REVIEWS

Treatment of HER2-positive breast cancer:

current status and future perspectives
Carlos L. Arteaga, Mark X. Sliwkowski, C. Kent Osborne, Edith A. Perez, Fabio Puglisi and Luca Gianni
Abstract | The advent of HER2-directed therapies has significantly improved the outlook for patients with
HER2-positive early stage breast cancer. However, a significant proportion of these patients still relapse and
die of breast cancer. Trials to define, refine and optimize the use of the two approved HER2-targeted agents
(trastuzumab and lapatinib) in patients with HER2-positive early stage breast cancer are ongoing. In addition,
promising new approaches are being developed including monoclonal antibodies and small-molecule tyrosine
kinase inhibitors targeting HER2 or other HER family members, antibodies linked to cytotoxic moieties or
modified to improve their immunological function, immunostimulatory peptides, and targeting the PI3K
and IGF-1R pathways. Improved understanding of the HER2 signaling pathway, its relationship with other
signaling pathways and mechanisms of resistance has also led to the development of rational combination
therapies and to a greater insight into treatment response in patients with HER2-positive breast cancer.
Based on promising results with new agents in HER2-positive advanced-stage disease, a series of large trials
in the adjuvant and neoadjuvant settings are planned or ongoing. This Review focuses on current treatment
for patients with HER2-positive breast cancer and aims to update practicing clinicians on likely future
developments in the treatment for this disease according to ongoing clinical trials and translational research.
Arteaga, C. L. et al. Nat. Rev. Clin. Oncol. advance online publication 29 November 2011; doi:10.1038/nrclinonc.2011.177

Introduction HER2-positive breast cancer therapy Breast Cancer

HER2 is a transmembrane receptor with tyrosine kinase Trastuzumab Research Program,
Vanderbilt Ingram
activity but without a known ligand that was initially iden- The monoclonal antibody trastuzumab is currently Comprehensive Cancer
tified in a rat glioblastoma model.1 It belongs to a family the only approved adjuvant treatment specifically for Center, Vanderbilt
of four receptors (EGFR/HER1, HER2, HER3, HER4) that patients with HER2-positive early stage breast cancer. University School of
Medicine, 1310 24th
are involved in regulating cell growth, survival and differ- Its anti­tumor action is not completely understood but is Avenue South,
entiation through interlinked signal transduction involv- thought to be mediated by several mechanisms follow- Nashville, TN
37212‑2637, USA
ing activation of the PI3K/Akt and the Ras/Raf/MEK/ ing binding of the antibody to the extracellular domain (C. L. Arteaga).
MAPK pathways (Figure 1).2 When highly expressed, an (ECD) of the HER2 receptor; these mechanisms include Genentech Research
excess of HER2 at the cell membrane results in constitu- antibody-dependent cell-mediated cytotoxicity (ADCC), Oncology, 1 DNA Way,
South San Francisco,
tive signaling of downstream pathways.2 Structural studies inhibition of cleavage of the ECD of the HER2 receptor CA 94080, USA
revealed that HER2 is always in an active conformation (preventing formation of a residual truncated but consti- (M. X. Sliwkowski).
Dan L. Duncan Cancer
and ready to interact with the ligand-activated HER recep- tutively active form),7 inhibition of ligand-independent Center and Lester and
tors,3 and a dominant role has been proposed for HER3 HER2 receptor dimerization, inhibition of downstream Sue Smith Breast
Center, Baylor College
in HER2 signaling.4 Amplification of the HER2 gene and/ signal transduction pathways, induction of cell-cycle of Medicine, One Baylor
or overexpression at the messenger RNA or protein level arrest, induction of apoptosis, inhibition of angio­genesis, Plaza, Houston, TX
occurs in about 20% of patients with early stage breast and interference with DNA repair.8,9 Other potential 77030, USA
(C. K. Osbourne). Mayo
cancer.5 Before the advent of HER2-directed therapies, mechanisms of action have been proposed, but data from Clinic, 4500 San Pablo
this increased level of HER2 was associated with high preclinical and translational studies are conflicting. These Road, Jacksonville,
FL 32224, USA
recurrence rates and increased mortality in patients with mechanisms include downregulation of HER2 through (E. A. Perez).
node-positive and node-negative disease.5,6 endocytosis and trastuzumab-induced internalization of Department of
HER2, with consequent increased intracellular degrada- Oncology, University
Hospital, Piazzale
tion, and potential immunological mechanisms such as Santa Maria della
Competing interests elimination of tumor-specific CD4+ CD25bright regula- Misericordia 15, 33100
M. X. Sliwkowski declares an association with the following Udine, Italy (F. Puglisi).
tory T cells resulting in an improved immune response Fondazione Centro San
company: Genentech. C. K. Osborne declares an association
with the following companies: Astra Zeneca, Genentech, against HER2-positive tumors.10 In patients, trastuzumab Raffaele del Monte
GlaxoSmithKline and Novartis. L. Gianni declares an association seems to induce tumor cell apoptosis, whereas in culture, Tabor, Via Olgettina 60,
20132 Milan, Italy
with the following companies: Astra Zeneca, Biogen Idec, anti­proliferative effects predominate.11 (L. Gianni).
Boehringer Ingelheim, Celgene, Eisai, Genentech, Genomic
In the adjuvant setting, trastuzumab is recommended
Health, GlaxoSmithKline, Millenium Takeda, Pfizer, Roche and Correspondence to:
Sanofi Aventis. See the article online for full details of the by both US (National Comprehensive Cancer Network L. Gianni
relationships. The other authors declare no competing interests. [NCCN]) and European (St Gallen) guidelines for use as gianni.luca@hsr.it

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REVIEWS
Key points
■■ HER2 gene amplification and/or overexpression occurs in about 20% of breast
cancers and is associated with more-aggressive disease and, until the advent
of HER2-targeted agents, a worse outcome
■■ The monoclonal antibody, trastuzumab (which targets HER2), and the small-
molecule tyrosine kinase inhibitor, lapatinib (which targets HER1 and HER2),
have considerable efficacy in HER2-positive breast cancer
■■ New agents in development include vaccines, modified antibodies and
derivatives, tyrosine kinase inhibitors and other agents directed against HER2,
other HER family members, and downstream and/or resistance pathways
■■ Targets in downstream and/or resistance pathways of particular interest in
HER2-positive breast cancer include mTOR, PI3K, IGF-1R, Akt, HSP90 and VEGF
■■ In advanced-stage disease, randomized trials suggest that the antibody–drug
conjugate, trastuzumab-DM1, and the dimerization inhibitor, pertuzumab, may
have superior efficacy or add to the efficacy of trastuzumab-based therapy
■■ Lapatinib, bevacizumab (which targets VEGF), neratinib (a dual HER1–HER2
inhibitor), and the peptide vaccines, GP2 and AE37, are all in adjuvant trials for
HER2-positive early stage breast cancer
monotherapy after completion of chemotherapy, and in
combination with paclitaxel or docetaxel after completion
of doxorubicin plus cyclophosphamide, or given concur-
rently with carboplatin and docetaxel.12,13 These recom-
mendations are based on results of four large ongoing
trials, in addition to several smaller trials (Table 1).
Results of individual studies are supported by a recent
meta-analysis that included six randomized clinical trials
and showed that the combination of trastuzumab with
adjuvant chemotherapy produced a significant benefit
in disease-free survival (DFS; odds ratio [OR] = 0.69),
overall survival (OR = 0.78), locoregional recurrence
(OR = 0.53), and distant recurrence (OR = 0.62), as com-
pared to chemotherapy alone.14 Of note, the statistically
significant advantage in overall survival initially observed
with the addition of trastuzumab to chemotherapy in the
HERA trial15,16 was not evident at the most recent analy-
sis.16 However, this finding is probably because 65% of
patients in the observation arm crossed over to trastu-
zumab after the release of positive trial results in 2005.16
Although small tumors (<1 cm) were not included in
the majority of randomized trials that assessed trastu-
zumab, women with node-negative HER2-positive
tumors that are 0.6–1.0 cm in size are thought to benefit
from adjuvant trastuzumab therapy, on the basis of the
demonstration of higher risk than previously appreciated
in this population. In addition, subgroup analyses from
several of the randomized trials have shown consistent
benefit of trastuzumab irrespective of tumor size.17
Despite the wealth of clinical data available on adjuvant
trastuzumab therapy, a number of important questions
are still unanswered, including the optimal duration of
treatment and how best to combine trastuzumab with
cytotoxic and other agents so as to maximize efficacy,
but minimize toxicity. Several trials are addressing the
question of the optimal duration of trastuzumab therapy
(Table 2). Data from the 2‑year arm of the ongoing HERA
study—expected in 2012—should indicate whether
longer trastuzumab therapy is better than the current
standard duration of 1 year, and several other trials are
comparing short durations (9 weeks or 6 months) with
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the standard treatment. The FinHER study has already
provided evidence that 9 weeks of adjuvant trastuzumab
(given concurrently with chemotherapy) has improved
efficacy in terms of distant relapse-free survival compared
with chemotherapy alone, but this was not compared with
the standard 1-year duration of trastuzumab treat-
ment.18,19 Data from the NCCTG N9831 trial (Table 1)
suggest that trastuzumab can be more effective if started
concurrently with the taxane component of adjuvant
chemotherapy than if started after chemotherapy has
finished.20 This approach also reduces the duration of
intravenous therapy by approximately 3 months, which
might improve convenience.21
According to the results of large clinical trials, trastu-
zumab is generally well tolerated when added to, or
administered following, a chemotherapy regimen. 22
Although potential cardiotoxicity is a concern, the major-
ity of trastuzumab-related cardiac events are asympto­
matic decreases in left ventricular ejection fraction
(LVEF). On the basis of available data on the use of trastu-
zumab in the adjuvant setting, both asymptomatic and
symptomatic (including congestive heart failure [CHF])
side effects seem to be treatable and mostly reversible.22
The risk of severe CHF or cardiac events in patients who
received anthracyclines as treatment for breast cancer
before receiving trastuzumab ranges from 0.6% to 3.9%,
on the basis of the data from the main adjuvant trials.22 In
addition, a meta-analysis including 10,955 patients from
adjuvant trials showed that the risk of clinically significant
cardiac events (grade 3 or 4) related to chemotherapy and
1 year of trastuzumab therapy was 1.9% versus 0.3% in
patients who did not receive the antibody.23
The BCIRG 006 trial compared the efficacy and safety
of a non-anthracycline regimen (docetaxel, carbo­
platin and trastuzumab) with doxorubicin and cyclo-
phosphamide; both arms were followed by docetaxel
treatment.24 In addition, another arm evaluated doxo-
rubicin and cyclophosphamide followed by docetaxel
and trastuzumab. A higher incidence of symptomatic
CHF was observed when trastuzumab was added to the
anthra­c ycline-based regimen than when added to the
non-anthracycline regimen (2% versus 0.4%; P <0.001).24
Clinical evaluation before treatment with trastuzumab
should include careful screening for cardiac risk factors
(that is, baseline LVEF 50–55% in patients >65 years with
hypertension, diabetes, or smoking habit, and with BMI
>25) and consequent close cardiac monitoring according
to specific circumstances. Trastuzumab must be avoided
if baseline LVEF is <50%.
Data from two major randomized trials in the neo­
adjuvant setting,25,26 as well as many nonrandomized
trials,27 indicate that the addition of trastuzumab to neo-
adjuvant chemotherapy also significantly improves patho­
logical complete response (pCR) rates and event-free
survival in patients with locally advanced-stage or early
stage breast cancer suitable for preoperative (primary
systemic) therapy. In the two randomized neoadjuvant
trials,25,26 trastuzumab was administered concomitantly
with anthracyclines and, although a decrease in LVEF
was observed in 27% of patients,25 symptomatic cardiac
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 REVIEWS

