Table 6.
Priorities for breast cancer: medical oncology—metastatic breast cancer
| High priority | Medium priority | Low priority |
|---|---|---|
| Early line chemotherapy, endocrine therapy, targeted agents or immune-checkpoint inhibitors likely to improve outcomes in metastatic disease (high priority to pertuzumab/trastuzumab plus chemotherapy in HER2-positive breast cancer). Consider also, discussing case-by-case in multidisciplinary tumour board, endocrine therapy with CDK 4–6 inhibitors in ER-positive/HER2-negative breast cancer, chemotherapy plus atezolizumab in PD-L1-positive TNBC |
Second, third, beyond third-line treatment when therapy may provide clinical benefit and impact on outcome. | Bone agents therapy (zoledronic acid, denosumab) that are not needed urgently for hypercalcaemia, or not needed for pain control and in patients who are otherwise not in need for coming to the hospital (ie, receiving oral chemotherapy or endocrine therapy). Bone agents can be administered every 3 months. |
| Visceral crisis | Consider avoiding or delaying the addition of mTOR inhibitors or PIK3CA inhibitors (still not approved in European Union) to endocrine therapy, particularly in elderly patients with comorbidities. | If clinically asymptomatic follow-up imaging, restaging studies, echocardiograms and ECGs can be delayed or done at lengthened intervals. |
| Continuation of treatment in the context of a clinical trial, provided patient benefits overweight risks, with possible adaptation of procedures without affecting patient safety and study conduct. Regulatory agencies and sponsors may provide guidance on rules on study conduct during the pandemics. |
Consider, discussing case-by-case, inclusion in a clinical trial, provided patient benefits overweight risks, with possible adaptation of procedures without affecting patient safety and study conduct. | - |
mTOR, mammalian target of rapamycin; PD-L1, programmed death-ligand 1; PIK3CA, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha; TNBC, triple-negative breast cancer.