What are the ASCO treatment guidelines for HER2-positive breast cancer?

Updated: Feb 04, 2021
  • Author: Pavani Chalasani, MD, MPH; Chief Editor: John V Kiluk, MD, FACS  more...
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Evidence-based guidelines from the American Society of Clinical Oncology (ASCO) for treatment of HER2 -positive breast cancer, which are largely adapted from the 2015 Cancer Care Ontario (CCO) clinical practice guidelines, are as follows [184, 185, 186] :

  • Trastuzumab plus chemotherapy is recommended for all patients with HER2-positive, node-positive breast cancer and for patients with HER2-positive, node-negative breast cancer (>1 cm)

  • Trastuzumab plus chemotherapy may be considered in small (≤1 cm), node-negative tumors in patients with HER2-positive T1a-b N0 disease

  • In high-risk HER2-positive disease, the recommended regimen is sequential anthracycline and taxanes given concurrently with trastuzumab; or docetaxel, carboplatin, and trastuzumab for six cycles

  • For lower-risk node-negative HER2-positive disease, an alternative regimen is paclitaxel and trastuzumab in combination once weekly for 12 weeks, with trastuzumab then given for 1 year

  • In patients with high-risk disease and when a taxane is contraindicated, the optimal dose of an anthracycline three-drug regimen that contains cyclophosphamide is recommended, with a cumulative dose of doxorubicin ≥240 mg/m² or epirubicin ≥600 mg/m², but no higher than 720 mg/m²; the cumulative dose of doxorubicin in two-drug regimens should not exceed 240 mg/m²

  • Docetaxel and cyclophosphamide for four cycles is an acceptable non-anthracycline regimen

  • For patients in whom anthracycline-taxane is contraindicated, cyclophosphamide-methotrexate-fluorouracil (with oral cyclophosphamide) is an acceptable chemotherapy alternative to doxorubicin-cyclophosphamide

  • Concurrent administration of trastuzumab with the anthracycline component of a chemotherapy regimen is not recommended because of the potential for increased cardiotoxicity, but trastuzumab should be preferentially administered concurrently (not sequentially) with a non-anthracycline chemotherapy regimen

  • Second-line treatment, for patients whose disease progresses during or after first-line treatment with HER2-targeted agents, is with ado-trastuzumab emtansine (T-DM1)

  • T-DM1 can be used as third-line treatment if the cancer progresses during or after second-line treatment, in patients who have not previously received the drug

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