ASCO Issues New Guideline for Advanced HER2-Negative Breast Cancer

Ann H. Partridge, MD, MPH

The American Society of Clinical Oncology (ASCO) has released a new clinical practice guideline on the treatment of patients with advanced HER2-negative breast cancer.

The guideline, Chemo- and Targeted Therapy for Women with HER2-Negative (or unknown) Advanced Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline was published yesterday in the Journal of Clinical Oncology.

The guideline was developed by an ASCO panel of experts who conducted a review of medical literature published from 1993 through May 2013. It provides detailed, evidenced-based information on the efficacy and side effects of therapies, including chemotherapy and targeted therapies.

This particular guideline, Ann H. Partridge, MD, MPH, co-chair of ASCO’s expert panel that developed the guidelines said, is part of a set aimed at helping to support the care of all patients with cancer. It began with breast cancer, Partridge said, because “there are lots of controversies in this area that it was felt that the patients and their providers would benefit from additional guidelines.”

Partridge, founder and director of the Program for Young Women with Breast Cancer, director of the Adult Survivorship Program at the Dana-Farber Cancer Institute, and associate professor at Harvard Medical School, explained that it can be difficult for patients and physicians to digest all the new studies advanced breast cancer in order to make an informed treatment decision.

“These guidelines are designed to help patients and their doctors to synthesize the data, digest it, and come up with the best strategy based on the available research,” Partridge said.

The new guideline recommends that hormone therapy be offered as the standard first-line therapy for women with hormone receptor-positive advanced breast cancer, except for patients with immediately life-threatening disease or if there is concern about resistance to hormone therapy.

The guideline also states that in an attempt to combat toxicity, different chemotherapy agents should normally be given sequentially, rather than in combination. This will also help preserve quality of life.

"There are many different types of treatments available but some are unnecessarily toxic," Ian E. Smith, MD, co-chair of ASCO's expert panel that developed the guideline said in a statement. "This guideline emphasizes that breast cancer can often be controlled with less intensive approaches that offer a better quality of life for patients.“

The guideline also goes over the use of targeted therapies, which are still in development.

Today, Partridge said, only everolimus is used beyond hormonal therapy and standard cytotoxic chemotherapy. Partridge said she hopes future research will produce more effective and tolerable targeted therapies.

In order for the research of targeted therapies to progress, the guideline recommends that physicians are encouraged to educate their patients on the value of clinical trials.

“The public needs to be more aware of the opportunities of clinical trials,” Partridge said. “We can only get studies done if patients are willing to volunteer for research.”

Partridge said while it has been shown that bevacizumab added to single-agent chemotherapy improves response and progression-free survival, it does not improve overall survival. Because of its antitumor activity and approval outside of the US, the panel decided to include a recommendation to use bevacizumab with single-agent chemotherapy for patients with immediately life-threatening disease or severe symptoms. No other targeted agents should be used in addition to, or as a replacement for, chemotherapy.

The guideline recommendations revolve around the theme of palliative care, Partridge said.

“Palliative care is a critical component of the care of all patients with cancer, but of course for patients with advanced cancer,” Partridge said.

An appropriate palliative care approach can substantially improve a patients’ quality of life, Partridge said, while early palliative care can actually extend survival.

“Part of the job of a good clinician and a good team is to tend to not only the anti-cancer goals and the control of disease and extension of life goals but also attend to symptom management: both physical and emotional.”