TGF-α NRG4
EPR
EGF BTC HB-EGF
EPG NRG1
EPR EPG
HB-EGF BTC
NRG1
NRG2 NRG3
AR
Ligand HER family
binding dimerization Extracellular
domain space

Kinase P P Cytoplasm
domain
EGFR/HER1 HER2 HER3 HER4

PI3K SOS

P
Nucleus Akt Ras

HER1 ligand
Raf
■ Proliferation
HER3 ligand ■ Motility
■ Invasiveness
HER4 ligand ■ Resistance to apoptosis MEK
■ Angiogenesis

P
MAPK

Figure 1 | Heterodimer formation of members of the HER family and downstream signaling. Signaling downstream of HER
family activation is dependent on heterodimerization of the HER family member triggered by ligand binding to the
extracellular ligand-binding domain (with the exception of HER2, which has no identified ligand and is always in an open
conformation that allows dimerization). Phosphorylation of the HER kinase domains (with the exception of HER3, which
does not have a kinase domain) initiates a downstream cascade resulting in VEGF transcription and other physiological
responses required for carcinogenesis. Abbreviations: AR, amphiregulin; BTC, betacellulin; EPG, epigen; EPR, epiregulin;
HB‑EFG, heparin-binding EGF-like ligand; NRG, neuregulin.

events occurred in only 2% of patients given trastuzumab Lapatinib

concurrently with doxorubicin.25
Trastuzumab is also approved and widely used for
patients with metastatic HER2-positive disease in com-
bination with paclitaxel28 or docetaxel,29 or as mono-
therapy.30 On the basis of the preclinical data on the
chemotherapy-sensitizing effect of trastuzumab, the
benefit of continuing anti-HER2 treatment beyond pro-
gression was examined in several retrospective trials
and these studies supported this strategy.31 In addition,
although prematurely closed, a randomized phase III
trial demonstrated that the combination of trastuzumab
plus capecitabine resulted in a significant improvement
in overall response and time to progression compared
with capecitabine alone in patients with HER‑2-positive
breast cancer who experienced progression during
trastuzumab treatment.32
Trastuzumab can be combined with a range of other
cytotoxic agents,33–36 including anthracyclines, although
concurrent administration with anthracyclines is associ-
ated with an increased risk of cardiotoxicity.28 This risk
can be manageable if the cumulative dose of anthra­
cycline is kept low and/or less-cardiotoxic anthra­cyclines
are used. 25,37,38 Importantly, the cardiac dysfunction
associated with trastuzumab use, which is thought to
be mediated via inhibition of HER2 signaling in cardiac
myocytes, seems to be largely reversible.39–41
Lapatinib is the only treatment, other than trastuzumab,
approved specifically for patients with HER2-positive
advanced-stage breast cancer. Lapatinib reversibly inhib-
its the intracellular tyrosine kinase activity of both HER2
and EGFR (also known as HER1), suppressing tyrosine
autophosphorylation and thereby downstream pathways,
such as the MAPK/Erk1/2 and PI3K/Akt pathways.42–44
Importantly, preclinical studies showed that lapatinib
could inhibit the growth of HER2-positive breast cancer
cells that were resistant to trastuzumab (including those
with truncated HER2 receptors),45 and that lapatinib
could enhance the apoptotic effect of anti-HER2 anti-
bodies.44,46,47 These findings suggested that lapatinib
might have additive or even synergistic activity if com-
bined with trastuzumab, and that it might have activity
in patients with disease resistant to trastuzumab. Better
central nervous system (CNS) penetration was also pre-
dicted (since lapatinib is a small molecule), potentially
leading to improved control of CNS disease by lapatinib
compared with trastuzumab.
Early clinical trials indicated modest clinical acti­
vity (response rates <10%) for single-agent lapatinib in
patients whose disease had progressed when receiving
trastuzumab, 48 but the combination of lapatinib and
capecitabine showed significantly superior efficacy
compared to capecitabine alone in such patients.49.50

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Table 1 | Phase III data for adjuvant trastuzumab in patients with HER2-postive early stage breast cancer
Trial name Patients (n) Median Treatment DFS* (P value) OS* (P value)
follow-up
(months)
HERA15,16,146 Node-positive or high-risk 48.4 No additional therapy 78.6% 89.3%
node-negative EBC having Trastuzumab‡ for 1 year 72.2% (P <0.0001) 87.7% (P = 0.11)
completed standard Trastuzumab‡ for 2 years NR NR
adjuvant chemotherapy
(5,090)
NSABP Node-positive EBC (2,101) 46.8§ Doxorubicin–cyclophosphamide paclitaxel|| 85.8% 93.5%
B‑31147,148 Doxorubicin–cyclophosphamide paclitaxel–trastuzumab¶ 75.8% (P <0.001) 89.4% (P <0.001)
NCCTG Node-positive or high-risk 63.6 Doxorubicin–cyclophosphamide paclitaxel–trastuzumab‡ 84% (5 years) NR
N983120,148,149 node-negative EBC (1,944) Doxorubicin–cyclophosphamide paclitaxel trastuzumab¶ 80% (P = 0.019) NR
BCIRG Node-positive or high-risk 65 Doxorubicin–cyclophosphamide docetaxel 75% 87%
00624,150 node-negative EBC Doxorubicin–cyclophosphamide docetaxel–trastuzumab‡ 84% (P <0.001 92% (P <0.001
(3,222) vs chemotherapy) vs chemotherapy)
Docetaxel–carboplatin–trastuzumab‡ 81% (P = 0.04 87% (P = 0.038
vs chemotherapy) vs chemotherapy)
PACS‑04151 Operable node-positive 47 5-FU–cyclophosphamide–epirubicin or epirubicin–docetaxel 78% (3 years) 96% (3 years)
EBC (528#) 5-FU–cyclophosphamide–epirubicin or epirubicin–docetaxel 81% (P = 0.41) 95% (P = 2.38)
trastuzumab‡ for 1 year
ECOG Stage II BC (234) 64 Paclitaxel–trastuzumab doxorubicin–cyclophosphamide 76% (5 years) 88% (5 years)
E2198152,153** Paclitaxel–trastuzumab doxorubicin–cyclophosphamide 73% (P = 0.55) 83% (P = 0.29)
trastuzumab¶
FinHER18,19 Node-positive or high-risk 62 Docetaxel or vinorelbine 73.3% 82.3%
node-negative EBC (232#) 5‑FU–cyclophosphamide–epirubicin
Docetaxel or vinorelbine 83% (P = 0.12) 91.3% (5 years)
5‑FU–cyclophosphamide–epirubicin–trastuzumab¶ (P = 0.094)
*Medians provided when available (generally not estimable). ‡8 mg/kg trastuzumab initially, then 6 mg/kg every 3 weeks. §Based on the first joint analysis of NSABP B‑31 and NCCTG N9831
studies (doxorubicin–cyclophosphamide paclitaxel vs doxorubicin–cyclophosphamide paclitaxel–trastuzumab).147 ||Protocol amended to allow paclitaxel–trastuzumab in 2003. ¶4 mg/kg
trastuzumab initially, then 2 mg/kg weekly. #Subset of main study. **Pilot randomized safety study. Abbreviations: , followed by; 5‑FU, 5‑fluorouracil; BC, breast cancer; DFS, disease-free survival;
EBC, early stage BC; NR, not reported; OS, overall survival.

