New medications and longer survival rates have helped spur new ASCO guidelines on how clinicians can best treat their patients with different subsets of breast cancer. Compiled by co-chairs who worked with panels of experts from around the world, the guidelines encompass all aspects of cancer care. They include contributions from physicians, nurses, ASCO methodologists, patient representatives, and other authorities in patient quality of life, economics, and disease control. As a result, each ASCO guideline represents the latest in cancer literature, scholarly analysis and evaluation of available protocols, and the highest resources to set the standards of care for medical teams working to help patients with breast cancer.
Advanced HER2-Positive Breast Cancer With Brain Metastases
A 2014 ASCO clinical practice guideline on how to treat patients with advanced HER2-positive breast cancer that has spread to the brain was the first guideline to show that all patients with brain metastases cannot be treated the same way, according to Naren Ramakrishna, MD, PhD, the guideline’s lead author.
Dr. Naren Ramakrishna
Historically, between 30% and 50% of all patients with any kind of metastatic cancer developed brain metastases; through the 1990s and 2000s, they were typically treated with a “one-size-fits-all” therapy based on studies of patients with lung cancer with brain metastases, Dr. Ramakrishna said. But with better systemic therapies, patients with advanced HER2-positive breast cancer with brain metastases are surviving longer—2 years or more, compared to 8 months for patients with lung cancer with brain metastases.1-3 “We didn’t feel it was fair to patients with breast cancer to treat them with the evidence from the 1990s mainly generated from patients with lung cancer,” he said.
Additionally, patients with HER2-positive breast cancer were living long enough that they were facing side effects from the brain metastases treatment—another reason to change the one-size-fits-all approach. “The guideline takes into account the patient’s quality of life,” Dr. Ramakrishna said. “If a patient with cancer is only living 6 to 9 months after treatment for brain metastasis, certain toxicities may not become apparent. If you have some patients living 2 to 4 years or longer, you must consider the potential risks of that therapy that may manifest with longer survival.”
The guideline, “Recommendations on Disease Management for Patients With Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer and Brain Metastases: American Society of Clinical Oncology Clinical Practice Guideline,”4 was published online in May 2014 and in Journal of Clinical Oncology in July 2014. It details the different ways to evaluate the best treatment for brain metastases in this subset of patients with breast cancer, taking into consideration tumor size and frequency and patient prognosis. Dr. Ramakrishna co-chaired the guideline with Nancy U. Lin, MD, and relied on an expert panel of 14 physicians and patients who analyzed the existing literature and gave feedback in order to arrive at the final recommendations.
Such guidelines will “set the stage for further disease-specific recommendations for brain metastases, such as patients with melanoma or lung cancer, as they respond to different drugs,” Dr. Ramakrishna said, particularly as “the treatment of brain metastases will evolve rapidly in the next few years.”
Endocrine Therapy for HR-Positive Metastatic Breast Cancer
For patients with HR-positive metastatic breast cancer, estrogen therapy combined with newly available drugs can be a real game changer.
So says Harold Burstein, MD, PhD, FASCO, co-chair of the ASCO guidelines on “Endocrine Therapy for Hormone Receptor–Positive Metastatic Breast Cancer.” Dr. Burstein said that the guidelines, published in Journal of Clinical Oncology in February 2016,5 remind clinicians that first-line treatment for this kind of breast cancer should be hormone therapy and not chemotherapy.
But new drugs, such as the CDK-4/6 inhibitor palbociclib, approved by the U.S. Food and Drug Administration in February 2015,6 have “really changed the way we manage this kind of cancer,” he said.
The guidelines were developed by an expert panel of 16 co-authors, including experts from the United States and the United Kingdom, a patient representative, an ASCO methodologist, a clinical nurse, experts in quality of life and disease control, and other clinicians. They analyzed existing literature on the topic published between 2008 and 2015.
The guidelines recommend that when developing a treatment plan, physicians should consider a patient’s experience with adjuvant treatment, how long she has been in remission, how well her organs are working, and whether she is pre- or postmenopausal.
Such work is important because it ensures that “patients are treated with the best-possible evidence-based medicine,” said Hope S. Rugo, MD, the guidelines’ co-chair. “Developed by experts in the field, the guidelines help to provide quality of care for our patients, and they allow physicians and patients to have one-stop shopping for a particular patient situation, with up-to-date information including new targeted agents. Focusing on disease stage and biology is what make the guidelines ASCO-specific.”
Chemotherapy and Targeted Therapy Recommendations for Early-Stage Breast Cancer
Dr. Antonio Wolff
“Most of these patients will move on and live full lives, and that’s wonderful news,” he said. “But it puts the onus on us to give just the right treatment.” Too little treatment might not be enough to effectively treat the cancer, although “we want to avoid toxicity from excessive treatment, because most patients go on to live their lives without recurrence,” he said.
Dr. Neelima Denduluri
The recommendations give specifics on the optimal use of cytotoxic chemotherapy and HER2-directed therapy, with guidelines given for patients older than age 65, first-line treatments and alternatives when those treatments are contraindicated, treatments based on tumor size, and which medications should be avoided because of toxic cardiac side effects.
“The Canadians did a comprehensive job with their recommendations, and what we tried to do is update and tweak small things that may have changed, or reconcile some of the regional differences,” said Neelima Denduluri, MD, who co-chaired the guideline. Overall, the guidelines are a summary of the latest standards of care for patients with early breast cancer treated with chemotherapy, she said.
Published April 18, 2016, in Journal of Clinical Oncology, the guidelines were analyzed and discussed with a panel of experts, including a patient representative and physicians from cancer centers across Canada and the United States. “It was nice to see people from different institutions come together with these recommendations,” Dr. Denduluri said.
Overall, “efforts like this can simplify the dissemination of new information for the uptake of recommendations to a larger audience of providers and patients,” Dr. Wolff said. “They also increase the likelihood that well–thought out recommendations will be absorbed and implemented.”
– Cheryl Alkon