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...
...st-line...
...e receptor-positive (HR-positive)...
...itive...
...ative...
...econd-lin...
...In Enhanced...
...ive...
...sitive, BRCA1/2 mutations...
...gative...
...ird-line...
...2-positive...
...iple-negative...
...Line Systemic Metastatic Breast Cancer Trea...
.... In Basic settings, the recommendations p...
...Positive, HER2-Negativ...
....1.1...
Basic Tamoxifen, palliative,* and best su...
...Sequential hormone therapy** Aromatase inh...
...Sequential hormone therapy** (, , , )1048...
1.1.2
...fen Palliative* and best supportive care...
...e-agent chemotherapy Combination regimens ma...
...ingle-agent chemotherapy Combination regimens...
....1.3
...n Palliative* and best supportive ca...
...imited Single-agent chemotherapy...
...ed Single-agent chemotherapy Combination regi...
1.1.4
...amoxifen (, , , )1048203...
...ed Tamoxifen (Nonsteroidal AI if availabl...
...ced A nonsteroidal AI** and a CDK4/6 inhibit...
1.1.5
Basic Tamoxifen Bilateral oophorectomy (, ,...
...mited Tamoxifen or alternate hormone therapy S...
...rian suppression or ablation in comb...
1.1.6
...sic Tamoxifen (, , , )1...
...moxifen or AI** Nonsteroidal if available...
...ed Nonsteroidal AI** and a CDK4/6 inhibi...
1.1....
...Tamoxifen (, , , )1048203...
Limited Alternative hormonal treatment (tamoxif...
...hanced Fulvestrant and a CDK4/6 inhibitor (, , ,...
....1.8...
...Tamoxifen (, , , )1048203
...May reuse specific hormone agent (, ,...
...AI** + CDK4/6 inhibitor May reuse...
1.1....
...amoxifen (, , , )1048203...
...Tamoxifen or (combined hormone blockage nonstero...
Enhanced Hormonal therapy (A nonsteroidal...
...-Positive
1.2....
...c Palliative* and best supportive care (, , , )...
...Chemotherapy, options include anthrac...
...ced HER2-targeted therapy combined wit...
....2.2
...Single-agent hormone therapy (tamoxifen)....
...gle-agent chemotherapy with anthracyclines, o...
...nced HER2-targeted therapy (tras...
Triple-Negativ...
....3.1...
...ative* and best supportive care (,...
...le-agent chemotherapy (, , , )1048203...
...le-agent chemotherapy rather than combination ch...
....3.2
...Palliative* and best supportive car...
...Single-agent chemotherapy Combinati...
...Single-agent chemotherapy Combina...
....3.3
...ve* and best supportive care (PD-L1 te...
Limited Single-agent chemotherap...
...Addition of immune checkpoint inhibitor...
...utations (note: the recommendations fo...
....4.1....
...Tamoxifen — If ER-positive, then see...
...ited Tamoxifen with OA AI with OA Si...
...d PARPi Single-agent chemotherap...
1.4.1.b
...ive* and best supportive care (, , , )104820...
...ted Single-agent chemotherapy (, , ,...
...d PARPiD/Chemotherapy (, , , )104...
1.4....
...asic Palliative* and best supportive car...
...e-agent chemotherapy, combination regimens may be...
...RPi (in the first- through to third-line...
...4. Second-Line Systemic Metastatic Breas...
.... In Basic settings, the recommendations...
...tive, HER2-Negative...
....1.1
...iative* and best supportive care (, , , )1048203...
...Single-agent chemotherapy, combination...
...nced Single-agent chemotherapy, combination regi...
....1.2
...n if previously not used (, , , )1048203...
...ted Tamoxifen or single-agent chemotherapy,...
...estane and everolimus (, , , )1048203...
2.1.3
...ative* and best supportive care (, , ,...
...Tamoxifen or single-agent* chemotherapy, comb...
...elisib in combination with endocrin...
2.1.4
...lliative* and best supportive care (, , , )1...
...fen or single-agent chemotherapy,...
...Endocrine therapy, AI, or fulvestrant...
....1.5...
...e therapy Palliative* care and best supporti...
...imited Single-agent chemotherapy, comb...
...nced Hormone therapy with or without targeted t...
....1.6
...ic Palliative* and best supportiv...
...Single-agent chemotherapy, combination re...
...ARPi Single-agent chemotherapy, combination r...
...ER2-Positive...
2.2.1
...ive* and best supportive care (HE...
...Chemotherapy (anthracyclines, docetaxel, once...
...anced (1) Trastuzumab deruxtecan....
2.2.2
...Total mastectomy for ipsilateral in-breast rec...
...Chemotherapy with anthracyclines, d...
...(1) Trastuzumab deruxtecan. If 1 n...
....2.3...
...Palliative* and best supportive care (, , , )...
...Chemotherapy (anthracyclines, docetaxel, ca...
...(1) Trastuzumab deruxtecan. If 1...
....2.4
Basic Palliative* and best supportive care (,...
...ited Chemotherapy (anthracyclines, once weekly...
...d HER2-targeted therapy combined with...
...ple-Negati...
2.3....
...ve* and best supportive care (, , ,...
...d Single-agent chemotherapy; start...
...Single-agent chemotherapy rather than combina...
...le 5. Maximal Setting: Third-line Op...
...rlined = not on EML Italics = medica...
...’s HER2-positive advanced breast c...
...ient has not received trastuzumab emtansin...
...ucatinib combined with trastuzumab and capecitabi...
...zumab deruxtecan (, , , S)1048203...
...tinib combined with capecitabine (, ,...
...d trastuzumab (, , , W)1048203...
...ib and capecitabine (, , , W)1...
Other combinations of chemotherapy and trastuzu...
...rgetuximab plus chemotherapy (, , , W)...
...t has not received pertuzumab, pertuzumab (, , , W...
...therapy (in patients with ER-positive...
...ib combined with trastuzumab and fulves...
Table 6. Third-Line and Beyond Systemic Met...
...Basic settings, the recommendations presume tha...
...riple-Negative
....1.1...
...Palliative* and best supportive care (, , , )1048...
...Palliative* and best supportive c...
...gle-agent chemotherapy rather than combin...
....1.2
...tive* and best supportive care (, , ,...
...i (for those with known mutation stat...
...d PARPi (for those with known muta...
...-positive, BRCA mutati...
....2.1
...Palliative* and best supportive care (, ,...
...imited PARPi (for those with known mutat...
...nhanced PARPi (for those with known mutation s...
HER2-Posi...
3.3....
...ive* and best supportive care (, , , )1048203...
...d Chemotherapy (, , , )1...
...ced Trastuzumab emtansine (, , , )1048203...
3.3.2
...ive* and best supportive care (, ,...
...Hormonal therapy (, , , )1048203
...tuzumab + hormonal therapy (, , , )1048203...
....3.3...
...Not relevant (, , , )1048...
...patient is receiving HER2-targeted therapy and ch...
...ced If a patient is receiving HER2-t...
ASCO believes that cancer clinica...