| Guideline statement | LoE/GoR | Consensus |
|---|---|---|
| Supportive care allowing safer and more tolerable delivery of appropriate treatments should always be part of the treatment plan. | I/A | 100% |
| Early introduction of expert palliative care, including effective control of pain and other symptoms, should be a priority. | I/A | 100% |
| Access to effective pain treatment (including morphine, which is inexpensive) is necessary for all patients in need of pain relief. | I/A | 100% |
| Optimally, discussions about patient preferences at the end of life should begin early in the course of metastatic disease. However, when active treatment no longer is able to control widespread and life-threatening disease, and the toxicities of remaining options outweigh benefits, physicians and other members of the healthcare team should initiate discussions with the patient (and family members/friends, if the patient agrees) about end-of-life care. | Expert opinion/A | 96% |
| Management of cancer-related fatigue | ||
| Cancer-related fatigue is frequently experienced by patients with ABC, exerts a deleterious impact on QoL and limits physical, functional, psychological and social well-being. The aetiology of this fatigue is complex; therefore, effective management needs to be multidimensional. | – | 100% |
| It is important to assess cancer-related fatigue using appropriate PROMs before implementing various non-pharmacological approaches, such as exercise [I, A], and, if needed, pharmacological interventions [II, B]. | See in statement | 100% |
| Management of CDK inhibitor-induced neutropaenia | ||
| Neutropaenia is the most common toxicity associated with CDK 4/6 inhibition and is not generally associated with febrile neutropaenia, although an increase in infections has been reported. Treatment should be delayed until neutrophils have recovered to at least 1000/μL; dose reduction can also be considered. | II/A | 100% |
| Management of non-infectious pneumonitis | ||
| NIP is an uncommon complication of mTOR inhibition. Patient education is critical to ensure early reporting of respiratory symptoms. Treatment interruption and dose reduction are generally effective for grade 2 symptomatic NIP with use of systemic steroids and treatment discontinuation for grade 3 or greater toxicity. | II/A | 100% |
| Management of dyspnoea | ||
| Treatable causes like pleural effusion, pulmonary emboli, cardiac insufficiency, anaemia or drug toxicity must be ruled out. Patient support is essential. Oxygen is of no use in non-hypoxic patients. | – | 100% |
| Opioids are the drugs of choice in the palliation of dyspnoea. | I/A | 100% |
| Benzodiazepines can be used in patients experiencing anxiety. | II/A | 100% |
| Steroids can be effective in dyspnoea caused by lymphangitis carcinomatosis, RT or drug-induced pneumonitis, superior vena cava syndrome, an inflammatory component or in (cancer-induced) obstruction of the airways (in which case laser/stent is to be considered). | Expert opinion/B | 100% |
| Management of nausea and vomiting | ||
| ESMO/MASCC guidelines [64] are available for management of ChT-induced and morphine-induced nausea and vomiting, and these are endorsed by the ABC community. | n/a | 100% |
| There is a need to study nausea and vomiting related to chronic use of anticancer drugs. | Expert opinion/A | 100% |
| Management of endocrine toxicities of mTOR inhibition | ||
| Hyperglycaemia and hyperlipidaemia are common sub-acute complications of mTOR inhibition. Evaluation of pre-existing diabetes or hyperglycaemia at baseline is essential. Regular careful monitoring of glycaemia and lipid panel is needed to identify these toxicities. Management of grade 1 and 2 hyperglycaemia includes treatment with oral antidiabetics and basal insulin, in accordance with international recommendation for diabetes mellitus treatment. Statins are indicated to treat grade 2 and 3 hypercholesterolaemia, and fibrates should be introduced if triglyceride level >500 mg/dL (with attention to possible drug–drug interaction between everolimus and fibrates). Treatment interruption and dose reduction are generally effective for grade 2 and 3 toxicity. Treatment should be discontinued for grade 4 toxicity. | II/A | 100% |
| Management of mucositis/stomatitis | ||
| Steroid mouthwash should be used for prevention of stomatitis induced by mTOR inhibitors (suggested schedule: 0.5 mg/5 mL dexamethasone, 10 mL to swish×2 min, then spit out; qid). | I/B | 100% |
| Early intervention is recommended. | Expert opinion/A | 100% |
| For >grade 2 stomatitis, delaying treatment until the toxicity resolves and considering lowering the dose of the targeted agent are also recommended. | Expert opinion/A | 100% |
| Mild toothpaste and gentle hygiene are recommended for the treatment of stomatitis. | Expert opinion/B | 100% |
| Consider adding steroid dental paste to treat developing ulcerations. | Expert opinion/B | 100% |
| Management of chemotherapy-induced peripheral neuropathy | ||
| CIPN is frequent and potentially dose-limiting. Risk factors for neuropathy and pre-existing neuropathy need to be identified. | – | 100% |
| No medical prevention can currently be recommended. | II/C | 100% |
| Drug-related factors (dosing, timing, route) can lower the risk of CIPN. | – | 100% |
| The use of tight gloves and socks during ChT may help reduce the incidence and severity of CIPN. | Expert opinion/C | 100% |
| There are limited evidence-based treatments for CIPN, with tricyclic antidepressants, serotonin-noradrenaline re-uptake inhibitors, pregabalin and gabapentin being most often used. | II/B | 100% |
| High-quality studies are needed to evaluate strategies for prevention and management of CIPN. | – | 100% |
| Management of hand and foot syndrome | ||
| HFS is also described as palmar–plantar erythrodysesthaesia syndrome. Most frequent causes are capecitabine; pegylated liposomal doxorubicin; multikinase inhibitors. | – | 100% |
| Patients should be instructed about early recognition of HFS. | – | 100% |
| Drug-related factors (dosing, timing, route) can lower the risk of HFS. | – | 100% |
| Treatment of hyperkeratosis/fungal infections, comfortable shoes, avoidance of friction and heat are recommended. | Expert opinion/A | 100% |
| Intensive skin care of hands and feet (urea cream/ointment) is recommended. | II/A | 100% |
| High-quality studies are needed to evaluate strategies for prevention and management of HFS. | – | 100% |
In green, NEW ABC 4 statements.
ABC, advanced breast cancer; CDK, cyclin-dependent kinase; ChT, chemotherapy; CIPN, chemotherapy-induced peripheral neuropathy; Consensus, percentage of panel members in agreement with the statement; ESMO, European Society for Medical Oncology; GoR, grade of recommendation; HFS, hand and foot syndrome; LoE, available level of evidence; MASCC, Multinational Association of Supportive Care in Cancer; mTOR, mechanistic target of rapamycin; NIP, non-infectious pneumonitis; PROM, patient-reported outcome measure; qid, four times a day; QoL, quality of life; RT, radiotherapy.