➤ Sequential hormonal therapy should be offered to patients with
endocrine responsive disease.
➤ Fulvestrant should be administered using the 500 mg dose and with a
loading schedule.
➤ Exemestane and everolimus may be offered to postmenopausal women
with hormone receptor positive metastatic breast cancer progressing
on prior treatment with non-steroidal AIs, either before or after
treatment with fulvestrant, as PFS but not OS is improved compared to
exemestane alone. This combination should not be offered as first-
line therapy for patients who relapse more than 12 months from prior
nonsteroidal AI therapy or for those who are naïve to hormonal therapy.
➤ Hormonal therapy should be offered to patients whose tumors express
any level of estrogen and/or progesterone receptors.
➤ Treatment recommendations should be offered based on the type of
adjuvant treatment, disease free interval and extent of disease at the
time of recurrence. A specific hormone agent may be used again if
recurrence occurs >12 months from last treatment.
➤ Endocrine therapy should be recommended as initial treatment for
patients with HR-positive, metastatic breast cancer except in patients
with immediately life-threatening disease or in those with rapid visceral
recurrence on adjuvant endocrine therapy.
➤ The use of combined endocrine therapy and chemotherapy is not
recommended.
➤ Treatment should be given until there is unequivocal evidence of
disease progression as documented by imaging, clinical examination or
disease-related symptoms. Tumor markers or circulating tumor cells
should not be used as the sole criteria for determining progression.
➤ The addition of HER2 targeted therapy to first-line AIs should be offered
to patients with hormone receptor positive, HER2 positive metastatic
breast cancer in whom chemotherapy is not immediately indicated.
The addition of HER2 targeted therapy to first-line AIs improves PFS
without a demonstrated improvement in OS. HER2 targeted therapy
combined with chemotherapy has resulted in improvement in OS, and is
the preferred first-line approach in most cases.
➤ Patients should be encouraged to consider enrolling in clinical trials,
including those receiving treatment in the first-line setting. Multiple
clinical trials are ongoing or planned, with a focus on improving
response to hormonal therapy in metastatic disease
