The first 60 days: Early HER2-positive breast cancer
HER2-positive breast cancer caught early is usually cured. Chemotherapy with the antibodies trastuzumab and pertuzumab comes before surgery; if the tumour has gone by then, antibodies alone finish the year, and if cancer remains, trastuzumab emtansine or trastuzumab deruxtecan take over. Small tumours get a gentler regimen, and trials now ask how much treatment can be left out. Below, week by week, is what OnCo's record of Early HER2-positive breast cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Local therapy and the heart.
- SurgeonNamed in the standard of care for: Stage I, small node-negative tumours, Local therapy and the heart.
- Medical oncologistNamed in the standard of care for: Stage I, small node-negative tumours, Stage II to III, before surgery, Pathological complete response at surgery, Residual invasive disease at surgery and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Local therapy and the heart.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Surgery first, then twelve weeks of paclitaxel with a year of trastuzumab (APT).
Carboplatin, a taxane, trastuzumab and pertuzumab for six cycles without an anthracycline (TRAIN-2), or trastuzumab deruxtecan followed by taxane, trastuzumab and pertuzumab (DESTINY-Breast11).
Trastuzumab, with pertuzumab in node-positive disease, to complete one year (APHINITY, HERA); endocrine therapy if hormone receptor-positive.
Trastuzumab deruxtecan (DESTINY-Breast05) or trastuzumab emtansine for fourteen cycles (KATHERINE).
Breast conservation or mastectomy with sentinel node biopsy, radiotherapy by stage, and echocardiography every three months during trastuzumab.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example HER2 immunohistochemistry 3+ or in situ hybridisation amplification, Hormone receptor status, Pathological complete response and residual cancer burden at surgery, Left ventricular ejection fraction before and during trastuzumab, Early FDG PET response), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Stage I, node-negative HER2-positive tumours of 3 cm or less, Stage II to III hormone receptor-negative HER2-positive disease, Stage II to III hormone receptor-positive HER2-positive disease.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Stage I, small node-negative tumours
- For my situation (stage i, small node-negative tumours), which of the standard options do you recommend and why?Guideline options include: Surgery first, then twelve weeks of paclitaxel with a year of trastuzumab (APT).
- Am I a candidate for Paclitaxel / nab-paclitaxel, Trastuzumab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of APT (adjuvant paclitaxel-trastuzumab) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Stage II to III, before surgery
- For my situation (stage ii to iii, before surgery), which of the standard options do you recommend and why?Guideline options include: Carboplatin, a taxane, trastuzumab and pertuzumab for six cycles without an anthracycline (TRAIN-2), or trastuzumab deruxtecan followed by taxane, trastuzumab and pertuzumab (DESTINY-Breast11).
- Am I a candidate for Carboplatin, Docetaxel, Paclitaxel / nab-paclitaxel or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of TRAIN-2 and DESTINY-Breast11 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Pathological complete response at surgery
- For my situation (pathological complete response at surgery), which of the standard options do you recommend and why?Guideline options include: Trastuzumab, with pertuzumab in node-positive disease, to complete one year (APHINITY, HERA); endocrine therapy if hormone receptor-positive.
- Am I a candidate for Trastuzumab, Pertuzumab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of APHINITY and HERA, NSABP B-31 & NCCTG N9831 (adjuvant trastuzumab) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Residual invasive disease at surgery
- For my situation (residual invasive disease at surgery), which of the standard options do you recommend and why?Guideline options include: Trastuzumab deruxtecan (DESTINY-Breast05) or trastuzumab emtansine for fourteen cycles (KATHERINE).
- Am I a candidate for Trastuzumab deruxtecan, Trastuzumab emtansine, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of DESTINY-Breast05 and KATHERINE apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Local therapy and the heart
- For my situation (local therapy and the heart), which of the standard options do you recommend and why?Guideline options include: Breast conservation or mastectomy with sentinel node biopsy, radiotherapy by stage, and echocardiography every three months during trastuzumab.
Any stage
- Are there clinical trials I could join, for example of DESTINY-Breast05, DESTINY-Breast11, PHERGain, Trastuzumab deruxtecan?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Which women can skip chemotherapy entirely without losing cure”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Interstitial lung disease from trastuzumab deruxtecan in women who would otherwise have been cured”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Early HER2-positive breast cancer: the full pageHER2-positive breast cancer caught early is usually cured. Chemotherapy with the antibodies trastuzumab and pertuzumab comes before surgery; if the tumour has gone by then, antibodies alone finish the year, and if cancer remains, trastuzumab emtansine or trastuzumab deruxtecan take over. Small tumours get a gentler regimen, and trials now ask how much treatment can be left out.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Trastuzumab cardiotoxicity: HER2 drugs can weaken the heart's pumping, usually reversibly, so heart function is checked every three months during treatment.
- Residual cancer burden (RCB): A pathology score for how much cancer remains in the breast and lymph nodes after pre-surgery treatment, from 0 (none) to III (a large amount), combining tumour bed size, cellularity and nodal involvement.
- Pathologic complete response (pCR): No invasive cancer left in the breast and lymph nodes when the surgeon removes the tissue after pre-surgery treatment.
- Lumpectomy (breast-conserving surgery): Removing only the tumour with a rim of normal breast, keeping the breast; almost always followed by radiotherapy.
- Mastectomy: Removing the whole breast, either for cancer or preventively in BRCA1/2 carriers, where bilateral risk-reducing mastectomy cuts breast cancer risk by 90% or more.
Every term links to the glossary.