ASCO GUIDELINES Bundle

Metastatic HER2-Negative Breast Cancer – Chemo and Targeted Therapy Either Endocrine-Pretreated or Hormone Receptor-Negative

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Treatment ➤ Patients with metastatic triple negative breast cancer with expression of programmed cell death ligand-1 (PD-L1-positive) and no existing contraindications may be offered the addition of immune checkpoint inhibitor to chemotherapy (atezolizumab plus nab-paclitaxel or pembrolizumab plus chemotherapy) as first-line therapy. (Strong recommendation; EB-B-M) ➤ Patients with metastatic triple negative breast cancer without expression of programmed cell death ligand-1 (PD-L1-negative) should be offered single agent chemotherapy rather than combination chemotherapy as first-line treatment, although combination regimens may be offered for symptomatic or immediately life-threatening disease for which time may allow only one potential chance for therapy. (Strong recommendation; EB-B-M) Practical Information: Patients may be offered either platinum- or non-platinum- based regimens based on individualized patient and provider assessment of preferences, risks, and benefits. ➤ Patients with metastatic triple negative breast cancer who have received at least two prior therapies for metastatic disease should be offered treatment with sacituzumab govitecan. (Strong recommendation; EB-B-H) ➤ Patients with metastatic triple negative breast cancer with germline BRCA1 or 2 mutations who have previously been treated with chemotherapy in the neoadjuvant, adjuvant, or metastatic disease setting may be offered an oral PARP inhibitor (olaparib or talazoparib) rather than chemotherapy. (Strong recommendation; EB-B-M) Practical Information: Small single-arm studies show that oral PARP inhibitor therapy demonstrates high response rates in metastatic breast cancer encoding DNA repair defects, such as germline PALB2 mutation carriers and somatic BRCA mutations. It should also be noted that the randomized PARP inhibitor trials made no direct comparison with taxanes, anthracyclines, or platinums. Comparative efficacy against these compounds is unknown.

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