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NCCN Guidelines for Patients



Breast Cancer – Metastatic (STAGE IV), Version 2.2017


Treatment guide

Hormone receptor–negative cancers

If you’re still premenopausal, chemotherapy may

cause menopause. However, don’t depend on

chemotherapy for birth control. You may become

pregnant while on chemotherapy, which can cause

birth defects. If you had menstrual periods before

chemotherapy, use birth control but not birth control

with hormones (eg, “the pill”).

Not all the side effects of chemotherapy are listed

here. Please ask your treatment team for a complete

list. If a side effect bothers you, tell your treatment

team. There may be ways to help you feel better.

Targeted therapy

There are five targeted therapies for hormone

receptor–negative breast cancer. All but one involves

HER2. As explained on page 19, some breast

cancers have many HER2s. HER2 targeted therapy

uses the HER2s to treat HER2-positive cancer.

Cancer cells need the food and oxygen in blood to

grow. Cancer cells get blood from blood vessels

that have grown into the tumor. VEGF (








actor) is one of the molecules

that triggers the growth of these blood vessels.

Targeted therapies involving HER2 or VEGF are

listed in

Guide 5


HER2 antibodies

stop the action of HER2.

Antibodies work outside of the cell. HER2 antibodies

attach to HER2 and prevent growth signals from


See Figure 11.

Trastuzumab and pertuzumab are given by infusion.

It takes about 90 minutes to get the first dose of

trastuzumab and about 30 minutes for later doses.

For pertuzumab, it takes about 60 minutes to get the

first dose and about 30 to 60 minutes for later doses.

You may have a mild flu-like response to the first

dose of trastuzumab that includes fever, chills,

headache, muscle aches, and nausea. This response

is less common with the second and third doses.

Other side effects may include damage to the heart

and rarely to the lungs.

Common side effects of pertuzumab are diarrhea,

nausea, and feeling tired and weak. Less common

side effects include skin rash, low white blood

cell counts, and mouth sores. It is not yet clear

if pertuzumab damages the heart, although

trastuzumab may do so.

HER2 conjugates

deliver cell-specific

chemotherapy. As a targeted therapy, HER2

conjugates attach to HER2s then enter the cell. Once

inside, chemotherapy is released.

Ado-trastuzumab emtansine is given by infusion. It

takes about 90 minutes to get the first dose and 30

minutes for later doses. It is given every three weeks.

Common side effects include headache, nausea,

tiredness, diarrhea or constipation, nosebleeds, and

pain in your muscles, joints, or bones. Other side

effects may include damage to the heart, liver, or


HER2 inhibitors

stop the action of HER2. Inhibitors

work inside the cell. HER2 inhibitors attach to HER2

and stop growth signals.

See Figure 11.

Lapatinib is made as a pill that is taken every day

one hour before or after a meal. Common side

effects include diarrhea and skin rash. Your hands

and feet may become red, swollen, numb, and

painful. Less common side effects include fatigue,

vomiting, headaches, shortness of breath, and

heartburn. Other side effects include heart, liver, and

lung problems.

VEGF antibodies

stop the action of VEGF. For

breast cancer, VEGF inhibitors attach to VEGF. Once

attached, VEGF cannot attach to endothelial cells

and start growth signals.