ASCO Clinical Practice Guideline Update: Disease Management for Patients With Advanced HER2-Positive Breast Cancer and Brain Metastases

As reported in the Journal of Clinical Oncology by Naren Ramakrishna, MD, of the University of Florida Health Cancer Center at Orlando Health, and colleagues, ASCO has released a clinical practice guideline update on disease management for patients with advanced HER2-positive breast cancer and brain metastases. The update was informed by an expert panel targeted systematic literature review that identified 622 relevant publications.

Review of the publications found no additional evidence warranting substantive changes to the 2014 recommendations. The expert panel was co-chaired by Dr. Ramakrishna and Nancy U. Lin, MD, of Dana-Farber Cancer Institute. Key recommendations are reproduced or summarized below.

Key Recommendations

  • For patients with a favorable prognosis for survival and a single brain metastasis, treatment options include surgery with postoperative radiation, stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT; ± SRS), fractionated stereotactic radiotherapy (FSRT), and SRS (± WBRT), depending on metastasis size, resectability, and symptoms. After treatment, serial imaging every 2 to 4 months may be used to monitor for local and distant brain failure.
  • For patients with a favorable prognosis for survival and limited (2–4) metastases, treatment options include resection for large symptomatic lesion(s) plus postoperative radiotherapy, SRS for additional smaller lesions, WBRT (± SRS), SRS (± WBRT), and FSRT for metastases > 3 to 4 cm. For metastases < 3 to 4 cm, treatment options include resection with postoperative radiotherapy. In both cases, available options depend on resectability and symptoms.
  • For patients with diffuse disease or extensive metastases and a more favorable prognosis and those with symptomatic leptomeningeal metastasis in the brain, WBRT may be offered.
  • For patients with poor prognosis, options include WBRT, best supportive care, and/or palliative care.
  • For patients with progressive intracranial metastases despite initial radiation therapy, options include SRS, surgery, WBRT, a trial of systemic therapy, or enrollment in a clinical trial, depending on initial treatment. For patients in this group who also have diffuse recurrence, best supportive care is an additional option.
  • For patients whose systemic disease is not progressive at the time of brain metastasis diagnosis, systemic therapy should not be switched.
  • For patients 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.
  • If a patient does not have a known history or symptoms of brain metastases, routine surveillance with brain magnetic resonance imaging (MRI) should not be performed.
  • Clinicians should have a low threshold for performing diagnostic brain MRI testing in the setting of any neurologic symptoms suggestive of brain involvement.

More information is available at

The corresponding author for the Journal of Clinical Oncology article is ASCO; e-mail:

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.




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