Figure 2. Hormone Therapy for Premenopausal Women
with HR+ Metastatic Breast Cancer
No prior adjuvant
endocrine therapy
Note. Use of palbociclib
should be reserved for patients
without prior exposure to
cyclin-dependent kinase 4/6
inhibitors. Fulvestrant should
be administered at 500 mg every 2 weeks for three cycles, then once per month as an
intramuscular injection. Withdrawal of tamoxifen or progestins was reported to result in
short-term disease responses in older literature.
Steroidal = exemestane; nonsteroidal = anastrozole or letrozole.
Prior adjuvant endocrine therapy
Prior treatment
with tamoxifen with or
without ovarian suppression
Prior treatment
with an Al and ovarian
suppression
Early relapse
(≤ 12 months
since adjuvant
therapy)
Late relapse
(> 12 months
since adjuvant
therapy)
Early relapse
(≤ 12 months
since adjuvant
therapy)
Late relapse
(> 12 months
since adjuvant
therapy)
OS plus:
• Al
(nonsteroidal)
• Fulvestrant
(500 mg)
• Al + palbociclib
OS plus:
• Al
(nonsteroidal)
• Al + fulvestrant
• Al + palbociclib
• Tamoxifen
OS plus:
• Fulvestrant ±
palbociclib
• Al + everolimus
• Al (steroidal)
• Tamoxifen
OS plus:
• Al
(nonsteroidal)
• Fulvestrant
• Al + palbociclib
• Tamoxifen
• Fulvestrant ±
palbociclib
• Al + everolimus
• Al (steroidal)
• Tamoxifen (late
relapse)
Depending on prior
therapy:
• Fulvestrant ±
palbociclib
• Al + everolimus
• Al (steroidal)
• Tamoxifen
Sequential therapy based on prior exposure and
response to hormone therapy
• Estradiol (2 mg tid)
• Megestrol acetate
• Fluoxymesterone
• Reintroduction of prior therapy
OS plus:
• Al,
nonsteroidal
preferred
• Al + fulvestrant
• Al + palbociclib
• Tamoxifen
• Fulvestrant ±
palbociclib
• Al +
everolimus
• Al (steroidal)
• Tamoxifen
First-line
Second-line
(with continued OS)
Third-line or greater