A subsequent randomized trial also showed that the com-
bination of lapatinib and trastuzumab had better efficacy
than lapatinib alone in patients whose disease had pro-
gressed on trastuzumab.51,52 The combination of trastu-
zumab and lapatinib was well tolerated in this study, with
a low incidence of symptomatic (2%) and asymptomatic
cardiac events (3.4%). Overall, despite targeting the same
pathway, the incidence of cardiac toxicity seems to be
lower with lapatinib than with trastuzumab,53 possibly
owing to different effects on cardiomyocyte mitochon-
drial ATP stores,54 other differences in the mechanism of
action, or to less-sustained inhibition of HER2 by lapa-
tinib compared with trastuzumab. Randomized trials
(Table 3) have shown that CNS involvement might be
reduced by lapatinib co-administration with chemo­
therapy,49 but results of definitive head-to-head com-
parisons with trastuzumab are awaited (Table 4). The
efficacy of lapatinib seems to be confined to patients
with strong HER2 overexpression, as with trastuzumab,
although some trials are still ongoing in patients with
HER2-negative disease (Tables 3 and 4).55
Two major adjuvant trials of lapatinib are now ongoing
(TEACH and ALTTO), in addition to several trials in
the neoadjuvant setting and in patients with advanced-
stage disease. These trials should establish in the next few
years whether lapatinib and trastuzumab should be used
together or sequentially, and which settings are optimal
for the two agents.
Initial results of the NEO-ALTTO trial have been
presented.56 The study randomized 455 patients with
>2 cm HER2-positive breast cancer tumors suitable
for neoadjuvant therapy to receive lapatinib, trastu-
zumab or the combination of both. Anti-HER2 agents
were given without chemotherapy for 6 weeks, and
then weekly paclitaxel was added for 12 weeks before
surgery. Adjuvant therapy consisted of three cycles of
5‑fluorouracil–epirubicin–cyclophosphamide, and the
same anti-HER2 therapy administered in the preopera-
tive phase was continued up to a year. The rate of pCR
was significantly higher with the combination of lapa-
tinib and trastuzumab compared with trastuzumab alone
(51.3% versus 29.5%; P = 0.0001); the pCR rate was 24.7%
with lapatinib alone. In terms of toxic effects, patients in
the lapatinib arm experienced more grade ≥3 diarrhea
(23%), hepato­toxicity (13%), neutropenia (16%) and skin
disorders (7%) than patients in other arms.56
Another phase III neoadjuvant trial (GeparQuinto)
enrolled 620 patients with HER2-positive disease to
receive trastuzumab and chemotherapy or lapatinib
and chemotherapy.57 A higher rate of pCR was observed
in patients treated with trastuzumab (31.7%) than in
patients treated with lapatinib (21.7%). Of note, in the
lapatinib-treated arm 3.4% of patients discontinued
treatment because of toxic effects.
In the randomized phase II CHERLOB trial, the acti­
vity of preoperative taxane–anthracycline chemotherapy
in combination with trastuzumab, lapatinib, or combined
treatment of trastuzumab and lapatinib was evaluated in
patients with HER2-positive, stage II–IIIA breast cancer.58
For all arms, chemotherapy consisted of weekly paclitaxel

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Table 2 | Ongoing phase III trials of adjuvant trastuzumab in patients with HER2+ early stage breast cancer
Trial name Patient characteristics Treatment Primary end Data
(clinicaltrials.gov identifier) (target accrual) point expected
PHARE (NCT00381901) Resectable BC (3,400) Standard chemotherapy + trastuzumab for 1 year (concurrent TTR 2010
or sequential) vs standard chemotherapy + trastuzumab for
6 months (concurrent or sequential)
NCT00615602 Node-positive EBC (478) 5‑FU–cyclophosphamide docetaxel*–trastuzumab‡ DFS 2010
trastuzumab* for 1 year vs 5‑FU–cyclophosphamide
docetaxel*–trastuzumab‡ trastuzumab§ for 6 months
NSABP B‑43 (NCT00769379) HER2+ DCIS resected WBI over 5 weeks vs WBI over 5–6 weeks + trastuzumab Time to ipsilateral 2011
by lumpectomy (2,000) in week 1 and 3 DCIS recurrence
or invasive BC
PERSEPHONE EBC (4,000) Standard adjuvant or neoadjuvant chemotherapy + trastuzumab§ DFS 2011
(NCT00712140) for 1 year (concurrent or sequential) vs standard adjuvant
or neoadjuvant chemotherapy + trastuzumab§ for 1 year
(concurrent or sequential)
SHORT-HER (NCT00629278) Stage I–IIIA BC (2,500) Doxorubicin–cyclophosphamide or epirubicin–cyclophosphamide DFS 2012
paclitaxel or docetaxel + trastuzmab§ trastuzumab§
vs docetaxel–trastuzmab|| 5‑FU–cyclophosphamide–epirubicin
NCT00950300 Stage I–IIIC HER2+ BC with Docetaxel 5‑FU–cyclophosphamide–epirubicin + intravenous pCR and serum 2014
measurable disease (552) trastuzumab vs docetaxel 5‑FU–cyclophosphamide–epirubicin trastuzumab
+ subcutaneous trastuzumab concentrations
SOLD (NCT00593697) Node-positive or high-risk Docetaxel–trastuzumab|| 5‑FU–cyclophosphamide–epirubicin DFS 2015
node-negative EBC (3,000) vs docetaxel–trastuzumab|| 5‑FU–cyclophosphamide–epirubicin
trastuzumab
RESPECT (NCT01104935) Stage I–IIIA HER2+ BC, age Trastuzumab plus chemotherapy (choice of 5 regimens) DFS 2016
71–80 years (300) vs trastuzumab
*Dose-dense docetaxel (every 2 weeks with granulocyte-colony stimulating factor). ‡6 mg/kg trastuzumab every 2 weeks. §8 mg/kg trastuzumab initially, then 6 mg/kg every 3 weeks. ||4 mg/kg
trastuzumab initially, then 2 mg/kg weekly. Abbreviations: , followed by; 5‑FU, 5‑fluorouracil; BC, breast cancer; EBC, early stage BC; DCIS, ductal carcinoma in situ; DFS, disease-free survival;
HER2+, HER2-positive; pCR: pathological complete response; TTR, time to recurrence; WBI, whole breast irradiation.

followed by 5‑fluorouracil–epirubicin–cyclophosphamide. Potential mechanisms of resistance to trastuzumab

The pCR rate was 28% in the trastuzumab arm, 32% in the
lapatinib arm, and 48% in the combination (trastuzumab–
lapatinib) arm. No patient had symptomatic cardiac events,
including CHF. Diarrhea, rash, and hepatic disorders
occurred more frequently in lapatinib-containing arms
than in the trastuzumab arm.
Overall, these data suggest that the combined use of
trastuzumab and lapatinib might provide superior efficacy
to either agent used alone, with manageable toxic effects.
The recent premature closure of the lapatinib-alone arm
of the ALTTO study supports this view.
Mechanisms of resistance
Although trial results anticipated in the next few years will
help to optimize the adjuvant trastuzumab therapy and
establish the role of lapatinib, it is likely that inherent
and acquired resistance to trastuzumab and lapatinib will
still result in relapse and progression of HER2-positive
disease. At the moment, approximately 5,000 patients
with HER2-positive breast cancer die from this disease
each year in the USA, despite the availability of trastu-
zumab and lapatinib (M. Sliwkowski, personal com-
munication). Furthermore, the risk of cardiotoxicity
currently precludes certain patients from trastuzumab
treatment, limits the choice of agents that can be used
concurrently with trastuzumab, and necessitates careful
cardiac monitoring during HER2-directed therapy. As
a result, there is still a real need for new therapies for
patients with HER2-positive breast cancer.
include factors related to HER2 interactions with other
members of the HER family or trastuzumab, including
the loss of,59 or increased, HER2 expression;60 increased
HER1 or HER3 expression;61 increased TGF‑α expres-
sion (a ligand for EGFR/HER1); steric hindrance of
HER2-antibody interaction by membrane-associated
glycoproteins;62 and inhibition of trastuzumab binding by
HER2 ECD fragments cleaved from the HER2 receptor.61
Incomplete HER family blockade might be an important
resistance mechanism, since it could allow another HER
receptor to compensate when one receptor is blocked.63
Resistance to trastuzumab might also arise through
alternative signaling pathways or through constitutive
activation of the PI3K/Akt signaling pathway, which is
activated by HER2 signaling (and therefore suppressed
by HER2 inhibitors such as trastuzumab). Constitutive
activation might occur, for example, due to mutations
in the PIK3CA gene and/or loss of PTEN. Similar to
HER2, the IGF-1R, which can form heterodimers or
hetero­t rimers with HER2, 64 activates the PI3K/Akt
pathway and this mechanism is thought to be an impor-
tant source of trastuzumab resistance.61,62,65 Conversely,
PTEN suppresses the activation of the PI3K/Akt
pathway and loss of PTEN activity results in increased
Akt activity and resistance to trastuzumab.61,62,65 In addi-
tion, down­regulation of the cyclin-dependent kinase
p27kip1,62 increased acti­vity of the GTPase p21-rac1,66 and
increased Met receptor tyrosine kinase activity,67 have
all been implicated in trastuzumab resistance, at least in

