Ovarian suppression or ablat...
1.1....
...moxifen (, , , )1048203...
...ited Tamoxifen or AI** Nonsteroi...
...hanced Nonsteroidal AI** and a CDK4/6 inhi...
....1.7
...asic Tamoxifen (, , , )1048203
...ternative hormonal treatment (tamoxifen,...
...nced Fulvestrant and a CDK4/6 inhibito...
1.1.8
...Tamoxifen (, , , )1048203...
...ed May reuse specific hormone agent...
...** + CDK4/6 inhibitor May reuse spe...
....1.9
...Tamoxifen (, , , )10482...
...ited Tamoxifen or (combined hormone blockage no...
...Hormonal therapy (A nonsteroidal AI and a CD...
...2-Positive...
1.2.1
...c Palliative* and best supportive care (...
...motherapy, options include anthracyclines (not...
...nced HER2-targeted therapy combined with c...
....2.2
...asic Single-agent hormone therapy (tamoxifen)....
...ted Single-agent chemotherapy with...
...ER2-targeted therapy (trastuzumab + p...
...e-Negative...
1.3....
...iative* and best supportive care (, , , )104...
...Single-agent chemotherapy (, , , )104...
...d Single-agent chemotherapy rather than...
....3.2...
...iative* and best supportive care (, , ,...
...ed Single-agent chemotherapy Combination ch...
Enhanced Single-agent chemotherapy Combi...
....3.3...
...c Palliative* and best supportive care (PD-L1...
...Single-agent chemotherapy (, , , )...
Enhanced Addition of immune checkpoint...
...(note: the recommendations for patients with HR-p...
....4.1.a...
...xifen — If ER-positive, then see ER...
...Tamoxifen with OA AI with OA Single-agen...
...hanced PARPi Single-agent chemotherapy r...
...4.1.b
...c Palliative* and best supportive care (,...
...d Single-agent chemotherapy (, , , )1048203...
...ed PARPiD/Chemotherapy (, , ,...
1.4....
...tive* and best supportive care (, , , )1048203...
...ingle-agent chemotherapy, combinatio...
...ARPi (in the first- through to third-line setting...
...le 4. Second-Line Systemic Metastatic Breast...
...sic settings, the recommendations...
...ive, HER2-Negative...
2.1.1
...liative* and best supportive care (, , , )10...
...ingle-agent chemotherapy, combination regi...
Enhanced Single-agent chemotherapy, combination...
2.1....
...xifen if previously not used (, , , )...
...ifen or single-agent chemotherapy, combinatio...
...xemestane and everolimus (, , , )10482...
....1.3
...asic Palliative* and best supportive care (, , ,...
...ited Tamoxifen or single-agent* chemotherapy...
...elisib in combination with endocrine therapy in c...
2.1....
...tive* and best supportive care (, , , )...
Limited Tamoxifen or single-agent ch...
...Endocrine therapy, AI, or fulvestrant ±...
....1.5
...Hormone therapy Palliative* care and...
...-agent chemotherapy, combination regim...
...Hormone therapy with or without targeted the...
2.1.6
...ive* and best supportive care (, ,...
...gle-agent chemotherapy, combinatio...
...ced PARPi Single-agent chemotherapy, combi...
...-Positive...
....2.1...
...liative* and best supportive care (HER2 testing...
...therapy (anthracyclines, docetaxel,...
...rastuzumab deruxtecan. If 1 not availab...
....2.2...
Basic (Total mastectomy for ipsil...
...therapy with anthracyclines, docetaxel, o...
...(1) Trastuzumab deruxtecan. If 1...
2.2.3
...Palliative* and best supportive care...
...mited Chemotherapy (anthracyclines, doce...
...(1) Trastuzumab deruxtecan. If 1 not...
....2.4
...ive* and best supportive care (, , , )1048203...
...mited Chemotherapy (anthracyclines, onc...
...R2-targeted therapy combined with chemo...
...le-Negative...
....3.1
...Palliative* and best supportive care (,...
...ed Single-agent chemotherapy; start w...
...ced Single-agent chemotherapy rathe...
...ble 5. Maximal Setting: Third-line Options for HE...
...cs, Underlined = not on EML Italics = medicat...
...a patient’s HER2-positive advanced breast cancer...
...patient has not received trastuzumab emtans...
Tucatinib combined with trastuzumab and capecita...
Trastuzumab deruxtecan (, , , S)1...
...ratinib combined with capecitabine (, ,...
...trastuzumab (, , , W)1048203...
...b and capecitabine (, , , W)104...
...mbinations of chemotherapy and trastuzumab (, , ,...
...plus chemotherapy (, , , W)1048203...
...ient has not received pertuzumab, pertuzu...
...ormonal therapy (in patients with ER...
...bemaciclib combined with trastuzum...
Table 6. Third-Line and Beyond Systemic Meta...
...c settings, the recommendations presume that nei...
...iple-Negative
3.1....
...iative* and best supportive care (...
...Palliative* and best supportive ca...
...ingle-agent chemotherapy rather than com...
3.1.2
...Palliative* and best supportive care...
...ed PARPi (for those with known mutation s...
...RPi (for those with known mutation status) (,...
...-positive, BRCA mut...
3.2.1
...ve* and best supportive care (, , , )104...
...i (for those with known mutation sta...
...(for those with known mutation status)...
HER2-Posi...
....3.1
...ic Palliative* and best supportive care (, , ,...
...mited Chemotherapy (, , , )10482...
...nced Trastuzumab emtansine (,...
3.3....
...ve* and best supportive care (, , ,...
...rmonal therapy (, , , )1048203...
...tuzumab + hormonal therapy (, , , )1048203...
3.3....
...relevant (, , , )1048203...
...atient is receiving HER2-targeted therapy an...
...If a patient is receiving HER2-targe...
...ves that cancer clinical trials are vit...