Systemic Treatment of Patients With Metastatic Breast Cancer

Publication Date: January 9, 2024

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

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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.
Data adapted. To be useful, maximal-level resources typically depend on the existence and functionality of all lower level resources. Maximal level recommendations are not included in this guideline.

Treatment

...atment...

...ble 2. Diagnosis, Staging, and Tre...


...rst-line...

...eptor-positive (HR-positive)...

...-positive...

...e-negative...


...econd-line...

...ositive...

...-positive...

HR-positive, BRCA1/2 mutations...

...ve...


...hird-lin...

...tive In t...

...In the t...


.... First-Line Systemic Metastatic Breast Ca...

...c settings, the recommendations presume...

...itive, HER2-Negativ...

....1.1...

...amoxifen, palliative,* and best supportive...

...imited Sequential hormone therapy** Aroma...

...Sequential hormone therapy** (, , , )104820...

....1.2

...c Tamoxifen Palliative* and best supportive...

...imited Single-agent chemotherapy Combin...

...ced Single-agent chemotherapy Combi...

1.1.3

Basic Tamoxifen Palliative* and...

...d Single-agent chemotherapy Combination r...

...gle-agent chemotherapy Combination...

1.1....

...moxifen (, , , )1048203...

...mited Tamoxifen (Nonsteroidal AI i...

...onsteroidal AI** and a CDK4/6 inhibit...

....1.5

...ifen Bilateral oophorectomy (, ,...

...ited Tamoxifen or alternate horm...

...Ovarian suppression or ablation in combinati...

....1.6

...Tamoxifen (, , , )1048203

...Tamoxifen or AI** Nonsteroidal if available...

...d Nonsteroidal AI** and a CDK4/6...

....1.7

...Tamoxifen (, , , )1048203...

...ed Alternative hormonal treatmen...

...nced Fulvestrant and a CDK4/6 in...

1.1....

...c Tamoxifen (, , , )1048203...

...ay reuse specific hormone agent (, , , )104820...

...I** + CDK4/6 inhibitor May reuse specific horm...

1.1.9

...oxifen (, , , )1048203...

...d Tamoxifen or (combined hormone blockage...

...rmonal therapy (A nonsteroidal AI and a CDK4/6 i...

...R2-Positive...

....2.1

...Palliative* and best supportive c...

...ted Chemotherapy, options include a...

...HER2-targeted therapy combined with chemothera...

1.2.2

...gle-agent hormone therapy (tamoxifen). Ho...

...ted Single-agent chemotherapy with anthracyclin...

...nhanced HER2-targeted therapy (tr...

...le-Negative...

1.3.1

...ative* and best supportive care (, , , )1048203...

...ted Single-agent chemotherapy (, , , )1...

...le-agent chemotherapy rather than combination che...

....3.2...

...asic Palliative* and best support...

...ngle-agent chemotherapy Combination...

...ngle-agent chemotherapy Combinat...

1.3....

Basic Palliative* and best supportive ca...

Limited Single-agent chemotherapy...

...dition of immune checkpoint inhibitor to chemo...

...ns (note: the recommendations for patients...

1.4.1.a

...fen — If ER-positive, then see ER-positive rec...

...Tamoxifen with OA AI with OA Single-age...

...Pi Single-agent chemotherapy rather...

...4.1.b...

...Palliative* and best supportive car...

...-agent chemotherapy (, , , )1048203...

...RPiD/Chemotherapy (, , , )1048203...

....4.2

...Palliative* and best supportive care (, ,...

...Single-agent chemotherapy, combination r...

...anced PARPi (in the first- through to t...


.... Second-Line Systemic Metastatic Breast Cance...

...Basic settings, the recommendations presume...

...tive, HER2-Negative...

2.1....

...lliative* and best supportive care (, ,...

...e-agent chemotherapy, combination regimens ma...

...ngle-agent chemotherapy, combination regim...

2.1....

...Tamoxifen if previously not used (, , , )...

...Tamoxifen or single-agent chemotherapy, comb...

...nhanced Exemestane and everolimus (...

2.1....

...Palliative* and best supportive care...

...xifen or single-agent* chemotherapy, combinatio...

...lpelisib in combination with endocrine therapy i...

....1.4...

...sic Palliative* and best supportive care...

...amoxifen or single-agent chemotherapy, comb...

...Endocrine therapy, AI, or fulvestra...

2.1.5

...Hormone therapy Palliative* care a...

...mited Single-agent chemotherapy,...

...mone therapy with or without targeted therap...

2.1.6

...c Palliative* and best supportive ca...

Limited Single-agent chemotherapy,...

...RPi Single-agent chemotherapy, combination...

...ER2-Positiv...

2.2....

...alliative* and best supportive care (HER2...

...mited Chemotherapy (anthracyclines, doc...

...Trastuzumab deruxtecan. If 1 not availab...

....2.2

...al mastectomy for ipsilateral in-breast re...

...ited Chemotherapy with anthracyclines,...

...(1) Trastuzumab deruxtecan. If 1 not ava...

2.2....

...ic Palliative* and best supportive care (, ,...

...Chemotherapy (anthracyclines, docetaxel, ca...

...Trastuzumab deruxtecan. If 1 no...

....2.4...

...asic Palliative* and best supportive care (,...

...Chemotherapy (anthracyclines, once week...

...ER2-targeted therapy combined with chemotherapy...

Triple-Negativ...

....3.1

...alliative* and best supportive care (, , ,...

...d Single-agent chemotherapy; start with...

...nhanced Single-agent chemotherapy...


.... Maximal Setting: Third-line Option...

...alics, Underlined = not on EML Italics...

...HER2-positive advanced breast can...

...has not received trastuzumab emtansine (T-DM1) in...

...ib combined with trastuzumab and capeci...

...stuzumab deruxtecan (, , ,...

...ned with capecitabine (, , , W)104820...

...nib and trastuzumab (, , , W)10482...

...nd capecitabine (, , , W)1048...

...ions of chemotherapy and trastuzumab (, , , W)...

...us chemotherapy (, , , W)1048203...

...ent has not received pertuzumab, pertuzumab...

...l therapy (in patients with ER-positive and...

...lib combined with trastuzumab and fulvestrant (, ,...


...Third-Line and Beyond Systemic Metasta...

...ings, the recommendations presume that neithe...

Triple-Negati...

3.1....

...Palliative* and best supportive care (, , , )1...

...alliative* and best supportive care (...

...nced Single-agent chemotherapy rather t...

3.1.2

...c Palliative* and best supportive care...

...ted PARPi (for those with known mutati...

...anced PARPi (for those with known mu...

...tive, BRCA mutation...

3.2....

...alliative* and best supportive care (...

...mited PARPi (for those with known...

...RPi (for those with known mutation status) Sin...

...-Positive...

3.3.1

...ic Palliative* and best supportive care (...

...d Chemotherapy (, , , )1048203

...Trastuzumab emtansine (, , , )1048203

3.3....

Basic Palliative* and best supportive care (,...

Limited Hormonal therapy (,...

...Trastuzumab + hormonal therapy (, , , )1048203...

3.3.3

...c Not relevant (, , , )10...

...ed If a patient is receiving HER2-targeted th...

...If a patient is receiving HER2-targeted the...


...believes that cancer clinical trials are vital to...