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Table 3 | Selected phase III data for lapatinib in patients with breast cancer
Trial name Patients (n) Treatment Primary end point Other outcomes
EGF10015149,50 HER2+ ABC* (399) Capecitabine vs capecitabine–lapatinib Median TTP 4.3 months ORR 14% vs 24% (P = 0.017);
vs 6.2 months (P <0.001)‡ median OS 15.3 months
vs 15.6 months (P = 0.177)‡
EGF30001154 Previously untreated Paclitaxel–placebo vs paclitaxel–lapatinib TTP 22.9 weeks vs 29 weeks ORR 25% vs 35% (P = 0.008); EFS or
MBC§ (86 HER2+, (P = 0.142) OS not significant; in HER2+ subset:
493 HER2–) In HER2+ subset: 25.1 weeks EFS, ORR, and CBR significantly
vs 36.4 weeks (P = 0.005) better with paclitaxel–lapatinib
EGF 30008155,156 Postmenopausal Letrozole–placebo vs letrozole–lapatinib In HER2+ subset: median In HER2+ subset: ORR 15% vs 28%
women with HR+ PFS 3.0 months (P = 0.021), CBR 29% vs 48%
ABC§ (219 HER2+, vs 8.2 months (P = 0.019) (P = 0.003), OS 32.3 months
1,067 HER2–) vs 33.3 months (P = 0.113)
EGF10490052 HER2+ MBC|| (296) Lapatinib vs lapatinib–trastuzumab¶ Median PFS 8.1 weeks CBR 12.4% vs 24.7% (P = 0.01),
vs 12.0 weeks (P = 0.008) OS 39.0 weeks vs 51.6 weeks
(P = 0.106), ORR 6.9% vs 10.3%
(P = 0.46)
NEO-ALTTO56 HER2+ tumors Lapatinib lapatinib–paclitaxel surgery pCR rate 24.7% vs 29.5% ORR, percentage of node-negative
>2 cm (stage II–IIIA) FEC lapatinib vs trastuzumab¶ vs 51.3% (P = 0.0001 favoring disease at surgery, rate of breast
(target accrual 455) trastuzumab¶–paclitaxel surgery FEC the combination of lapatinib conserving surgery, DFS, OS to be
trastuzumab¶ vs lapatinib–trastuzumab¶ and trastuzumab) reported
lapatinib–trastuzumab¶–paclitaxel
surgery FEC lapatinib–trastuzumab¶
GeparQuinto#,57 HER2+ primary BC Epirubicin–cyclophosphamide pCR rate 31.7% vs 21.7% Breast conservation rate, DFS, OS,
requiring adjuvant docetaxel–trastuzumab (P <0.05) cerebral DFS to be reported
therapy (target vs epirubicin–cyclophosphamide
accrual 2,547) docetaxel–lapatinib
*Progressed on anthracycline, taxane, and trastuzumab. ‡Results are based on the most recent data.35 §Not selected for HER2. ||Progressed on prior trastuzumab. ¶4 mg/kg trastuzumab
initially, then 2 mg/kg every week. #HER2+ part (trial included four other arms for patients with HER– disease). Abbreviations: , followed by; ABC, advanced-stage BC; BC, breast cancer; CBR,
clinical benefit rate; DFS, disease-free survival; EFS, event-free survival; FEC, 5‑fluorouracil–epirubicin–cyclophosphamide; HER2+, HER2-positive; HER2–, HER2-negative; HR, hormone receptor;
MBC, metastatic breast cancer; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; pCR, pathological complete response; TTP, time-to-tumor progression.

in vitro studies. It is thought that multiple mechanisms
of resistance may coexist in trastuzumab-resistant cells.59
Many of the mechanisms of resistance to trastuzumab
would not be expected to interfere with the activity of
lapatinib, notably those involving interactions with the
ECD of the HER2 receptor, ligand binding or dimeriza-
tion. Resistance due to PI3KCA mutations and a low
PTEN expression would be expected to affect the sensi-
tivity of tumor cells to both trastuzumab and lapatinib.59
However, despite some recent conflicting results, data
suggest that PI3K amino acid substitutions and PTEN
loss may be less important in resistance to lapatinib com-
pared with trastuzumab.61,68,69 Indeed, resistance to lapa-
tinib has been attributed to redundant survival pathways
that could be induced as a consequence of a marked inhi-
bition of HER2 kinase activity. For example, prolonged
inhibition of the PI3K/Akt pathway in lapatinib-exposed
cells might result in upregulation of the transcription
factor FOXO3A, which in turn leads to increased estrogen
receptor signaling.70
Similar to the derepression of estrogen receptor,
increased phosphorylation of RelA, the pro-survival
subunit of NFκB, has been proposed as a potential
estrogen receptor-independent mechanism of acquired
autoresistance to lapatinib.71 Preclinical data suggest that
activation of RelA by persistent exposure to lapatinib
might promote cell survival and, in turn, cause resistance
by competing with the drug-induced proapoptotic effects.
A number of therapeutic strategies have been devised
to overcome or avoid resistance to trastuzumab and lapa-
tinib (Table 5). Strategies that are not likely to specifically
benefit patients with HER2-positive disease or do not
clearly involve the HER2 pathway (for example, new
cytotoxic agents) will not be considered further here,
although such agents can logically be ideal candidates
for combination with HER2-targeted therapies owing to
non-cross resistance and non-overlapping toxicity.
Antibody modification
ADCC involves an interaction between the constant
region (Fc) of an antibody and leukocyte (Fcγ) recep-
tors (FcγRs). The genotype of the FcγRIIIa‑158 corre-
lates with response and progression-free survival (PFS) in
patients receiving trastuzumab-based therapy for meta-
static breast cancer, suggesting that ADCC is important
in the antitumor activity of trastuzumab.72 Attempts to
improve the immune effector function of therapeutic
antibodies include synthesis of an IgE homolog of trastu-
zumab,73 and modification of the Fc region by amino acid
substitution or depletion of fucose from the oligosaccha-
ride moiety.74 Recombinant antibodies lacking fucose
show enhanced FcγR binding and ADCC,75 and in mice,
nonfucosylated trastuzumab was more effective against
tumor xenografts than unmodified trastuzumab. 76
Interestingly, ADCC of a fucose-negative version of
trastuzumab and ADCC of commercial trastuzumab
(fucosylated) were analyzed using peripheral blood
mononuclear cells (PBMC) from 30 volunteers includ-
ing 20 patients with breast cancer.77 PBMC were used as
effector cells and HER2-positive breast cancer cell lines
as target cells. The study showed a significantly enhanced
ADCC with the fucose-negative version of trastuzumab,

