Skill Checkup: A 56-Year-Old Woman With a History of Breast Cancer and Pain in Her Ribs and Spine

Pavani Chalasani, MD, MPH;  Stefania Morganti, MD

Disclosures

January 23, 2023

According to National Comprehensive Cancer Network (NCCN) clinical practice guidelines, category 1 recommendations (based on phase 3 clinical trial evidence) for first-line systemic therapy for patients with endocrine-sensitive, HR-positive/HER2-negative metastatic breast cancer are an aromatase inhibitor (ie, anastrozole, exemestane, or letrozole) in combination with a CDK4/6 inhibitor (ie, palbociclib, ribociclib, or abemaciclib); fulvestrant with or without an aromatase inhibitor (ie, anastrozole or letrozole); or fulvestrant in combination with a CDK4/6 inhibitor.

Anti-HER2 agents, with or without chemotherapy, are used only for HER2-positive breast cancer. According to the NCCN guidelines, the combination of trastuzumab, pertuzumab and a taxane is the first-line preferred choice for patients with metastatic, HER2-positive breast cancer. Other anti-HER2 agents are available in further lines of therapy. Many studies have shown that these treatments dramatically improve survival for women with HER2-positive breast cancer.

Cytotoxic chemotherapy is still the mainstay of systemic treatment for advanced triple-negative disease. In the past decade, immunotherapy (ie, pembrolizumab) and antibody-drug conjugates (ie, sacituzumab govitecan and trastuzumab deruxtecan) also became available for treatment of TNBC. Pembrolizumab is approved in combination with chemotherapy in the first-line setting. Sacituzumab govitecan and trastuzumab deruxtecan are available in later lines, and the latter is approved only for patients with HER2-low breast cancer.

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