ASCO Releases Companion Guideline on Disease Management for Patients With Advanced HER2-Positive Breast Cancer and Brain Metastases
As many as half of patients with metastatic HER2-positive breast cancer develop brain metastases over time. The American Society of Clinical Oncology recently released a clinical practice guideline on disease management for patients with advanced HER2-positive breast cancer and brain metastases. A companion ASCO clinical practice guideline on systemic therapy for patients with advanced HER2-positive breast cancer has also been published in the Journal of Clinical Oncology.
The guideline recommendations were developed using evidence from observational studies and clinical experience. A literature search for evidence on brain metastases was conducted, but no publications met the inclusion criteria. On review of the available evidence, the ASCO expert panel concluded that the majority of the evidence was insufficient to inform evidence-based recommendations for a traditional ASCO clinical practice guideline.
Thus, the recommendations were developed by a multidisciplinary group of experts and reviewed by a consensus ratings panel including radiation oncologists, neurosurgeons, members of the ASCO Breast Cancer Guidelines Advisory Group, and others using a formal consensus process based on the best available evidence and clinical experience.
The ASCO expert panel was co-chaired by Sharon H. Giordano, MD, of The University of Texas MD Anderson Cancer Center, and Eric P. Winer, MD, of Dana-Farber Cancer Institute.
Guideline Questions
The clinical practice guideline was aimed at addressing an overarching question and four associated questions. The primary question was: “What is the appropriate course of treatment for patients with HER2-positive advanced breast cancer and brain metastases?” The additional questions were:
- “Does the approach to local therapy of brain metastases differ in patients with HER2-positive breast cancer?”
- “How should systemic therapy be managed in patients with HER2-positive brain metastases (including management of systemic therapy when the brain is the only site of progression vs when progression occurs in both the brain and elsewhere)?”
- “Is there a role for systemic therapy specifically to treat brain metastases in HER2-positive breast cancer?” and
- “Should patients with HER2-positive breast cancer be screened for development of brain metastases?”
The guideline recommendations are summarized below. A recommendation strength of weak was assigned to most recommendations; this rating indicates that there is some confidence that the recommendation offers the best current guidance for practice.
Recommendations
- For patients with a favorable prognosis for survival and a single brain metastasis, treatment options include surgery with postoperative radiation, stereotactic radiosurgery, whole-brain radiotherapy (with or without stereotactic radiosurgery), fractionated stereotactic radiotherapy, and stereotactic radiosurgery (with or without whole-brain radiotherapy), depending on metastasis size, resectability, and symptoms. After treatment, serial imaging every 2 to 4 months may be used to monitor for local and distant brain failure.
- For patients with a favorable prognosis for survival and limited (two to four) metastases, treatment options include resection for large symptomatic lesion(s) plus postoperative radiotherapy, stereotactic radiosurgery for additional smaller lesions, whole-brain radiotherapy (with or without stereotactic radiosurgery), stereotactic radiosurgery (with or without whole-brain radiotherapy), and fractionated stereotactic radiotherapy for metastases > 3 to 4 cm. For metastases < 3 to 4 cm, treatment options include resection with postoperative radiotherapy. In both cases, options depend on resectability and symptoms.
- For patients with diffuse disease/extensive metastases and a more favorable prognosis and those with symptomatic leptomeningeal brain metastasis, whole-brain radiotherapy may be offered.
- For patients with poor prognosis, options include whole-brain radiotherapy, best supportive care, and palliative care.
- For patients with progressive intracranial metastases despite initial radiation therapy, options include stereotactic radiosurgery, surgery, whole-brain radiotherapy, a trial of systemic therapy, and enrollment onto a clinical trial, depending on initial treatment. For patients who also have diffuse recurrence, best supportive care is an additional option.
- For patients whose systemic disease is not progressive at the time of brain metastasis diagnosis, systemic therapy should not be switched.
- For patients whose systemic disease is progressive at the time of brain metastasis diagnosis, clinicians should offer HER2-targeted therapy according to the algorithms for treatment of HER2-positive metastatic breast cancer.
- If a patient does not have a known history or symptoms of brain metastases, routine surveillance with brain magnetic resonance imaging (MRI) should not be performed.
- Clinicians should have a low threshold for performing diagnostic brain MRI testing if any neurologic symptoms suggestive of brain involvement are present.
For full disclosures of the study authors, visit jco.ascopubs.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
