The Journal of Clinical Oncology recently reported that ASCO has made it easier for clinicians to choose the optimal systemic therapy for patients with advanced HER2+ breast cancer with its latest guideline update.  

Specifically, the guidelines recommend trastuzumab, pertuzumab, and a taxane for first-line treatment, and trastuzumab-deruxtecan for second-line treatment in this vulnerable patient population. 

According to lead author Sharon H. Giordano, MD, MPH, of the University of Texas, MD Anderson Cancer Center, Houston, the update process began with a targeted systematic literature review, which identified a total of 545 articles. Of these, 14 were chosen as the evidentiary foundation of the new recommendations. 

The new guidelines recommend HER2-targeted therapy for patients with HER2+ advanced breast cancer, except for individuals with clinical congestive heart failure or significantly compromised left ventricular ejection fraction. In these instances, patients should be evaluated on a case-by-case basis.  

With respect to first-line therapy, combination therapy with trastuzumab, pertuzumab, and a taxane is recommended, unless the patient has a contraindication to taxanes. This recommendation has not changed since the last iteration of the guidelines.  

In the second-line setting, trastuzumab-deruxtecan are recommended in patients whose HER2+ advanced breast cancer has progressed during or after first-line HER2-targeted therapy, as long as the patient has not received trastuzumab-deruxtecan.  

Choices increase in the third-line (or greater) setting, although the authors said there is insufficient evidence to recommend one regimen over another. Nevertheless, third-line therapy comprising HER2-targeted combinations is recommended if a patient's HER2+ advanced breast cancer has progressed either during or after second-line HER2-targeted treatment and the patient has already received pertuzumab and trastuzumab-deruxtecan.  

Therapeutic options in the third-line setting include tucatinib, trastuzumab emtansine, trastuzumab-deruxtecan (if either not previously administered), neratinib, lapatinib, chemotherapy, margetuximab, hormonal therapy (in patients with estrogen receptor-positive and/or progesterone receptor-positive disease), and combination therapy with abemaciclib-trastuzumab-fulvestrant. Clinicians may also offer pertuzumab if the patient has not previously received it.  

Reference: 
https://ascopubs.org/doi/full/10.1200/JCO.22.00519?bid=173603842&cid=DM10595& 

Disclosures: Authors declared financial ties to drugmakers; see guidelines for details.
Photo Credit: Getty Images.  

By Michael Vlessides, MD /alert Contributor