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Table 4 | Ongoing randomized trials with lapatinib in patients with HER2-positive breast cancer
Trial Phase Patient characteristics* Treatment Primary end Data
(ClinicalTrials.gov) (target accrual) point expected
Adjuvant setting
TEACH III HER2+ stage I–IIIC BC having Placebo (1 year) vs lapatinib (1 year) DFS 2012
(NCT00374322) completed standard adjuvant/
neoadjuvant chemotherapy
(3,000)
ALTTO, III HER2+ BC having completed Trastuzumab‡ trastuzumab§ (total 52 weeks) vs lapatinib DFS 2013
BIG 2‑06/N063D standard adjuvant/neoadjuvant (total 52 weeks) vs trastuzumab‡ washout lapatinib
(NCT00490139)157 chemotherapy (8,000) vs lapatinib–trastuzumab‡ vs ‘alternative design’: same
arms as above plus concurrent docetaxel–paclitaxel
Neoadjuvant setting
LETLOB II PW with HER2–, HR+ tumors Letrozole–placebo vs letrozole–lapatinib Response rate by 2009||
(NCT00422903) >2 cm (stage II–IIIA) (91) ultrasound
TRIO-TORI‑B-07 II HER2+ operable stage I–III BC Trastuzumab§ docetaxel–carboplatin vs lapatinib pCR rate 2011
(NCT00769470) (140) docetaxel–carboplatin vs lapatinib–trastuzumab§
docetaxel–carboplatin–lapatinib–trastuzumab
ELATE II HER2+ operable stage I–IIIA BC Lapatinib–epirubicin–cyclophosphamide paclitaxel– pCR in breast 2012
(NCT01205217) (164) lapatinib vs epirubicin–cyclophosphamide paclitaxel–
trastuzumab
CHERLOB II HER2+, tumors >2 cm below Paclitaxel FEC–trastuzumab‡ vs paclitaxel FEC– pCR rate after 2011
(NCT00429299)58,159 stage IIIB (120) lapatinib vs paclitaxel FEC–lapatinib–trastuzumab‡ 24 weeks 28%
vs 32% vs 48%
GEICAM/2006‑14 II–III HER2+ resectable BC or LABC Epirubicin–cyclophosphamide docetaxel–trastuzumab§ pCR rate 2011
(NCT00841828) (stage I–IIIB) (102) vs epirubicin–cyclophosphamide docetaxel–lapatinib
CALGB 40601 III HER2+, operable, measurable Paclitaxel–trastuzumab‡ surgery vs paclitaxel–lapatinib pCR 2010¶
(NCT00770809) stage II–III BC (400) surgery vs paclitaxel–lapatinib–trastuzumab‡ surgery
NSABP B‑41 III HER2+ tumors >2 cm diameter Doxorubicin–cyclophosphamide paclitaxel–trastuzumab‡ pCR rate 2012
(NCT00486668) (522) surgery trastuzumab vs doxorubicin–cyclophosphamide
paclitaxel–lapatinib surgery trastuzumab
vs doxorubicin–cyclophosphamide paclitaxel–lapatinib–
trastuzumab‡ surgery trastuzumab
EPHOS‑B III HER2+ operable BC (250) Surgery only vs trastuzumab surgery trastuzumab Apoptosis, 2012
(NCT01104571) vs lapatinib surgery lapatinib proliferation, RFS
Advanced-stage disease
HERLAP II Untreated patients with Trastuzumab§ vs lapatinib ORR 2011
(NCT00842998) measurable HER2+ MBC (120)
NCT01137994 II Untreated patients with HER2+, Trastuzumab–docetaxel/paclitaxel/vinorelbine PFS 2015
p95HER2+ MBC (300) vs lapatinib–docetaxel/paclitaxel/vinorelbine
CALGB 40302 III PW with measurable HR+ ABC Fulvestrant vs fulvestrant–lapatinib PFS 2008#
(NCT00390455) (324)
CAN-NCIC-MA31 III Untreated HER2+ MBC (600) Paclitaxel/docetaxel–trastuzumab§ PFS 2011
(NCT00667251) vs paclitaxel/docetaxel–lapatinib
CEREBEL III HER2+ MBC (650) Capecitabine–trastuzumab§ vs capecitabine–lapatinib Incidence of CNS 2013
(NCT00820222) metastases as
site of first relapse
NCT00968968 III HER2+ MBC (276) Trastuzumab§ vs lapatinib–trastuzumab§ PFS 2014
NCT01160211 III PW with HR+, HER2+ MBC (525) AI–trastuzumab vs AI–trastuzumab–lapatinib vs AI–lapatinib OS 2017
*See the trial on ClinicalTrials.gov for full details of patient inclusion criteria. ‡4 mg/kg trastuzumab initially, then 2 mg/kg every week. §8 mg/kg trastuzumab initially, then 6 mg/kg every
3 weeks. ||Preliminary (blinded) results presented ASCO 2009.158 ¶Data expected 2010 (recruiting in April 2011). #Data expected 2008 (active, but not recruiting in July 2011).
Abbreviations: , followed by; ABC, advanced-stage BC; AI, aromatase inhibitor; BC, breast cancer; CNS, central nervous system; DFS, disease-free survival; FEC, 5‑fluorouracil–epirubicin–
cyclophosphamide; HER2+, HER2-positive; HER2–, HER2-negative; HR, hormone receptor; LABC, locally advanced BC; MBC, metastatic BC; ORR, overall response rate; OS, overall survival;
PFS, progression-free survival; pCR, pathological complete response; PW, postmenopausal women; RFS, recurrence-free survival.

suggesting that removal of a fucose from the antibody
structure could result in improved efficacy (and, possibly,
a low dose of the drug required).
Other ways of enhancing the immunological func-
tion of trastuzumab include construction of bispe-
cific or trispecific antibodies, antibody fragments, or
single-chain derivatives that bind to specific FcγRs or
CD3 on the surface of immune effector cells, as well as
to HER2. Single-chain antibodies can also be manipu-
lated to reduce unwanted immunological effects, such
as cytokine release.78 Most single-chain antibodies have
not progressed beyond preclinical evaluation, although
ertumaxomab reached phase II clinical assessment.
Ertumaxomab is a trifunctional, hybrid monoclonal

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Table 5 | New approaches in the therapy of patients with HER2-positive breast cancer*
Strategies and drugs Stage of development Reference or ClinicalTrials.gov identifier
Optimization of trastuzumab antibody structure
Ertumaxomab (trifunctional, bispecific mAb targeting HER2 Phase II (terminated) Kiew et al. (2008),79 Jäger et al. (2009),80 Kiewe et al.
and CD3) (2006)81
Conjugation of HER2-targeted agents with toxins
Trastuzumab–DM1 (trastuzumab conjugated to the maytansine Phase III Krop et al. (2009)160
derivative DM1)
Targeting HER1
Pelitinib (irreversible HER1 TKI) Phase I–II (suspended) Ocaña et al. (2009)107
Targeting HER3
MM‑121 (HER3-targeted mAb) Phase I–II Schoeberl et al. (2010),161 NCT01097460,
NCT00911898
MM‑111 (HER2/HER3 bispecific antibody) Phase I–II Huhalov et al. (2010),162 NCT00911898, NCT01097460
Targeting HER2
Pertuzumab (mAb, HER2 dimerization inhibitor) Phase III Baselga et al. (2010)93
Broad-spectrum TKIs
Neratinib (irreversible HER1/HER2 TKI) Phase III‡ Burstein et al. (2010)108
BIBW‑2992 (irreversible HER1/HER2 TKI) Phase II Hickish et al. (2009)163
Inhibition of PI3K (class I)
XL147 (pan-PI3K inhibitor [all class I isoforms]) Phase I–II Shapiro et al. (2009),115 NCT01042925, NCT01082068
BGT226 (p110α-selective PI3K inhibitor) Phase I–II NCT00600275, NCT00742105
Inhibition of mTOR
Everolimus Phase III Ellard et al. (2009),129 Baselga et al. (2009),164
Inhibition of IGF‑1R pathway
Figitumumab (mAb against IGF‑1R) Phase II Gualberto (2010),165 NCT00635245
Cixutumumab (mAb against IGF‑1R) Phase II McKian & Haluska (2009),166 NCT00699491,
NCT00728949
AVE1642 (mAb against IGF‑1R) Phase II (terminated, NCT0074878
company decision)
Dalotuzumab (mAb against IGF‑1R) Phase I–II (completed) NCT00759785
AMG479 (mAb targeting IGF‑1R) Phase II NCT00626106
OSI‑906 (IGF‑1R inhibitor) Phase I–II NCT01013506
Inhibition of HSP90
Alvespimycin Phase I–II (phase II in Miller et al. (2007)137
HER2+ BC completed)
Retaspimycin Phase II Hanson et al. (2009),138 NCT00817362
BIIB021 Phase I–II Lundgren et al. (2009),140 NCT00412412
AUY922 Phase I–II NCT00526045
Vaccines and immunotherapy
E75 (peptide vaccine based on extracellular domain of HER2) Phase II Peoples et al. (2008),167 Mittendorf et al. (2008),168 Patil
et al. (2010),169 Holmes et al. (2008)170
GP2 (peptide vaccine based on transmembrane domain of HER2) Phase II Carmichael et al. (2010)171
AE37 (Ii-key hybrid HER2 peptide vaccine) Phase II Holmes et al. (2008)172
HER2 intracellular-domain peptide vaccine Phase I–II NCT00343109, NCT00791037, NCT00363012
HER2 protein AUTOVAC (PX104.1.6) Phase I–II (discontinued) NCT00068614
dHER2 (a modified HER2 protein) with AS15 adjuvant Phase I–II NCT00058526, NCT00952692
Allogeneic GM‑CSF-secreting whole-cell breast-cancer vaccine Phase II NCT00399529, NCT00095862, NCT00847171,
NCT00971737, NCT00397371
Autologous dendritic-cell vaccines (dendritic cells are loaded with Phase I–II Morse et al. (2007),173 NCT00266110, NCT00228358
HER2 peptides or genetically manipulated to express HER2)
PG13-4D5‑D12 (anti-HER2 CAR; autologous peripheral blood Phase I–II NCT00924287
lymphocytes transduced with a retroviral vector)

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Table 5 (Cont.) | New approaches in the therapy of patients with HER2-positive breast cancer*
Strategies and drugs Stage of development Reference or clinicaltrials.gov identifier
Multitarget kinase and angiogenesis inhibitors
Bevacizumab (mAb against VEGF‑A) Phase III‡ Pegram et al. (2006)144
Pazopanib (inhibitor of VEGFR, PDGFR and c‑kit; inhibits cross-talk Phase II Slamon et al. (2008)174
between HER2 and VEGFR pathways)
Sunitinib (inhibitor of VEGFR, PDGFR, c‑Kit, RET, FLT3, and CSF-1R) Phase II§ Burstein et al. (2008)175
*In clinical trials at phase I–II or higher. As adjuvant and for patients with advanced-stage disease. Two negative phase III trials in HER2-negative disease. Abbreviations: AS15, antigen-
‡ §

specific cancer immunotherapy; BC, breast cancer; CAR, coxsackievirus and adenovirus receptor; CSF-1R, macrophage colony-stimulating factor 1 receptor; FLT3, Fms-like tyrosine kinase 3;
GM‑CSF, granulocyte macrophage-colony stimulating factor; HSP90, heat-shock protein 90; IGF‑1R, insulin-like growth factor‑1 receptor; mAb, monoclonal antibody; TKI, tyrosine kinase inhibitor.

