Episode # 81 • 15 Sept 2026
CNS Disease in Breast Cancer: Clinical Management & Strategies
How should a breast cancer team manage central nervous system (CNS) disease now that systemic therapy, radiation, and surgery all compete for the first move? On this episode of BackTable Tumor Board, host Dr. Lindsay Peterson interviews Dr. Barbara O'Brien, neuro-oncologist at MD Anderson, about diagnosis, sequencing, and follow-up for CNS disease in breast cancer. They discuss risk by subtype, when to image and screen, and the importance of multidisciplinary workup for new brain metastases, as well as how to choose and sequence local and systemic options.
Timestamps
00:00 - Introduction
04:24 - Risk by Subtype and CNS Screening Decisions
07:42 - Multidisciplinary Evaluation of New Brain Metastases
10:35 - Local Therapy Choices and Radiation Advances
15:43 - HER-2 Positive Disease and CNS Active Therapy
18:36 - Intrathecal Therapy, Response Imaging and CSF Testing
23:34 - Triple Negative and HR+ Disease
28:33 - Prognosis and Patient Counseling
32:59 - Symptom Management and Supportive Care
36:02 - Advice for Community Oncologists
39:34 - Key Takeaways for Clinicians and Patients
44:16 - Prevention of CNS Metastases
46:46 - Closing Remarks
Resources
- HER2CLIMB, tucatinib with trastuzumab and capecitabine in pretreated HER2 positive metastatic breast cancer
- DESTINY-Breast12, trastuzumab deruxtecan in HER2 positive advanced breast cancer with or without brain metastases
- ASCO guideline update on management of advanced HER2 positive breast cancer and brain metastases
- American Society of Clinical Oncology
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More about this episode
Dr. O'Brien reviews the shift away from whole brain radiation toward stereotactic radiosurgery, when to try CNS-active systemic therapy before radiation, and the role of proton craniospinal irradiation in leptomeningeal disease. The conversation covers HER2-positive disease, intrathecal trastuzumab, MRI and lumbar puncture for surveillance, and the evolving evidence for triple negative and hormone receptor positive disease. They close with strategies for symptom management, patient counseling, referral pathways for community oncologists, and why clinical trials and prevention are the future for patients with brain and leptomeningeal metastases.
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