Last updated May 31, 2022

Systemic Therapy for Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer

Treatment

HER2+

First-Line

Recommendation 1.0
Clinicians should recommend HER2-targeted therapy-based combinations for first-line treatment, except for highly selected patients with estrogen receptor-positive (ER+) or progesterone receptor-positive (PgR+) and HER2-positive disease for whom clinicians may use endocrine therapy alone. (EB, , H, S)
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Recommendation 1.1
Clinicians should recommend the combination of trastuzumab, pertuzumab, and a taxane for first-line treatment, unless the patient has a contraindication to taxanes. (EB, B, H, S)
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Second-Line

Recommendation 2.0
If a patient’s HER2-positive advanced breast cancer has progressed during or after first-line HER2-targeted therapy, clinicians should recommend second-line HER2-targeted therapy-based treatment. (EB, , H, S)
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Recommendation 2.1 (updated)
If a patient’s HER2-positive advanced breast cancer has progressed during or after first-line HER2-targeted therapy (and the patient has not received trastuzumab deruxtecan), clinicians should recommend trastuzumab deruxtecan as a second-line treatment. (EB, B, M, S)
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Third-Line

Recommendation 3.0
If a patient’s HER2-positive advanced breast cancer has progressed during or after second-line or greater HER2-targeted treatment, clinicians should recommend third-line or greater-line HER2-targeted therapy-based treatment. (EB, , I, M)
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Overall, there are a lack of head-to-head trials, therefore there is insufficient evidence to recommend one regimen over another. The patient and clinician should discuss differences in treatment schedules, routes, and toxicities during the decision-making process.

Options include the following:
Recommendation 3.1 (updated)
If a patient’s HER2-positive advanced breast cancer has progressed during or after second-line or greater HER2-targeted treatment and the patient has already received pertuzumab and trastuzumab deruxtecan, clinicians should recommend third-line or greater HER2-targeted therapy-based treatment. (, , , )
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Recommendation 3.1.1 (updated)
If a patient has not received trastuzumab emtansine (T-DM1) in second-line, should offer T-DM1 regimen. (EB, B, H, S)
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Recommendation 3.1.2 (updated)
May offer tucatinib combined with trastuzumab and capecitabine. (EB, B, M, S)
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Recommendation 3.1.3 (updated)
May offer trastuzumab deruxtecan. (EB, B, M, S)
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Recommendation 3.1.4 (updated)
May offer neratinib combined with capecitabine. (EB, B, M, W)
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Recommendation 3.1.5
May offer lapatinib and trastuzumab. (EB, B, M, W)
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Recommendation 3.1.6
May offer lapatinib and capecitabine. (EB, B, M, W)
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Recommendation 3.1.7
May offer other combinations of chemotherapy and trastuzumab. (EB, B, M, W)
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Recommendation 3.1.8 (updated)
May offer margetuximab plus chemotherapy. (EB, B, M, W)
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Recommendation 3.1.9
If a patient has not received pertuzumab, clinicians may offer pertuzumab. (IC, B, Ins, W)
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Recommendation 3.2.0
May offer hormonal therapy (in patients with ER+ and/or PgR+ disease). (EB, B, M, W)
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Recommendation 3.2.1 (updated)
May offer abemaciclib combined with trastuzumab and fulvestrant. (EB, B, M, W)
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Timing, Dose, Schedule, and Duration

Recommendation 4.0

If a patient is receiving HER2-targeted therapy and chemotherapy combinations, the chemotherapy should continue for approximately 4–6 months (or longer) and/or to the time of maximal response, depending on toxicity and in the absence of progression. When chemotherapy is stopped, clinicians should continue the HER2-targeted therapy; no further change in the regimen is needed until the time of progression or unacceptable toxicities. (EB, , I, M)
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Recurrence

Recommendation 5.0

If a patient finished trastuzumab-based adjuvant treatment ≤12 months before recurrence, clinicians should follow the second-line HER2-targeted therapy-based treatment recommendations. (EB, , I, M)
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Recommendation 5.1

If a patient finished trastuzumab-based adjuvant treatment >12 months before recurrence, clinicians should follow the first-line HER2-targeted therapy-based treatment recommendations. (EB, , H, S)
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HER2+, ER+, PgR+

First-Line

Recommendation 6.0
If a patient’s cancer is hormone receptor-positive and HER2-positive, clinicians may recommend either: (, , , )
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Recommendation 6.0.1
HER2-targeted therapy plus chemotherapy. (EB, , H, S)
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Recommendation 6.0.2
Endocrine therapy plus trastuzumab or lapatinib (in selected cases). (EB, , M, S)
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Recommendation 6.0.3
Endocrine therapy alone (in selected cases). (EB, , I, W)
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Endocrine Therapy Sequencing

Recommendation 7.0

If the patient has started with a HER2-positive targeted therapy and chemotherapy combination, clinicians may add endocrine therapy to the HER2-targeted therapy when chemotherapy ends and/or when the cancer progresses. (IC, , Ins, W)
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First-Line Endocrine Therapy

Recommendation 8.0

In special circumstances, such as low disease burden, the presence of co-morbidities (contradictions to HER2-targeted therapy such as congestive heart failure), and/or the presence of a long disease free-interval, clinicians may offer first-line endocrine therapy alone. (IC, , Ins, W)
Qualifying Statement: Although the clinician may discuss using endocrine therapy with or without HER2-targeted, the majority of patients should still receive chemotherapy plus HER2-targeted therapy.
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Recommendation Grading

Overview

Title

Systemic Therapy for Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer

Authoring Organization

Publication Month/Year

May 31, 2022

Document Type

Guideline

Country of Publication

US

Target Patient Population

Patients with HER2-positive advanced breast cancer

Target Provider Population

Oncologist

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment

Diseases/Conditions (MeSH)

D001943 - Breast Neoplasms

Keywords

breast cancer, human epidermal growth factor receptor 2 (HER2), Advanced Breast Cancer, HER2, HER2 Positive

Source Citation

Giordano SH, Franzoi MB, Temin S, et al. Systemic Therapy for Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer: ASCO Guideline Update. J Clin Oncol. 2022 May 31. doi: 10.1200/JCO.22.00519.