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
...atment...
...osis, Staging, and Treatment Capacities by Setti...
First-line
...eceptor-positive (HR-positive)...
...HER2-ta...
...le-negative...
Second-lin...
HR-positive...
...itive...
...BRCA1/2 mutations...
...gative In...
Third-li...
...R2-positive...
...riple-negative...
.... First-Line Systemic Metastatic Breast C...
...Basic settings, the recommendations presume that...
...itive, HER2-Negative
....1.1
...n, palliative,* and best supportive car...
...ed Sequential hormone therapy** Arom...
...anced Sequential hormone therapy** (, , , )10482...
1.1....
...Tamoxifen Palliative* and best supportive care...
...Single-agent chemotherapy Combination r...
...hanced Single-agent chemotherapy Co...
....1.3
...Tamoxifen Palliative* and best suppor...
Limited Single-agent chemotherapy Com...
...le-agent chemotherapy Combination regimens...
1.1.4
...Tamoxifen (, , , )104...
...Tamoxifen (Nonsteroidal AI if availabl...
...A nonsteroidal AI** and a CDK4/6 inh...
1.1....
...n Bilateral oophorectomy (, , , )1048203...
...Tamoxifen or alternate hormone therapy Su...
...nhanced Ovarian suppression or ablation in...
1.1.6
...c Tamoxifen (, , , )104820...
...ited Tamoxifen or AI** Nonsteroid...
...anced Nonsteroidal AI** and a CD...
....1.7
...asic Tamoxifen (, , , )1048203
...ternative hormonal treatment (tamoxife...
...ulvestrant and a CDK4/6 inhibitor (, , , )1048...
....1.8
...moxifen (, , , )1048203
...y reuse specific hormone agent (,...
...nced AI** + CDK4/6 inhibitor May reuse speci...
1.1.9
...c Tamoxifen (, , , )104...
...amoxifen or (combined hormone blockage nonsteroi...
...monal therapy (A nonsteroidal AI and...
...-Positive...
....2.1
...liative* and best supportive care (,...
...motherapy, options include anthracyclines...
...anced HER2-targeted therapy combined with chemo...
1.2....
...asic Single-agent hormone therapy...
...ted Single-agent chemotherapy with anthracycl...
...-targeted therapy (trastuzumab + pertuzum...
...le-Negativ...
1.3....
...Palliative* and best supportive care (,...
...ngle-agent chemotherapy (, , , )10482...
...nced Single-agent chemotherapy rather than c...
....3.2
Basic Palliative* and best supportiv...
...Single-agent chemotherapy Combinatio...
...e-agent chemotherapy Combination chemother...
....3.3
...ative* and best supportive care (PD-L1 te...
...ited Single-agent chemotherapy (, , , )...
...hanced Addition of immune checkpoint inhibi...
...ons (note: the recommendations for patients wit...
1.4.1...
...asic Tamoxifen — If ER-positive, then see ER-...
...Tamoxifen with OA AI with OA Single-age...
Enhanced PARPi Single-agent chemo...
1.4.1...
Basic Palliative* and best supportive care...
...Single-agent chemotherapy (, , , )10...
...RPiD/Chemotherapy (, , , )1048203...
1.4....
...c Palliative* and best supportive care (...
...ted Single-agent chemotherapy, combination reg...
...ARPi (in the first- through to third-line se...
...econd-Line Systemic Metastatic Breast Ca...
...Basic settings, the recommendations...
...Positive, HER2-Negat...
....1.1
...Palliative* and best supportive care (, , , )1...
...ed Single-agent chemotherapy, combination reg...
...Single-agent chemotherapy, combination regi...
....1.2
...en if previously not used (, , , )...
...imited Tamoxifen or single-agent...
...nhanced Exemestane and everolimus (, , ,...
2.1....
...asic Palliative* and best supportiv...
...d Tamoxifen or single-agent* chemotherapy...
...isib in combination with endocrine th...
2.1.4
Basic Palliative* and best supportive...
...ited Tamoxifen or single-agent chem...
...rine therapy, AI, or fulvestrant ±...
2.1....
...sic Hormone therapy Palliative* care and best...
...ingle-agent chemotherapy, combinatio...
...rmone therapy with or without targeted therapy or...
....1.6...
...Palliative* and best supportive care (,...
...gle-agent chemotherapy, combination re...
Enhanced PARPi Single-agent chemotherapy, co...
...R2-Positive...
2.2....
...Palliative* and best supportive care (HER2 t...
...Chemotherapy (anthracyclines, docetaxel, once w...
...(1) Trastuzumab deruxtecan. If 1 not availa...
....2.2
...al mastectomy for ipsilateral in-breast recurre...
Limited Chemotherapy with anthracycl...
Enhnaced (1) Trastuzumab deruxtecan. If...
....2.3...
...liative* and best supportive care (, , , )...
...hemotherapy (anthracyclines, docetax...
...) Trastuzumab deruxtecan. If 1 not available,...
2.2.4
...sic Palliative* and best supportive...
...d Chemotherapy (anthracyclines, on...
...ed HER2-targeted therapy combined with chem...
...ple-Negati...
....3.1
...ive* and best supportive care (, ,...
...Single-agent chemotherapy; start with...
...Single-agent chemotherapy rather than...
...5. Maximal Setting: Third-line Option...
...Underlined = not on EML Italics = med...
...s HER2-positive advanced breast cancer has pro...
...nt has not received trastuzumab emtansine (T-DM1)...
...ined with trastuzumab and capecitabine (, ,...
...umab deruxtecan (, , , S)1048203...
...combined with capecitabine (, , , W)1048203...
Lapatinib and trastuzumab (,...
Lapatinib and capecitabine (, , , W)1048203
Other combinations of chemotherapy and trastuzum...
...us chemotherapy (, , , W)1048203...
...has not received pertuzumab, pertuzumab...
Hormonal therapy (in patients with ER-positive and...
...bemaciclib combined with trastuzumab and fulv...
Table 6. Third-Line and Beyond Systemic Metasta...
...asic settings, the recommendations presume...
Triple-Negative
3.1....
Basic Palliative* and best supportive care (, ,...
...d Palliative* and best supportive ca...
...anced Single-agent chemotherapy rather than...
3.1.2
...iative* and best supportive care (,...
...mited PARPi (for those with known...
Enhanced PARPi (for those with known m...
...positive, BRCA mutation...
....2.1
...tive* and best supportive care (,...
...imited PARPi (for those with known mu...
...PARPi (for those with known mutation status)...
...R2-Positive...
3.3....
...Palliative* and best supportive care (,...
...d Chemotherapy (, , , )1048203...
...nced Trastuzumab emtansine (, ,...
3.3....
...Palliative* and best supportive care (,...
...ed Hormonal therapy (, , , )1048203...
...astuzumab + hormonal therapy (, , , )1048203...
3.3....
...ot relevant (, , , )10482...
...ed If a patient is receiving HER2-targete...
...f a patient is receiving HER2-target...
...SCO believes that cancer clinical tri...