HER2-targeted therapy is recommended for patients with HER2-positive advanced breast cancer, except for those with clinical congestive heart failure or significantly compromised left ventricular ejection fraction, who should be evaluated on a case-by-case basis.
Trastuzumab, pertuzumab, and taxane for first-line treatment and trastuzumab emtansine for second-line treatment are recommended.
In the third-line setting, clinicians should offer other HER2-targeted therapy combinations or trastuzumab emtansine (if not previously administered) and may offer pertuzumab if the patient has not previously received it.
Optimal duration of chemotherapy is at least 4 to 6 months or until maximum response, depending on toxicity and in the absence of progression. HER2-targeted therapy can continue until time of progression or unacceptable toxicities.
For patients with HER2-positive and estrogen receptor–positive/progesterone receptor–positive breast cancer, clinicians may recommend either standard first-line therapy or, for selected patients, endocrine therapy plus HER2-targeted therapy or endocrine therapy alone.
The current recommendations for optimal medical therapy for patients with advanced HER2-positive breast cancer include the following.
HER2-targeted therapy–based combinations for first-line treatment should be recommended except for highly selected patients with estrogen receptor–positive or progesterone receptor–positive and HER2-positive disease. In those cases, endocrine therapy may be used alone.
If disease progresses during or after first-line HER2-targeted therapy, second-line HER2-targeted therapy–based treatment is recommended.
If disease progresses during or after second-line or greater HER2-targeted treatment, third-line or greater HER2-targeted therapy–based treatment is recommended.
Combination treatment with trastuzumab, pertuzumab, and a taxane is recommended for first-line treatment, unless taxanes are contraindicated.
If disease progresses during or after first-line HER2-targeted therapy, trastuzumab emtansine (T-DM1) is recommended as second-line treatment.
If disease progresses during or after second-line or greater HER2-targeted therapy but the patient has not received T-DM1, clinicians should offer T-DM1.
For those already receiving HER2-targeted therapy and chemotherapy combinations, chemotherapy should continue for approximately 4 to 6 months (or longer) and/or to the time of maximal response, depending on toxicity and in the absence of progression. HER2-targeted therapy should continue after chemotherapy is stopped, and no further change in the regimen is needed until progression or unacceptable toxicities.
If a patient finished trastuzumab-based adjuvant treatment 12 months or less before recurrence, the second-line HER2-targeted therapy–based treatment recommendations should be followed.
If trastuzumab-based adjuvant treatment is completed more than 12 months before recurrence, first-line HER2-targeted therapy–based treatment recommendations should be followed.
For hormone receptor–positive and HER2-positive disease, the following may be recommended.
HER2-targeted therapy plus chemotherapy.
Endocrine therapy plus trastuzumab or lapatinib.
Endocrine therapy alone.
For management of brain metastases in patients with HER-2 positive advanced breast cancer, key recommendations include the following.
Options for patients with a favorable prognosis and a single brain metastasis include surgery with postoperative radiation, stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT with or without SRS), fractionated stereotactic radiotherapy (FSRT), and SRS (with or without WBRT); serial imaging every 2 to 4 months may be used to continue to monitor for local and distant brain failure.
Options for patients with a favorable prognosis for survival and limited (two to four) metastases include resection for large symptomatic lesion(s) plus postoperative radiotherapy, SRS for additional smaller lesions, WBRT (with or without SRS), SRS (with or without WBRT), and FSRT for metastases greater than 3 to 4 cm. For metastases less than 3 to 4 cm, options include resection with postoperative radiotherapy.
WBRT may be offered for patients with diffuse disease/extensive metastases and a more favorable prognosis or symptomatic leptomeningeal metastasis in the brain.
Options for patients with a poor prognosis include WBRT, best supportive care, and/or palliative care.
For patients with progressive intracranial metastases despite initial radiation therapy, options include SRS, surgery, WBRT, a trial of systemic therapy, or enrollment in a clinical trial.
For patients whose systemic disease is progressive at the time of brain metastasis diagnosis, HER2-targeted therapy is recommended.
Patients without a known history or symptoms of brain metastases should not undergo routine surveillance with brain MRI.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: HER2+ Advanced Breast Cancer Clinical Practice Guidelines (2018) - Medscape - Aug 09, 2018.