Advances in the management of breast cancer brain metastases

Abstract

The development of breast cancer (BC) brain metastases (BrM) is a common complication of advanced disease, occurring in up to half of the patients with advanced disease depending on the subtype. The management of BCBrM requires complex multidisciplinary care including local therapy, surgical resection and/or radiotherapy, palliative care, and carefully selected systemic therapies. Significant progress has been made in the human epidermal growth factor receptor 2-positive (HER2+) BCBrM population due to novel brain penetrable systemic therapies. Increased inclusion of patients with BCBrM in clinical trials using brain-penetrant systemic therapies recently led to the first FDA approval of a HER2-directed therapy specifically in the BCBrM population in the last year. Advances for the treatment of HR+/HER2- and TNBC BCBrM subgroups continue to evolve. In this review, we will discuss the diagnosis and multidisciplinary care of BCBrM. We focus on recent advances in neurosurgery, radiation therapy, and systemic treatment therapies with intracranial activity. We also provide an overview of the current clinical trial landscape for patients with BCBrM.

Keywords: brain metastases; breast cancer; stereotactic radiosurgery; surgical resection; systemic therapies.

Figure 1.

Treatment options for patients with newly suspected or recurrent breast cancer brain metastases, including surgery, radiation therapy, and systemic treatments. Strategies are based on level 1 evidence and NCCN guidelines. Randomized controlled trials to investigate stereotactic radiation approaches for 5–15 brain lesions are ongoing. Clinical trial participation is encouraged when appropriate. BrM, brain metastasis; ER+, estrogen receptor-positive; HER2+, human epidermal growth factor receptor 2-positive; PR+, progesterone receptor-positive; SRS, stereotactic radiosurgery; SRT, stereotactic radiotherapy; T-DM1, trastuzumab emtansine; TNBC, triple-negative breast cancer; (HA-)WBRT, (hippocampal avoidance) whole-brain radiotherapy. Recommendation per NCCN guidelines. *Clinical trial participation is encouraged.