antibody that binds to HER2, CD3, and the FcγR type I/
III. Thus, it linked T lymphocytes and macrophages to
HER2-expressing cancer cells, leading to their destruc-
tion by phagocytosis.79 In vitro studies indicated that
ertumaxomab could destroy cells with low levels of HER2
expression, as well as those with high HER2 overexpres-
sion.80 A phase I study in patients with HER2-positive
breast cancer showed antitumor responses in five of 15
patients, in addition to strong immunological responses
in almost all patients.81 Toxicity was mainly related to
cytokine release, and systemic inflammatory response
syndrome was the dose-limiting toxicity. Unfortunately,
the development of ertumaxomab in breast cancer seems
to have been terminated, although apparently not owing
to safety concerns (NCT00522457, NCT00351858 and
NCT00452140).
Arming HER2 targeting agents
Trastuzumab, or derivatives of trastuzumab, have also
been used as a means of delivering a range of toxins or
drugs to HER2-expressing cells. However, toxicity (for
example hepatotoxicity with pseudomomas exotoxin
conjugates82) can be problematic. The most advanced
compound in development is trastuzumab-DM1, a con-
jugate of trastuzumab (one molecule) with an average of
3.5 molecules of the microtubule polymerization inhibi-
tor DM1 (a derivate of maytansine), which retains the
known mechanisms of action of trastuzumab, despite
conjugation.83 Thrombocytopenia was a dose-limiting
toxicity in a phase I study.84 In two phase II studies in
patients with heavily pretreated HER2-positive cancers
who had progressed on trastuzumab and lapatinib in the
metastatic setting, trastuzumab-DM1 produced response
rates between 33.8% and 41%.85,86 Higher response rates
were seen in patients with centrally-confirmed HER2-
positive disease, reinforcing the importance of accurate
HER2 assessment in patients receiving HER2-targeted
therapies.85,86 Trastuzumab-DM1 also produced higher
response rates and had a favorable toxicity profile com-
pared with trastuzumab plus docetaxel, in a randomized
study in previously untreated patients with HER2-
positive breast cancer.88 In particular, the incidence of
grade ≥3 adverse events in the trastuzumab-DM1 arm
was half that in the trastuzumab plus docetaxel arm
(37% versus 75%), no grade 3 neutropenia was observed
with trastuzumab-DM1, and only 1.5% of patients expe-
rienced alopecia. Importantly, trastuzumab-DM1 was
not associated with an increased risk of cardiotoxicity
compared with trastuzumab plus docetaxel.88 Currently,
randomized studies are ongoing comparing trastuzumab-
DM1 with capecitabine plus lapatinib, and combining
trastuzumab-DM1 with pertuzumab, in patients with
HER2-positive advanced-stage disease (Table 6).
Inhibition of HER2 dimerization
Although active against HER2 homodimers, trastu-
zumab is not effective against ligand-induced HER2
heterodimers. HER2–EGFR interactions and, particu-
larly, HER2–HER3 interactions are important in driving
HER2-positive breast cancer cells, and also in bypass-
ing trastuzumab-mediated inhibition of cell growth and
proliferation.3,4 The monoclonal antibody, pertuzumab,
binds to the HER2 ECD but at a different site to trastu-
zumab, and is able to inhibit ligand-induced dimeriza-
tion of HER2 with its receptor partners.89,90 Preclinical
experiments showed that pertuzumab and trastuzumab
produced a more-complete blockade of the HER signal-
ing network when combined, and were more effective in
HER2-positive tumor xenografts, than either antibody
alone.91 However, cetuximab, a monoclonal antibody tar-
geting EGFR, did not increase the antiproliferative effects
of either trastuzumab or pertuzumab when administered
concurrently.92 In a phase II clinical trial, treatment with
pertuzumab and trastuzumab together resulted in a 24%
overall response rate and a 50% clinical benefit rate, in
patients with HER2-positive metastatic breast cancer that
had previously progressed on trastuzumab.93 However,
efficacy in patients with HER2-negative breast cancer
was disappointingly low (response rates <5%).94
Currently, the efficacy and tolerability of pertuzumab
in combination with trastuzumab are being evaluated in
several randomized trials in patients with HER2-positive
breast cancer. In the NEOSPHERE neoadjuvant trial,
patients with operable, locally advanced or inflamma-
tory HER2-positive breast cancer were randomized to
receive one of four combination treatments: docetaxel
plus trastuzumab and pertuzumab, docetaxel plus trastu-
zumab, docetaxel plus pertuzumab, or pertuzumab plus
trastuzumab (without chemotherapy).95 A statistically
significant increase in pCR rate was seen when pertu-
zumab was combined with docetaxel and trastuzumab as
compared with the docetaxel and trastuzumab combina-
tion (45.8% versus 29%; P = 0.014; Table 6). Interestingly,
a pCR rate of 16.8% was observed in patients who did not
receive chemotherapy. Although promising, these results
are not considered to be practice changing because the

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Table 6 | Key randomized trials of new agents for patients with HER2-positive breast cancer
Trial (ClinicalTrials.gov) Phase Patient characteristics* Treatment Primary Data
(target accrual) end point expected
Trastuzumab-DM1
MARIANNE (NCT01120184) III HER2+ LABC or MBC (1,092) Trastuzumab–taxane vs T‑DM1 ± pertuzumab PFS 2017
EMILIA (NCT00829166) III HER2+ LABC or MBC (580) T‑DM1 vs capecitabine–lapatinib PFS 2013
NCT00679341 II HER2+ MBC (120) T‑DM1 vs docetaxel–trastuzumab PFS 201088
Pertuzumab
CLEOPATRA (NCT00567190) III HER2+ MBC (800) Docetaxel–trastuzumab ± pertuzumab PFS 2011
PHEREXA (NCT01026142) II HER2+ MBC (450) Capecitabine–trastuzumab ± pertuzumab PFS 2015
NEOSPHERE (NCT00545688) II HER2+ LABC, inflammatory BC Docetaxel–trastuzumab vs pCR rate 201195
and EBC (400) Docetaxel–trastuzumab–pertuzumab 29%
Trastuzumab–pertuzumab 45.8%
Docetaxel–pertuzumab‡ 16.8%
TRYPHAENA (NCT00976989) II HER2+ LABC, inflammatory BC Trastuzumab–pertuzumab–FEC trastuzumab– pCR rate 2017
or EBC (225) pertuzumab–docetaxel vs FEC trastuzumab–
pertuzumab–docetaxel vs trastuzumab–
pertuzumab–docetaxel–carboplatin§
APHINITY (NCT01358877) III Operable BC (3,806) Chemotherapy–trastuzumab ± pertuzumab Invasive DFS 2024
Neratinib
ExteNET (NCT00878709) III HER2+ stage II–IIIC BC (3,850) Placebo vs neratinib DFS 2017
NSABP FB‑7 (NCT01008150) II HER2+ LABC (120) Paclitaxel–trastuzumab vs paclitaxel–neratinib|| pCR rate in 2012
breast and axilla
NCT00777101 II HER2+ ABC (233) Capecitabine–lapatinib vs neratinib PFS 2011
NEFERTT (NCT00915018) III HER2+ locally recurrent BC Paclitaxel–trastuzumab vs paclitaxel–neratinib PFS 2013
or MBC (1,200)
I-SPY2 (NCT01042379) II Stage II or III, or T4, any N, Paclitaxel cyclophosphamide–doxorubicin pCR rate 2014
M0 BC (800) surgery treatment depending on hormone
receptor or HER2 status vs neratinib
vs figitumumab vs velaparib–carboplatin
BIBW‑2992
LUX-Breast‑1 (NCT01125566) III Stage IV HER2+ BC (780) Vinorelbine–trastuzumab vs vinorelbine–BIBW‑2992 PFS 2012
NCT00826267 II HER2+ LABC (120) Neoadjuvant trastuzumab vs neoadjuvant lapatinib ORR 2011
vs neoadjuvant BIBW‑2992
Everolimus
BOLERO‑1 (NCT00876395) III HER2+ ABC (717) Paclitaxel–trastuzumab ± everolimus PFS 2012
BOLERO‑3 (NCT01007942) III HER2+ ABC (572) Vinorelbine–trastuzumab ± everolimus PFS 2012
NCT00674414 II HER2+ BC (120) Neoadjuvant trastuzumab ± everolimus Clinical and 2014
echographic
reponse
NCT00912340 II HER2– hormone-refractory Trastuzumab ± everolimus ORR 2011
MBC (80)
Cixutumumab
NCCTG‑N0733 II HER2+ ABC (154) Capecitabine–lapatinib ± cixutumumab PFS 2009¶
(NCT00684983)
GP2 and AE37 vaccines
NCT00524277 II HER2+ node-positive high-risk HLA‑A2+ patients: GM‑CSF ± HER2 peptide GP2 Disease 2011
BC (600) vaccine recurrence
HLA‑A2– patients: GM‑CSF ± modified HER2
peptide AE37 vaccine
Pazopanib
NCT00558103 III HER2+ inflammatory BC (360) Lapatinib ± pazopanib PFS 2012
NCT00347919 II HER2+ ABC (140) Lapatinib ± pazopanib 12-week PDR Completed
(27% vs 19%)
BMS‑690,514
NCT01068704 II HER2+, hormone receptor- Letrozole–lapatinib vs letrozole–BMS‑690,514 CBR 2013
positive ABC (140)

