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Recommendations for use of Chemotherapy

Clinical practice recommendations

Please see statements of evidence on which the following recommendations are based.

Recommendations to individuals should be based on their circumstances, the absolute benefits and harms of treatment, and their personal preferences. These factors should be discussed with the woman.8 Women receiving chemotherapy should be reviewed regularly and monitored for adverse events.

RECOMMENDATIONS LEVEL OF EVIDENCE9 REFERENCE
In women with advanced breast cancer:    
There are several specific chemotherapy drugs and/or and
combinations with similar efficacy in any given situation
In general:
- combination chemotherapy should be considered for women with little or no previous exposure to chemotherapy, widespread or rapidly progressing disease, and few or no co-morbidities
- sequential single-agent chemotherapy should be considered for women with limited or indolent disease, previous exposure to chemotherapy,or significant co-morbidities

I

II

III

Cochrane5
Sledge10
Soto11 
In women with visceral hormone receptor-positive disease that is extensive or rapidly progressing, initial chemotherapy should be considered in preference to initial endocrine therapy I Cochrane5
Duration of chemotherapy    
Tumour response should be assessed every 6-12 weeks (2-3 cycles) during chemotherapy IV  
If disease control (stable disease or better) is confirmed and toxicity is tolerable, then chemotherapy should be continued for 18-24 weeks (6-8 cycles) I Gennari12
Extending chemotherapy beyond the standard duration (18-24 weeks; 6-8 cycles) is an option if toxicity is minimal and the goal is to delay progression

Extending chemotherapy beyond the standard duration has little or no effect on overall survival
I Gennari12
Taxanes    
Single-agent taxanes are an alternative to anthracyclines for first-line treatment for women with advanced breast cancer I Picart-Gebhart13
Combination chemotherapy that includes a taxane should be considered for women who have rapidly progressing or extensive visceral disease and limited previous exposure to chemotherapy II Sledge10
Paclitaxel
The recommended dose and schedule for weekly paclitaxel is 80 mg/m2, with a one week break every 4-8 weeks according to toxicity and the woman's preferences

The recommended dose for 3-weekly paclitaxel is 175 mg/m2 given over 3 hours

II


II

CALGB 984014


CALGB 934215
Docetaxel
The recommended dose and schedule for 3-weekly docetaxel is 75-100 mg/m2
II
Harvey16
Albumin-bound paclitaxel
Nanoparticle albumin-bound paclitaxel is an alternative to 3-weekly paclitaxel, but has not been compared with standard paclitaxel given weeklya

II

Gradishar17
Guan18
Antimetabolites    
Capecitabine as first-line chemotherapy
Single-agent capecitabine is an option for women for whom more intensive chemotherapy is not appropriate
II
Stockler20
Antimetabolites and taxanes    
Capecitabine and docetaxel
The combination of capecitabine and docetaxel is an option for women with rapidly progressing or extensive visceral disease,
good performance status and limited exposure to previous chemotherapy
II O'Shaughnessy21
Gemcitabine and paclitaxel
The combination of gemcitabine and paclitaxel is an option for women with rapidly progressing or extensive visceral disease,
good performance status and limited exposure to previous chemotherapyb
II Albain22
Targeted therapies
Trastuzumab
Recommendations for women with HER2-positive advanced breast cancer are detailed in NBCC's* guideline Recommendations for use of trastuzumab (Herceptin®) for the treatment of HER2-positive breast cancer3
Bevacizumab with first- or second-line chemotherapy for metastatic breast cancer
The routine addition of bevacizumab to chemotherapy is not recommended because the benefits do not outweigh the additional adverse effectsc
II ECOG E210023
AVADO24
Miller25
Lapatinib after progression of disease on trastuzumab
The combination of lapatinib and capecitabine is a good option for women with disease that has progressed afterchemotherapy with an anthracycline, a taxane and trastuzumabd
II Geyer26,27

aA recent trial showed that first-line treatment with nab-paclitaxel significantly improved progression-free survival for women with metastatic breast cancer compared with 3-weekly docetaxel.19 
b Preliminary results from a recent trial indicate that the addition of a PARP inhibitor to gemcitabine/
carboplatin compared with gemcitabine/carboplatin alone shows potential benefit for progression-free
 survival and overall survival for women with triple negative metastatic breast cancer.28
c A recent trial showed that the addition of bevacizumab to first-line treatment with capecitabine/taxane/anthracycline significantly improved progression-free survival for women with HER2-negative metastatic
 breast cancer.29
d A recent trial showed that the combination of lapatinib and trastuzumab significantly improved
progression-free survival compared with lapatinib alone for women with HER2-positive metastatic
breast cancer.30

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