ASCO guidelines addressing the order of targeted agents in the management of patients with advanced HER2-positive breast cancer, and on the management of brain metastases, were published online May 5 in the Journal of Clinical Oncology.
Clinicians should recommend HER2-targeted therapy–based combinations for first-line treatment, except for highly selected patients with estrogen receptor–positive or progesterone receptor–positive and HER2-positive disease, for whom clinicians may use endocrine therapy alone, wrote Dr. Sharon H. Giordano and her colleagues in describing the guideline for systemic treatment (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.0948]).
A combination of trastuzumab, pertuzumab, and a taxane is recommended for first-line treatment of advanced disease. If a patient’s breast cancer has progressed during first-line HER2-targeted therapy, trastuzumab emtansine is recommended as a second-line therapy, said Dr. Giordano, of the University of Texas M.D. Anderson Cancer Center, Houston, and her colleagues.
As a third-line treatment, clinicians should prescribe other HER2-targeted therapy combinations or trastuzumab emtansine (if not previously administered) and pertuzumab (if not previously administered).
HER2-targeted therapy for those with clinical congestive heart failure or significantly compromised left-ventricular ejection fraction, should be evaluated on a case-by-case basis.
The guideline recommends chemotherapy for at least 4-6 months, but treatment can continue until time of progression or unacceptable toxicities.
The second ASCO guideline provides recommendations for management of brain metastases in patients with HER2-positive advanced breast cancer, which up to half of patients with HER2-positive metastatic breast cancer will experience over time, wrote Dr. Naren Ramakrishna, of the University of Florida Health Cancer Center at Orlando Health, and his colleagues (J. Clin. Oncol. 2014 May 5 [doi: 10.1200/JCO.2013.54.0955]).
For patients with a favorable prognosis for survival and a single brain metastasis, treatment options include surgery with postoperative radiation, stereotactic radiosurgery, whole-brain radiotherapy, and fractionated stereotactic radiotherapy, depending on metastasis size, resectability, and symptoms. After treatment, serial imaging every 2-4 months may be used to monitor for local and distant brain failure.
For patients with a favorable prognosis for survival and limited (two to four) metastases, treatment options include resection for a large symptomatic lesion(s) plus postoperative radiotherapy; stereotactic radiosurgery for additional smaller lesions; and a combination of whole-brain radiotherapy and/or stereotactic radiosurgery and fractionated stereotactic radiotherapy for other lesions, depending on resectability and symptoms.
For patients with diffuse disease or extensive metastases and a more favorable prognosis, and those with symptomatic leptomeningeal metastasis in the brain, whole-brain radiation therapy may be offered.
For patients with a poor prognosis, the guideline recommends whole-brain radiotherapy, best supportive care, clinical trial enrollment, and/or palliative care, Dr. Ramakrishna and his colleagues said.
Routine surveillance with magnetic resonance imaging is not recommended in patients without a history of or symptoms related to brain metastases or symptoms. However, clinicians should have a low threshold for diagnostic brain MRI testing in the setting of any neurologic symptoms, they said.