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...

...Diagnosis, Staging, and Treatment Capacities by...


...st-line...

...or-positive (HR-positive)...

...H...

...egative...


Second-l...

...sitive...

...2-positive...

...RCA1/2 mutations...

...-negative...


...rd-line...

...-positive...

...ative...


...rst-Line Systemic Metastatic Breast Cancer Tre...

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

...sitive, HER2-Negative

....1.1...

...xifen, palliative,* and best supportive care...

...uential hormone therapy** Aromatase in...

...Sequential hormone therapy** (, , , )1048203...

1.1....

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

...ed Single-agent chemotherapy Co...

...nced Single-agent chemotherapy Combination reg...

1.1....

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

...Single-agent chemotherapy Combination regimens...

...Single-agent chemotherapy Combination...

1.1.4

...amoxifen (, , , )1048203...

...Tamoxifen (Nonsteroidal AI if ava...

...ed A nonsteroidal AI** and a CDK4/6 inhibito...

....1.5

...Tamoxifen Bilateral oophorectomy (, , , )1048...

...ted Tamoxifen or alternate hormone therapy...

Enhanced Ovarian suppression or ablation in...

1.1....

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

...ed Tamoxifen or AI** Nonsteroidal if availa...

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

1.1.7

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

...ted Alternative hormonal treatment (tamo...

...Fulvestrant and a CDK4/6 inhibitor (, , , )1048...

1.1....

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

...imited May reuse specific hormone...

...nhanced AI** + CDK4/6 inhibitor May...

1.1.9

...sic Tamoxifen (, , , )1048203

...fen or (combined hormone blockage nonsteroi...

...monal therapy (A nonsteroidal AI and a CD...

...R2-Positive...

1.2.1

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

...mited Chemotherapy, options includ...

...ER2-targeted therapy combined with chem...

1.2.2

...e-agent hormone therapy (tamoxifen)....

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

...targeted therapy (trastuzumab + pertuzuma...

Triple-Neg...

....3.1

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

...e-agent chemotherapy (, , , )10482...

...ingle-agent chemotherapy rather th...

....3.2...

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

...Single-agent chemotherapy Combinatio...

...Single-agent chemotherapy Combination...

1.3....

...tive* and best supportive care (PD-L1 test...

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

...ion of immune checkpoint inhibitor to...

...ons (note: the recommendations for pa...

....4.1.a...

...n — If ER-positive, then see ER-posi...

...mited Tamoxifen with OA AI with OA...

...Single-agent chemotherapy rather than combin...

....4.1.b...

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

...ngle-agent chemotherapy (, , , )104...

...PARPiD/Chemotherapy (, , , )1048203...

....4.2

Basic Palliative* and best supportive car...

Limited Single-agent chemotherapy, combination...

...nced PARPi (in the first- through...


...econd-Line Systemic Metastatic Breast Cancer T...

.... In Basic settings, the recommendations presume t...

...itive, HER2-Negativ...

2.1.1

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

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

...Single-agent chemotherapy, combinat...

2.1.2

...fen if previously not used (, , , )1048203...

...ifen or single-agent chemotherapy, combinati...

...Exemestane and everolimus (, , , )104...

....1.3...

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

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

Enhanced Alpelisib in combination with endocrin...

....1.4

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

...oxifen or single-agent chemotherapy, combination...

...docrine therapy, AI, or fulvestrant ± eve...

....1.5...

...therapy Palliative* care and bes...

...Single-agent chemotherapy, combina...

...one therapy with or without targeted...

....1.6...

...alliative* and best supportive care (, , , )1048...

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

...PARPi Single-agent chemotherapy, comb...

...-Positive

2.2....

...liative* and best supportive care...

...imited Chemotherapy (anthracyclines, docetaxel,...

Enhanced (1) Trastuzumab deruxtecan. If...

2.2....

...ic (Total mastectomy for ipsilateral in-breast r...

...Chemotherapy with anthracyclines, do...

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

2.2.3

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

...otherapy (anthracyclines, docetaxel, carbopl...

Enhanced (1) Trastuzumab deruxtecan. If...

....2.4

...ic Palliative* and best supportive...

...Chemotherapy (anthracyclines, once...

...d HER2-targeted therapy combined with c...

...le-Negativ...

2.3....

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

...ingle-agent chemotherapy; start with sequen...

...Single-agent chemotherapy rather than combina...


...ximal Setting: Third-line Options for HER2-...

...talics, Underlined = not on EML Italics = medica...

...s HER2-positive advanced breast ca...

If a patient has not received trastuzuma...

...ombined with trastuzumab and capecitabine (...

...ab deruxtecan (, , , S)1048203...

Neratinib combined with capecitabine (, , ,...

...atinib and trastuzumab (, , , W)104820...

...ib and capecitabine (, , , W)1048...

...mbinations of chemotherapy and trastuzumab (, , ,...

...argetuximab plus chemotherapy (, ,...

...t has not received pertuzumab, pertu...

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

...combined with trastuzumab and fulvestr...


...ird-Line and Beyond Systemic Metastatic Breast...

...asic settings, the recommendations pres...

...riple-Negativ...

3.1....

...ic Palliative* and best supportiv...

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

...anced Single-agent chemotherapy rather than co...

....1.2...

...asic Palliative* and best supportiv...

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

...Pi (for those with known mutation status) (, , ,...

...-positive, BRCA mu...

....2.1...

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

...i (for those with known mutation status) (,...

...nhanced PARPi (for those with kno...

...ER2-Posit...

....3.1...

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

...Chemotherapy (, , , )1048203...

...astuzumab emtansine (, , , )1048203...

3.3.2

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

...Hormonal therapy (, , , )1048203...

...hanced Trastuzumab + hormonal th...

....3.3...

Basic Not relevant (, , ,...

...patient is receiving HER2-targeted t...

...a patient is receiving HER2-targeted thera...


...eves that cancer clinical trials are vital...