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Table 6 (Cont.) | Key randomized trials of new agents for patients with HER2-positive breast cancer
Trial (ClinicalTrials.gov) Phase Patient characteristics* Treatment Primary end Data
(target accrual) point expected
Bevacizumab
BETH, NSABP B‑44 III HER2+ node-positive or Docetaxel–carboplatin–trastuzumab ± bevacizumab Invasive DFS 2012
(NCT00625898) high-risk node-negative EBC maintenance trastuzumab ± bevacizumab vs
(3,500) docetaxel–trastuzumab ± bevacizumab FEC
maintenance trastuzumab ± bevacizumab
E1105 (NCT00520975) III HER2+ MBC (489) Paclitaxel–trastuzumab ± bevacizumab PFS 2011
± carboplatin
AVEREL (NCT00391092) III HER2+ ABC (410) Docetaxel–trastuzumab ± bevacizumab PFS 2013
NCT00365365 II Node-positive or high-risk node- Cyclophosphamide–doxorubicin–bevacizumab Safety 2019
negative EBC (225) paclitaxel–bevacizumab–G-CSF (4 vs 6 cycles
bevacizumab) vs docetaxel–carboplatin–
trastuzumab–bevacizumab–G-CSF
NCT01142778 II HER2+ EBC (156) Docetaxel–trastuzumab ± bevacizumab pCR 2018
*See the trial on ClinicalTrials.gov for full details of patient inclusion criteria. All arms followed by surgery and adjuvant and maintenance therapy. All arms followed by surgery and maintenance
‡ §

trastuzumab. ||Both arms followed by surgery and cyclophosphamide–doxorubicin + maintenance trastuzumab. ¶Still recruiting. Abbreviations: , followed by; ABC, advanced-stage breast cancer;
BC, breast cancer; CBR, clinical benefit rate; DFS, disease-free survival; EBC, early stage breast cancer; FEC, fluorouracil–epirubicin–cyclophosphamide; G‑CSF, granulocyte-colony stimulating factor;
GM‑CSF, granulocyte macrophage-colony stimulating factor; HER2+, HER2-positive; HER2–, HER2-negative; HLA‑A2, human leukocyte antigen A2; HLA‑A2+, HLA‑A2-positive; HLA‑A2–, HLA‑A2-
negative; LABC, locally advanced breast cancer; MBC, metastatic breast cancer; ORR, overall response rate; pCR, pathological complete response; PDR, progressive disease rate; PFS, progression-
free survival; T‑DM1, trastuzumab-DM1.

study was not designed to test long-term outcomes and
pCR is not unanimously accepted as a surrogate for
disease-free survival and overall survival. However, a
preliminary announcement of positive data from the
CLEOPATRA study (in which patients with metastatic
breast cancer were randomized to received pertuzumab
plus trastuzumab and docetaxel, or placebo plus trastu-
zumab and docetaxel) suggest that the findings of the
NEOSPHERE study may be validated in this larger and
more-definitive trial.
Since trastuzumab and pertuzumab both target the
HER2 receptor and are structurally very similar, addi-
tive toxicity might be anticipated when the two drugs
are administered concurrently. However, as seen with
concurrent administration of trastuzumab and lapatinib,
cardiac toxicity does not seem to be increased when per-
tuzumab is given with trastuzumab. A pooled analysis of
cardiac safety in 598 patients participating in pertuzumab
clinical trials showed no apparent increase in cardiac
dysfunction when pertuzumab was given concurrently
with trastuzumab.96 Of the patients treated with pertu-
zumab alone, pertuzumab in combination with a non-
anthracycline-containing cytotoxic, or pertuzumab with
trastuzumab, 6.9%, 3.4%, and 6.5%, respectively, devel-
oped asymptomatic reduction in LVEF. In addition, 0.3%,
1.1%, and 1.1%, respectively, developed symptomatic
CHF. However, the data on cardiac safety with novel anti-
HER2 agents need to be interpreted with caution because
the trials are conducted in carefully selected populations
of patients who tolerated prior trastuzumab treatment.
Selective HER1 or HER3 inhibition
Preclinical data indicate that overexpression of HER2 in
breast cancer is frequently associated with overexpres-
sion of HER1, and that inhibition of HER1 enhances the
response to trastuzumab in HER1–HER2 co-expressing
cells.47,97 The potential utility of simultaneous HER1 and
HER2 inhibition is supported by the positive findings of
lapatinib and pertuzumab trials. However, despite these
observations, clinical activity of selective HER1 inhibi-
tors in patients with breast cancer has been disappointing,
either as single agents,98,99 or in combination with chemo­
therapy (in patients unselected for HER2 status),100,101
or in combination with trastuzumab in patients with
HER2-positive breast cancer.102,103 As a result, attention
has shifted to other members of the HER family, par-
ticularly HER3. Although HER3 has only weak intrinsic
tyrosine kinase activity,104 HER2–HER3 heterodimers
form the most potent mitogenic signaling pair in the HER
family,105 and HER3 is now recognized as having a critical
role as a co-receptor for amplified HER2.106 Accordingly,
HER3 targeting agents are now in development, including
several antibodies (Table 5).
Novel tyrosine kinase inhibitors
New tyrosine kinase inhibitors (TKIs) in development
for patients with HER2-positive breast cancer include
irreversible TKIs, and TKIs with a broader spectrum
of activity than lapatinib (Table 5). Irreversible inhibi-
tors have been shown to be more potent and to prolong
target inhibition compared with lapatinib, 107 as well
as potentially bypassing pathways involved in resis-
tance to HER2-targeting agents. Neratinib is the most
advanced irreversible EGFR–HER2 TKI in develop-
ment for breast cancer. A phase II study of neratinib
in 136 patients with HER2-positive metastatic breast
cancer showed a 24% response rate in women previously
treated with trastuzumab, and a 56% response rate in
trastuzumab-naive patients. PFS at 16 weeks was 59%
and 78%, respectively—results that compare favorably
with other single-agent anti-HER2 therapies.108 No grade
3 or 4 cardio­toxicity related to neratinib was reported,
but grade 3 and 4 diarrhea was the most frequently
occurring adverse effect. Neratinib is now being studied
in various combinations and in head-to-head com-
parisons with trastuzumab, lapatinib and new targeted

