The first 60 days: HER2-positive breast cancer with brain metastases

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.

• RadiologistNamed in the standard of care for: Limited brain metastases at first presentation.
• SurgeonNamed in the standard of care for: Limited brain metastases at first presentation.
• Medical oncologistNamed in the standard of care for: Limited brain metastases at first presentation, Active brain metastases after trastuzumab, pertuzumab and trastuzumab emtansine, Brain metastases, stable or active, second line, First-line maintenance to delay brain progression and 1 more.
• Clinical oncologist (radiotherapy)Named in the standard of care for: Limited brain metastases at first presentation.

A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.

Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.

1. 1.Limited brain metastases at first presentation

   Stereotactic radiosurgery to each lesion, or surgery for a large symptomatic lesion, followed by HER2-directed systemic therapy; whole-brain radiotherapy reserved for many lesions.

   Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS)Stereotactic radiosurgery (SRS)Alliance N0574 (NCCTG N0574)MRIBrain metastases (intracranial disease)
2. 2.Active brain metastases after trastuzumab, pertuzumab and trastuzumab emtansine

   Tucatinib with trastuzumab and capecitabine (HER2CLIMB), which improved survival and delayed brain progression.

   TucatinibTrastuzumabCapecitabineHER2CLIMBHER2-positive brain metastases
3. 3.Brain metastases, stable or active, second line

   Trastuzumab deruxtecan, with intracranial responses in most patients (DESTINY-Breast12), positioned as second-line therapy after DESTINY-Breast03.

   Trastuzumab deruxtecanDESTINY-Breast12DESTINY-Breast03
4. 4.Later lines

   Neratinib or lapatinib with capecitabine, trastuzumab emtansine with tucatinib (HER2CLIMB-02), repeat radiosurgery, or a clinical trial.

   NeratinibLapatinibCapecitabineTrastuzumab emtansineHER2CLIMB-02
5. 5.First-line maintenance to delay brain progression

   Tucatinib added to trastuzumab and pertuzumab maintenance after induction chemotherapy (HER2CLIMB-05).

   TucatinibTrastuzumabPertuzumabHER2CLIMB-05

Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

• Free in oncologyFree testing, helplines, rides and lodging, second opinions and trial travel help, with who is eligible.
• Financial helpManufacturer programmes, national schemes and charities by country and product.
• Second opinionExpert centres for this cancer in your country and how referral works.

• HER2-positive breast cancer with brain metastases: the full pageThe brain is the weak point of HER2-positive breast cancer: antibodies control the rest of the body but cross poorly into the brain, so up to half of patients with advanced disease develop brain metastases. Tucatinib with trastuzumab and capecitabine was the first drug proven to help, and trastuzumab deruxtecan shrinks brain lesions in most patients.
• One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
• Treatment sequencingWhich treatment tends to follow which, line by line.
• NavigatorStandard of care for your stage, what you have tried, and trials near you.