Routine Screening for Brain Metastases Among Patients With HER2-Positive Breast Cancer

At the Great Debates and Updates in Women’s Oncology in New York, New York, Laura Huppert, MD, University of California, San Francisco, California, argued that routine screening for brain metastases is unnecessary for patients with either early or metastatic HER2-positive breast cancer.  

As Dr Huppert cited, “I really think we need to focus our efforts on identifying biomarkers and ways to predict which patients are highest risk of CNS metastases so that we can better implement these risk predictors and help guide screening programs in a more personalized fashion.” 

Transcript: 

Hello, my name is Laura Huppert from the University of California, San Francisco. I just got back from Great Debates in Women's Oncology in New York City, which was a wonderful meeting and I was part of the debate about brain metastases screening– in particular whether or not we should screen patients with HER2-positive disease. I was on the side arguing against central nervous system (CNS) screening.

I think it is a controversial area and of course, in these debates, you decide one side or the other, but I think arguments for the "no" side, particularly in the early-stage, HER2-positive space, some of the key points we discussed were that whether or not a patient responds to neoadjuvant chemotherapy and HER2-directed therapy does not predict risk of brain metastases, which is really interesting. We really need better biomarkers to help us predict which patients with early-stage HER2-positive breast cancer are at highest risk for CNS disease. If we were to implement a screening program for early-stage disease, because pCR doesn't correspond to risk of brain metastases, we really would need to be screening everyone and that would be a big burden on the health care system, in terms amount of cost of that screening, it would be a big burden on our patients, in terms of co-pays and stress about scans. Rather than implementing sort of a routine screening program for all early-stage patients, I really think we need to focus our efforts on identifying biomarkers and ways to predict which patients are highest risk of CNS metastases so that we can better implement these risk predictors and help guide screening programs in a more personalized fashion. That was sort of that early-stage side of the debate. 

The metastatic side, I also think is a very controversial area, I think we have better CNS-penetrant agents, which are wonderful for our patients. If we know a patient has brain metastases, we can make sure they're on a drug or combination of agents that does provide CNS penetration. I think the controversy and issue here is, do we know that instituting a screening program at some serial amount of time will help our patients live longer and do better, versus if a patient has a symptom, if we're responding based on their symptoms to get the MRI accordingly, is that enough? And we really just don't have enough data in this space. There are actually prospective trials now looking at if screening programs help our patients live longer, which I think are fabulous. If these prospective trials show benefit, then I hope we do move in that direction, but the argument against screening now is that we just don't have the data to support that it helps our patients live longer with less symptoms right at the moment. 

I think for now the current guidelines are not to do routine screening, but to do some triggered MRIs which I think makes sense until we have more data to help guide us.

Source: 

Huppert L. Debate: No We should not screen or HER2 brain mets. Presented at Great Debates & Updates in Women’s Oncology; May 3-4 2024; New York, NY.