Screening
Systemic Therapy
Recommendation 8.2
➤ For a patient who receives a standard surgical and/or radiotherapy-based
approach to treatment of brain metastases and whose systemic disease
is progressive at the time of brain metastasis diagnosis, clinicians should
offer HER2-targeted therapy according to the algorithms for treatment of
HER2-positive metastatic breast cancer. (Moderate recommendation; FC-I)
Qualifying Statement: Recommendation 8.2 applies with one exception. In addition
to trastuzumab deruxtecan in the second-line setting, the HER2CLIMB regimen of
tucatinib and capecitabine and trastuzumab may be offered to patients with stable brain
metastases after local therapy.
Recommendation 9.1
➤ If a patient develops intracranial disease progression after WBRT or SRS
(including when a patient is not a candidate for reirradiation), clinicians
may discuss offering systemic therapy using a regimen with some evidence
of activity in the setting of CNS disease. (Moderate Recommendation; FC-I)
Recommendation 10.1 (screening)
➤ If a patient does not have a known history or symptoms of brain
metastases, there are insufficient data to recommend for or against
performing routine surveillance with brain magnetic resonance imaging.
Clinicians and patients may discuss options using shared decision-making
processes. (Weak Recommendation; FC/IC-L)
Recommendation 10.2
➤ Clinicians should have a low threshold for performing diagnostic brain
magnetic resonance imaging (MRI) testing in the setting of any neurologic
symptoms suggestive of brain involvement, such as new-onset headaches,
unexplained nausea or vomiting, or change in motor or sensory function.
(Strong recommendation; FC-L)
a
Favorable prognosis: ose with good performance status and eligible for and access to effective systemic
therapy options. e criteria may include Karnofsky performance status (KPS) >70, controlled extracranial
disease, and/or whether good salvage systemic therapy options for extracranial disease are available.
b
Limited metastases: Two to four metastases.
c
Diffuse/extensive brain metastases: ≥ five metastases.
