Clinical practice guidelines for the management of central nervous system metastases in women with secondary breast cancer (#17)
Evidence-based clinical practice guidelines assist clinicians to integrate new research and to guide best practice in the management of cancer. Cancer Australia, with input from stakeholders, identified the management of central nervous system (CNS) metastases in women with secondary breast cancer (SBC) as an area of practice requiring evidence-based guidance. The incidence of brain metastases is increasing, likely because patients with SBC are surviving longer through improved control of systemic disease. CNS metastases are associated with a shorter survival time compared to other common metastases from SBC.
A multidisciplinary working group was established to oversee development of the evidence-based guideline. A systematic review of the literature was conducted, addressing research questions on the effectiveness of surgery, radiotherapy, systemic therapies and combinations of these treatments. The focus was on the management of CNS metastases from breast cancer, although studies with mixed patient populations were included. Evidence for both parenchymal and meningeal metastases was included.
The systematic review included 57 citations for the five primary research questions and included two Cochrane reviews with patients from mixed primary tumours. Based on the systematic review, recommendations and practice points were developed for a multidisciplinary setting. The evidence indicated that patients most likely to benefit from resection of metastases or stereotactic radiosurgery have a small number of accessible lesions, inactive or well controlled primary disease and limited comorbidities. For newly diagnosed brain metastases, there was no survival benefit shown when chemotherapies were added to local therapies.
There is emerging evidence for the use of HER2-directed therapies. Further research is required on the role of supportive and palliative care after a diagnosis of CNS metastases.
These evidence-based guidelines provide information to assist decision making and guide best practice in the management of CNS metastases in women with secondary breast cancer.