ASCO Issues Guideline on Hormonal Therapy for Metastatic Hormone Receptor-Positive Breast Cancer

This information is meant to help doctors and their patients choose which order to use these treatments, and in what combinations
Breast Cancer News
July 8, 2016
By: 
Erin Rowley, Writer and Content Coordinator
Reviewed By: 
Victoria Blinder, MD

The American Society of Clinicalinfo-icon Oncologyinfo-icon (ASCO) issued a new treatment guideline on hormonal therapyinfo-icon for hormone receptorinfo-icon-positive breast cancer that has spread outside the breast and nearby lymphinfo-icon nodes.

The new guideline was published online in May in the Journal of Clinical Oncology.

Background

Breast cancer that grows because of the hormones estrogeninfo-icon, progesteroneinfo-icon, or both, is called hormone receptor-positive, and it is the most common type of breast cancer. It is treated with hormonal therapy, also called endocrine therapyinfo-icon, which limits either the amount of those hormones in the body or the ability of those hormones to cause cancer to grow. Many hormonal therapies exist, including tamoxifeninfo-icon, aromatase inhibitors, fulvestrantinfo-icon (Faslodexinfo-icon) and surgeryinfo-icon to remove the ovaries.

Different treatments, and treatment combinations, are available based on a number of factors, including if a woman has gone through menopauseinfo-icon and what treatments she’s received in the past.

Why and How the Guideline Was Created

ASCO creates guidelines in order to help doctors and people diagnosed with cancer make treatment decisions that are based on scientific evidence. Before a guideline is issued, a committee of experts reviews the available research. To create this guideline, experts reviewed evidence that was gathered from 2008 to 2015.

Recommendations

The new guideline contains the following treatment recommendations for women with hormone receptor-positive metastaticinfo-icon breast cancer:

  • hormonal therapy should be used as the first treatment, unless:
    • the disease is immediately life-threatening, OR
    • the person is still taking hormonal therapy for early-stageinfo-icon disease and the cancer has spread to an internal organinfo-icon like the liver or lungs (called “visceral”) and is progressing quickly
  • Hormonal therapy should be offered  to anyone with hormone receptor-positive metastatic breast cancer, even if the level of receptors is low
  • Premenopausalinfo-icon women should be advised to stop their ovaries from working, either temporarily, with medicineinfo-icon (ovarian suppressioninfo-icon), or permanently, with surgery (ovarian ablationinfo-icon) to decrease the amount of estrogen their bodies make
  • If possible, each treatment should continue to be given until it is clear – from symptoms, imaginginfo-icon tests or clinical exams – that the disease has gotten worse
  • Hormonal therapy should be given one treatment after another – if one fails, a different hormonal therapy should be given in its place
  • Combining hormonal therapy and chemotherapyinfo-icon is not recommended
  • If the disease is hormone receptor-positive AND HER2-positive, and the person is not a candidate for chemotherapy, they should be offered HER2-targeted therapyinfo-icon in combination with an aromatase inhibitorinfo-icon
  • Doctors should encourage women to join clinical trials

First-line therapyinfo-icon

Premenopausal women who haven’t been treated with hormonal therapy in the past should receive:

  • Ovarian suppression or ablationinfo-icon AND an aromatase inhibitor, especially a nonsteroidal one such as letrozoleinfo-icon (Femarainfo-icon) or anastrozoleinfo-icon (Arimidex)
    • The aromatase inhibitor may be combined with another oralinfo-icon medicine called palbociclib (Ibrance) or an injected hormonal therapy called fulvestrant (Faslodex)

Premenopausal women who were treated with tamoxifen for early-stage breast cancerinfo-icon, and who were diagnosed with metastatic breast cancer less than a year after finishing tamoxifen treatment, should receive ovarian suppression or ablation AND:

Premenopausal women who were treated with tamoxifen for early-stage breast cancer, and who had a metastatic breast cancer recurrenceinfo-icon more than a year after finishing treatment, should receive ovarian suppression or ablation AND:

  • A nonsteroidal aromatase inhibitor, alone, with palbociclib, or with fulvestrant, OR
  • Tamoxifen

Premenopausal women who were treated with an aromatase inhibitor for early-stage breast cancer, and who had a metastatic breast cancer recurrence less than a year after finishing treatment, should receive ovarian suppression or ablation AND:

  • Fulvestrant, with or without palbociclib, OR
  • An aromatase inhibitor plus everolimusinfo-icon (Afinitor), OR
  • A steroidal aromatase inhibitor, such as exemestaneinfo-icon (Aromasininfo-icon), OR
  • Tamoxifen

Premenopausal women who were treated with an aromatase inhibitor for early-stage breast cancer, and who had a metastatic breast cancer recurrence more than a year after finishing treatment, should receive ovarian suppression or ablation AND:

  • A nonsteroidal aromatase inhibitor, OR
  • Fulvestrant, OR
  • An aromatase inhibitor plus palbociclib, OR
  • Tamoxifen

Second-Line Therapyinfo-icon

Depending on what treatments a person had in the past, options for second-line treatment of a premenopausal woman include ovarian suppression or ablation AND:

  • Fulvestrant, with or without palbociclib
  • An aromatase inhibitor plus everolimus
  • A steroidal aromatase inhibitor, such as exemestane
  • Tamoxifen

The guidelines for postmenopausalinfo-icon women are similar with the following exceptions:

  • Ovarian suppression or ablation is not needed
  • Tamoxifen is not recommended as first-line therapy in postmenopausal women who have never been treated with hormonal therapy
  • Tamoxifen is not recommended as first-line therapy in postmenopausal women who were treated with tamoxifen for early-stage breast cancer, and who were diagnosed with metastatic breast cancer less than a year after finishing tamoxifen treatment

What This Means for You

This guideline reinforces the idea that hormonal therapies are the preferred treatments for hormone receptor-positive metastatic breast cancer, even when the cancer is only slightly hormone receptor-positive. If you have hormone receptor-positive metastatic breast cancer, and you’re receiving hormonal therapy, this guideline may help you feel more confident that you’re getting the best treatment. Talk to your doctor about this guideline and how it may affect your treatment plan.

More Living Beyond Breast Cancer resources about metastatic breast cancer can be found here. You can also visit our Guides to Understanding page to learn more about our Metastatic Breast Cancer Series.

Rugo, HS, Fowble, B, Mehta, RS et al. Endocrine Therapy for Hormone Receptor–Positive Metastatic Breast Cancer: American Society of Clinical Oncology Guideline. Journal of Clinical Oncology, May 23, 2016; doi: 10.1200/JCO.2016.67.1487.

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Metastatic