title: Recommendations on disease management for patients with advanced human epidermal growth factor receptor 2-positive breast cancer and brain metastases: American Society of Clinical Oncology clinical practice guideline.
abstract: OBJECTIVE
  To provide formal expert consensus-based recommendations to practicing oncologists and others on the management of brain metastases for patients with human epidermal growth factor receptor 2 (HER2) -positive advanced breast cancer.
  
  
  METHODS
  The American Society of Clinical Oncology (ASCO) convened a panel of medical oncology, radiation oncology, guideline implementation, and advocacy experts and conducted a systematic review of the literature. When that failed to yield sufficiently strong quality evidence, the Expert Panel undertook a formal expert consensus-based process to produce these recommendations. ASCO used a modified Delphi process. The panel members drafted recommendations, and a group of other experts joined them for two rounds of formal ratings of the recommendations.
  
  
  RESULTS
  No studies or existing guidelines met the systematic review criteria; therefore, ASCO conducted a formal expert consensus-based process.
  
  
  CONCLUSIONS
  Patients with brain metastases should receive appropriate local therapy and systemic therapy, if indicated. Local therapies include surgery, whole-brain radiotherapy, and stereotactic radiosurgery. Treatments depend on factors such as patient prognosis, presence of symptoms, resectability, number and size of metastases, prior therapy, and whether metastases are diffuse. Other options include systemic therapy, best supportive care, enrollment onto a clinical trial, and/or palliative care. Clinicians should not perform routine magnetic resonance imaging (MRI) to screen for brain metastases, but rather should have a low threshold for MRI of the brain because of the high incidence of brain metastases among patients with HER2-positive advanced breast cancer.
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Naren
authors.initials: N
authors.lastname: Ramakrishna
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Sarah
authors.initials: S
authors.lastname: Temin
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Sarat
authors.initials: S
authors.lastname: Chandarlapaty
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Jennie R
authors.initials: JR
authors.lastname: Crews
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Davidson
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Esteva
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Ana M
authors.initials: AM
authors.lastname: Gonzalez-Angulo
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Kirshner
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Ian
authors.initials: I
authors.lastname: Krop
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Levinson
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Shanu
authors.initials: S
authors.lastname: Modi
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Debra A
authors.initials: DA
authors.lastname: Patt
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Edith A
authors.initials: EA
authors.lastname: Perez
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Jane
authors.initials: J
authors.lastname: Perlmutter
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Eric P
authors.initials: EP
authors.lastname: Winer
authors.affiliation: Naren Ramakrishna, University of Florida Health Cancer Center at Orlando Health, Orlando; Edith A. Perez, Mayo Clinic, Jacksonville; Jennifer Levinson, Ponte Vedra Beach, FL; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Sarat Chandarlapaty and Shanu Modi, Memorial Sloan Kettering Cancer Center; Francisco J. Esteva, New York University Cancer Institute, New York; Jeffrey J. Kirshner, Hematology/Oncology Associates of Central New York, East Syracuse, NY; Jennie R. Crews, PeaceHealth St Joseph Cancer Center, Bellingham, WA; Nancy E. Davidson, University of Pittsburgh Cancer Institute and University of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA; Sharon H. Giordano and Ana M. Gonzalez-Angulo, University of Texas MD Anderson Cancer Center, Houston; Debra A. Patt, Texas Oncology, Austin, TX; Ian Krop, Eric P. Winter, and Nancy U. Lin, Dana-Farber Cancer Institute, Boston, MA; and Jane Perlmutter, Ann Arbor, MI.
authors.forename: Nancy U
authors.initials: NU
authors.lastname: Lin
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D014408:Biomarkers, Tumor / Q000032:analysis*; D001932:Brain Neoplasms / Q000737:chemistry / Q000532:radiotherapy / Q000556:secondary* / Q000601:surgery / Q000628:therapy*; D001943:Breast Neoplasms / Q000737:chemistry* / Q000473:pathology* / Q000628:therapy; D015897:Comorbidity; D032921:Consensus; D016371:Cranial Irradiation; D019468:Disease Management; D019317:Evidence-Based Medicine; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006801:Humans; D016634:Radiosurgery; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000032:analysis*; D012955:Societies, Medical; D016896:Treatment Outcome; D014481:United States
chemical_list: D014408:Biomarkers, Tumor; D018719:Erb-b2 Receptor Tyrosine Kinases; C508053:ERBB2 protein, human