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


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.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.