Dept. of Oncology and Radiotherapy, Medical University of Gdańsk
Over the last 20 years huge progress has been made in the management of HER2-positive breast cancer, resulting in significant improvements in patients’ length and quality of life. Anti-HER-2 therapy should be offered early to all patients with HER2+ metastatic breast cancer (MBC) and continued through the disease course. In 1st line therapy, the combination of ChT + trastuzumab and pertuzumab provides clinically significant progression-free survival (PFS) and overall survival (OS) benefit, making it the preferred treatment option. If pertuzumab is not available, combinations of chemotherapy (ChT) + trastuzumab are superior to ChT + lapatinib in terms of PFS and OS. Patients who progress on anti-HER-2 therapy combined with a cytotoxic or endocrine agent should be offered additional anti-HER-2 therapy with subsequent treatment. After 1st line trastuzumab-based therapy, T-DM1 provides PFS and OS benefit relative to other HER-2-based therapies in the 2nd line (vs. lapatinib + capecitabine) and beyond (vs. treatment of physician’s choice). Lapatinib combined with capecitabine or trastuzumab remains an option for further treatment lines.
For most triple-negative breast cancer (TNBC) patients no specific (targeted) therapy exists and chemotherapy remains the only available systemic treatment. Alike in all HER2-negative patients requiring chemotherapy, treatment options include both combination and sequential single agent ChT, although sequential monotherapy is recommended due to its lower toxicity and quality of life impact. Combination ChT should be reserved for patients with rapid clinical progression, life-threatening visceral metastases, or need for rapid symptom control. There is no preferred ChT drug or drug combination and each regimen should be given until progression or unacceptable toxicity. In patients with BRCA-associated MBC PARP-inhibitor olaparib demonstrated superior efficacy and toxicity, compared to standard chemotherapy and became an important treatment option. A platinum may also be considered, as it leads to improved response rate and PFS prolongation.