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© 2011 Macmillan Publishers Limited. All rights reserved
REVIEWS
agents. A phase III trial of adjuvant neratinib has also
started (Table 6).
Inhibition of the PI3K pathway
The PI3K family is complex, consisting of multiple
members, divided into three main classes.109 Class IA
PI3Ks are activated by growth factors via tyrosine
kinase receptors (including HER family members)
and are most clearly involved in malignant diseases.
Deregulation of this pathway is thought to be a cause of
resistance to HER2-targeted therapies, as well as resis-
tance to cytotoxics and hormonal therapies.109–112 PI3K
pathway inhibition would be expected to restore sensi-
tivity to trastuzumab and/or lapatinib in patients with
HER2-positive breast cancer, as well as being inherently
antiproliferative and proapoptotic. However, multiple
PI3K isoforms are expressed in the heart, where they are
involved in hypertrophy and cardiac failure,113 so PI3K
inhibitors have the potential to exacerbate the cardiac
toxicity of HER2-targeted agents. PI3K also has an
important role in cellular responses to insulin, and inhi-
bition of PI3K (particularly the p110α catalytic isoform)
can potentially cause insulin resistance. Although this
mechanism has not been a major problem in clini-
cal studies so far, hyperglycemia has been observed in
phase I studies.114–119
Activation of PI3K results in stimulation of Akt and
mTOR kinases, leading to the promotion of tumor cell
proliferation and survival. Inhibitors of the PI3K pathway
can be categorized into four main groups: PI3K inhibi-
tors (isoform-specific or pan-class I PI3K inhibitors),
dual PI3K–mTOR inhibitors, Akt inhibitors, and mTOR
inhibitors. All seem to have only modest antitumor acti­
vity when used alone in patients with breast cancer and
are likely to need co-administration of other agents for
optimal activity.120
GDC‑0941 121 is one of several pan-class I PI3K
inhibitors currently in phase I–II clinical development
(Table 5). In preclinical experiments, GDC‑0941 was effi-
cacious in trastuzumab-resistant cells,111 was able to sup-
press the growth of >70% of breast cancer cell lines when
used in combination with trastuzumab, pertuzumab or
lapatinib,110 and was able to render HER2-amplified cells
and tumor xenografts more sensitive to docetaxel.110 In
phase I, there was evidence of antitumor activity in three
of 19 patients with no grade >3 treatment-related toxicity
or hyperglycemia.114 Ongoing phase I trials are evaluat-
ing GDC‑0941 in combination with trastuzumab-DM1
in patients with trastuzumab-resistant HER2-positive
breast cancer, and in combination with paclitaxel, carbo-
platin and bevacizumab in HER2-unselected metastatic
breast cancer.
Several dual PI3K–mTOR inhibitors are in clinical
development (Table 5 and Supplementary Table 1 online),
of note, SF1126—a pan PI3K inhibitor. In a phase I trial,
SF1126 produced disease stabilization with transient
dose-limiting diarrhea in one patient.117
Three mTOR inhibitors have been evaluated in patients
with breast cancer (Table 5). Temsirolimus monotherapy
produced a response rate of <10% in heavily pretreated
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© 2011 Macmillan Publishers Limited. All rights reserved
patients with advanced-stage disease,122 and did not sig-
nificantly improve the efficacy of letrozole in postmeno-
pausal women with advanced-stage breast cancer.123
The mTOR inhibitor ridaforolimus has also been evalu-
ated in phase I–II trials and found to produce generally
low response rates.124–127 The dose-limiting toxicity was
mucositis but metabolic effects including hyperglycemia,
hypertriglyceridemia, and hypercholesterolemia were
also observed.124–127 Preliminary data from a phase II
trial of ridaforolimus in combination with trastuzumab
in trastuzumab-refractory patients produced two partial
responses in the first 14 patients.128 However, there seem
to be no ongoing trials of ridaforolimus in patients with
breast cancer.
Trials of everolimus have been more encouraging.
Everolimus produced a response rate of 12% as mono-
therapy,129 and it was also combined with trastuzumab
and chemotherapy with manageable toxicity.130,131 Many
clinical trials of everolimus have now started in patients
with breast cancer, including randomized trials in
patients with HER2-positive disease and a trial of trastu-
zumab plus everolimus in patients with low to moderate
HER2 expression (Table 6).
HSP90 inhibitors
Heat shock protein 90 (HSP90) is a molecular chaper-
one that stabilizes and prevents the proteasomal degra-
dation of a range of cellular proteins, including HER2
and other proteins involved in signal transduction path-
ways. Inhibition of HSP90 increases the degradation
of HER2 and enhances trastuzumab-induced growth
arrest and apoptosis in HER2-expressing breast cancer
cells.132 Several HSP90 inhibitors have been evaluated
in patients with breast cancer. Although tanespimycin
alone did not show significant antitumor activity in
phase I trials,133 responses were seen in phase II trials
when given in combination with trastuzumab to patients
with HER2-positive breast cancer after progression on
trastuzumab-containing therapy.134 Five of 21 patients
achieved a partial response to tanespimycin plus trastu-
zumab and additional minor responses were seen. 135
However, despite these promising results and a change
in formulation to avoid the necessity of Cremophor to
improve solubility, no further trials of tanespimycin
in HER2-positive breast cancer seem to be planned.
Another HSP90 inhibitor, alvespimycin, also seems to
have stalled in development for patients with HER2-
positive breast cancer. Although no responses were seen
with alvespimycin monotherapy in unselected patients
in phase I,136 there was evidence of antitumor acti­vity
when alvespimycin was given in combination with
trastuzumab after failure of trastuzumab-containing
therapy. 137 However, a subsequent phase II trial in
HER2-positive breast cancer was terminated and there
seem to be no new trials of this agent. A phase II trial
of retaspimycin138 in combination with trastuzumab is
ongoing in patients with HER2-positive breast cancer
previously treated with trastuzumab, although a similar
trial (NCT00627627) was stopped before enrollment,
and development of retaspimycin seems to have ended
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following termination of a phase III trial in patients with
gastrointestinal stromal tumors owing to high mortality
in the experimental arm.139
Other HSP90 inhibitors in development include
BIIB021,140 which is orally active and currently being
evaluated in combination with trastuzumab in patients
with trastuzumab-resistant HER2-positive breast
cancer. AUY922 is also being evaluated as monotherapy
in a similar patient population trial (NCT00526045)
and several other compounds are in early clinical
development (Table 5).
Multikinase and angiogenesis inhibitors
HER2 signaling induces VEGF transcription (Figure 1),
and inhibition of HER2 with trastuzumab has been
shown to result in an antivascular effect.141 These pre-
clinical data provide a basis for the evaluation of angio-
genesis inhibitors in patients with HER2-positive and
other forms of breast cancer. To date, clinical trials of
angiogenesis inhibitors in breast cancer have tended to
be restricted to patients with HER2-negative disease.
However, this restriction is more due to a low incidence
of HER2-positive disease compared to HER2-negative
disease and the practicalities of integrating angiogenesis
inhibitors into regimens that already include a HER2-
targeted agent than for scientific reasons. Indeed, since
overexpression of HER2 is associated with increased
expression of VEGF and angiogenesis,142 patients with
HER2-positive disease might particularly benefit from
treatment with an angiogenesis inhibitor.
The monoclonal antibody, bevacizumab, blocks angio-
genesis by binding to circulating VEGF‑A, preventing
its binding to the VEGF receptor 2 (VEGFR2). In the
USA, bevacizumab was originally granted ‘acceler-
ated approval’ by the FDA for use in combination with
paclitaxel in patients with metastatic breast cancer, on
the basis of an improvement in PFS in the E2100 trial in
patients with predominantly HER2-negative disease.143
The license for bevacizumab in metastatic breast cancer
is currently being revoked in the USA following new
studies that failed to confirm a clinically significant
improvement in PFS or overall survival, and showed a
poor safety profile for bevacizumab. However, the debate
about the therapeutic benefits of bevacizumab in meta-
static breast cancer continues and it is still recommended
as a therapeutic option by the Breast Cancer Guideline
Committee of the NCCN and by the European Medicines
Agency (EMA).
Bevacizumab has been successfully combined with
trastuzumab in a phase II trial,144 and is currently being
evaluated in combination with trastuzumab and chemo­
therapy in several randomized trials in patients with
HER2-positive disease, including one trial in the adju-
vant setting (Table 6). These trials all incorporate careful
cardiac monitoring, because bevacizumab has been
associated with adverse cardiac events, most frequently
hypertension, which could potentially exacerbate the
cardiac toxicity of co-administered trastuzumab.145
Several multi-targeted kinase inhibitors have been
evaluated in patients with breast cancer (Table 5). These
NATURE REVIEWS | CLINICAL ONCOLOGY ADVANCE ONLINE PUBLICATION  |  13
© 2011 Macmillan Publishers Limited. All rights reserved
REVIEWS
are thought to act as angiogenesis inhibitors by targeting
VEGFR, but also to have inhibitory effects on other signal
transduction pathways. However, only modest results
have been reported in patients with breast cancer so far,
and only pazopanib seems to be in active development for
patients with HER2-positive disease (Table 6).
IGF-1R, cancer vaccines, immunotherapy
Inhibitors of the IGF-1R pathway, cancer vaccines and
immunotherapy for HER2-positive breast cancer are
summarized in Table 5. There is a growing interest in
HER2 as a target for immunotherapy. Several adjuvant
clinical trials using immunogenic peptides from the
HER2 protein (AE37 or E75 or GP2) plus GM‑CSF given
intradermally have been performed. Different trials were
conducted with a similar dose-escalation design with
increasing doses of peptide (AE37 or E75 or GP2) and
varying amounts of GM‑CSF. Preliminary data suggested
that all three peptide vaccines were safe and well toler-
ated. In addition, a synergistic effect between peptide
vaccination and trastuzumab was observed, suggesting
that integration of immune vaccination with standard
therapy is a promising strategy.
Conclusions
Currently, treatment with trastuzumab for 1 year in addi-
tion to chemotherapy is the only approved HER2-specific
adjuvant treatment for patients with HER2-positive early
stage breast cancer. However, many new agents are in
clinical development, including those directed at the
HER2 receptor itself, and those targeting downstream
effectors and interacting compensatory signaling path-
ways. Five new agents are currently in adjuvant trials
in patients with HER2-positive disease: lapatinib and
bevacizumab, which are both already approved for use
in patients with advanced-stage breast cancer; the dual
EGFR–HER2 inhibitor neratinib; and the peptide vac-
cines, GP2 and AE37. Several more agents are in phase III
trials in patients with advanced-stage HER2-positive
disease, notably the dimerization inhibitor pertuzumab,
the antibody–drug conjugate trastuzumab-DM1, and the
mTOR inhibitor everolimus. Assuming positive results,
these new treatments are likely to enter the adjuvant
setting in the near future.
Review criteria
This Review was inspired by a seminar organized by the
Fondazione Michelangelo to update clinicians on current
and future treatment options for HER2-positive early
stage breast cancer. PubMed was searched for articles
in English published before March 2011 using the terms
“breast cancer”, “HER2”, “trastuzumab”, “lapatinib”,
“pertuzumab”, “lapatinib”, “TDM‑1”, and “resistance”.
Additional relevant references published after this date
were included. Reference lists from key articles were
searched for additional material. Abstracts from the
ASCO and ESMO annual meetings, and San Antonio
Breast Cancer Symposium were considered. Articles
were identified on the basis of the authors’ knowledge of
the clinical development of anti-HER2 therapy for breast
cancer. ClinicalTrials.gov was searched for relevant trials.
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Acknowledgments
We would like to thank Claire Barton (consultant of
Fondazione Michelangelo, the non-profit organization
that organized the seminar on HER2) for assistance
in preparing the manuscript.
Author contributions
All authors contributed equally to all aspects of the
article, including researching data, discussion of
content, and writing, reviewing and editing the
manuscript before submission.
Supplementary information is linked to the online
version of the paper at www.nature.com/nrclinonc.