The Lynx Group

Guidelines Target Brain Metastases in HER2-Positive Breast Cancer

August 2014, Vol 5, No 6

Approximately 15% to 20% of patients with breast cancer have HER2-positive disease. Brain metastases are relatively common in patients with HER2-positive metastatic breast cancer, with up to 50% of patients developing metastases over time. The American Society of Clinical Oncology (ASCO) recently

issued an updated guideline for the management of brain metastases in patients with HER2-positive breast cancer (Ramakrishna N, et al. J Clin Oncol. 2014;32:2100-2108).

The main recommendations from ASCO are:

  • Patients with brain metastases should receive appropriate local therapy and systemic therapy, if indicated
    • Local therapies include surgery, whole-brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS)
    • Treatments depend on factors such as patient prognosis, presence of symptoms, resectability, number and size of metastases, previous therapy, and whether metastases are diffuse
  • WBRT may be offered in patients with diffuse disease or extensive metastases and a more favorable prognosis, and in patients with symptomatic leptomeningeal metastasis in the brain
  • Options for patients with 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, depending on initial treatment. For patients in this group who also have diffuse recurrence, best supportive care is an additional option
  • Systemic therapy should not be switched in patients whose systemic disease is not progressive at the time of a brain metastasis diagnosis
  • Clinicians should offer HER2-targeted therapy according to the algorithms for the treatment of HER2-positive metastatic breast cancer in patients whose systemic disease is progressive at the time of a diagnosis of brain metastasis
  • Because patients with HER2-positive advanced breast cancer have a high incidence of brain metastases, clinicians should not perform routine brain magnetic resonance imaging (MRI) to screen for brain metastases, but rather should have a low threshold for brain MRI.
  • The original panel and another group of experts subjected the draft recommendations to 2 rounds of formal ratings before approval.

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