Advanced Breast Cancer Clinical Practice Guidelines (2018)

European School of Oncology / European Society for Medical Oncology

Reviewed and summarized by Medscape editors

August 09, 2018

The clinical practice guidelines on advanced breast cancer were released on July 19, 2018, by the ESO/ESMO.[1]

The impact of the anticancer therapies on fertility should be discussed with all women with ABC of childbearing age and their partners, before the start of treatment. The discussion must also include appropriate information about the prognosis of the disease and the potential consequences of pregnancy (eg, stopping ongoing treatment).

Specialized oncology nurses (if possible, specialized breast nurses) should be part of the multidisciplinary team managing ABC patients. In some countries, this role may be played by a physician assistant or another trained and specialized healthcare practitioner.

The use of TELEMEDICINE in oncology to help management of patients with ABC living in remote places is an important option to consider when geographic distances are a problem and provided that issues of connectivity are solved.

Minimal staging workup for ABC includes a history and physical examination, hematology and biochemistry tests, and imaging of chest, abdomen and bone.

Brain imaging should not be routinely carried out in asymptomatic patients. This approach is applicable to all patients with ABC, including those with HER2-positive and/or metastatic TNBC.

Evaluation of response to therapy should generally occur every 2–4 months for endocrine therapy (ET) or after two to four cycles for ChT, depending on the dynamics of the disease, the location and extent of metastatic involvement, and type of treatment. Imaging of target lesions may be sufficient in many patients. In certain patients, such as those with indolent disease, less frequent monitoring is acceptable. Additional testing should be carried out in a timely manner, irrespective of the planned intervals, if disease progression (PD) is suspected or new symptoms appear. Thorough history and physical examination must always be carried out.

A biopsy (preferably providing histology) of a metastatic lesion should be carried out, if easily accessible, to confirm diagnosis, particularly when metastasis is diagnosed for the first time.

Biological markers (especially HR and HER2) should be reassessed at least once in the metastatic setting, if clinically feasible. Depending on the metastatic site (eg, bone tissue), technical considerations need to be discussed with the pathologist.

Treatment choice should take into account at least these factors: HR and HER2 status, previous therapies and their toxicities, DFI, tumor burden (defined as number and site of metastases), biological age, comorbidities (including organ dysfunctions), menopausal status (for ET), need for a rapid disease/symptom control, socioeconomic and psychological factors, available therapies in the patient’s country, and patient’s preferences.

The age of the patient should not be the sole reason to withhold effective therapy (in elderly patients) or to overtreat (in young patients). Age alone should not determine the intensity of treatment.

Both combination and sequential single-agent ChT are reasonable options. Based on the available data, we recommend sequential monotherapy as the preferred choice for ABC. Combination ChT should be reserved for patients with rapid clinical progression, life-threatening visceral metastases, or need for rapid symptom and/or disease control.

In the absence of medical contraindications or patient concerns, anthracycline- or taxane-based regimens, preferably as single agents, would usually be considered as first-line ChT for HER2-negative ABC, in those patients who have not received these regimens as (neo)adjuvant treatment, and for whom ChT is appropriate. Other options are, however, available and effective, such as capecitabine and vinorelbine, particularly if avoiding alopecia is a priority for the patient.

In patients with taxane-naive and anthracycline-resistant ABC or with anthracycline maximum cumulative dose or toxicity (ie, cardiac) who are being considered for further ChT, taxane-based therapy, preferably as single agent, would usually be considered as treatment of choice. Other options are, however, available and effective, such as capecitabine and vinorelbine, particularly if avoiding alopecia is a priority for the patient.

In patients pre-treated (in the adjuvant and/or metastatic setting) with an anthracycline and a taxane, and who do not need combination ChT, single-agent capecitabine, vinorelbine, or eribulin are the preferred choices. Additional choices include gemcitabine, platinum agents, taxanes, and liposomal anthracyclines. The decision should be individualized and take into account different toxicity profiles, previous exposure, patient preferences and country availability.


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