Surgery & procedures
| Breast-conserving surgery (lumpectomy) + SLNB when feasible Breast-conserving surgery (lumpectomy) + SLNB when feasible; oncoplastic techniques expand eligibility and cosmesis. | Curative | Standard | Curated |
| Mastectomy when disease extent, multicentricity, prior RT, or patient… Mastectomy when disease extent, multicentricity, prior RT, or patient preference dictates; nipple-sparing is feasible in selected cases with careful margin assessment. | Curative | Standard | Curated |
| Immediate reconstruction planning (implant or autologous) Immediate reconstruction planning (implant or autologous) should be coordinated with anticipated radiation to minimize complications and optimize outcomes. | Curative | Standard | Curated |
| Z0011 approach: omit ALND with 1–2 positive SLNs if lumpectomy + whol… Z0011 approach: omit ALND with 1–2 positive SLNs if lumpectomy + whole-breast RT is planned and no gross extranodal extension. | Curative | Standard | Curated |
| Targeted axillary dissection post-NAT for initially node-positive pat… Targeted axillary dissection post-NAT for initially node-positive patients (retrieve clipped node + SLNs) to accurately restage and potentially de-escalate ALND. | Curative | Standard | Curated |
| Re-excision for positive margins; for invasive cancer, ‘no ink on tumor’ Re-excision for positive margins; for invasive cancer, ‘no ink on tumor’ is adequate. For pure DCIS, aim ≥2 mm. | Curative | Standard | Curated |
| Place surgical clips in the tumor bed to guide boost RT and future im… Place surgical clips in the tumor bed to guide boost RT and future imaging. | Curative | Standard | Curated |
Radiotherapy
| Whole-breast irradiation (WBI) after lumpectomy Whole-breast irradiation (WBI) after lumpectomy is standard; hypofractionation preferred for most (e.g., ~3 weeks). Five-fraction regimens are reasonable in selected patients. | — | Standard | Curated |
| Tumor-bed boost for higher local-recurrence risk (younger age, close… Tumor-bed boost for higher local-recurrence risk (younger age, close margins, high grade, extensive intraductal component). | — | Standard | Curated |
| Post-mastectomy radiation (PMRT) for ≥4 positive nodes Post-mastectomy radiation (PMRT) for ≥4 positive nodes; consider for 1–3 positive nodes with additional risk factors (large tumor, LVI, close margins). | — | Standard | Curated |
| Regional nodal irradiation (RNI) to axillary/supraclavicular ± intern… Regional nodal irradiation (RNI) to axillary/supraclavicular ± internal mammary nodes based on nodal burden, biology, and response to NAT. | — | Standard | Curated |
| Deep-inspiration breath hold (DIBH) for left-sided WBI/PMRT to reduce… Deep-inspiration breath hold (DIBH) for left-sided WBI/PMRT to reduce heart dose; consider proton therapy in select complex IMN cases. | — | Standard | Curated |
| Stereotactic radiosurgery (SRS) for limited brain metastases Stereotactic radiosurgery (SRS) for limited brain metastases; SBRT for oligometastatic bone/liver/lung lesions case-by-case. | Advanced / metastatic | Standard | Curated |
| Partial-breast irradiation (PBI) Partial-breast irradiation (PBI) can be considered for carefully selected low-risk early cases as a shorter alternative to WBI. | — | Standard | Curated |
| Oligometastatic disease: discuss consolidative local therapy (SBRT, s… Oligometastatic disease: discuss consolidative local therapy (SBRT, surgery) after systemic response in a multidisciplinary tumor board. | Advanced / metastatic | Standard | Curated |
| Oligometastatic scenarios (all subtypes): consider SBRT or surgery af… Oligometastatic scenarios (all subtypes): consider SBRT or surgery after systemic response in tumor board. | Advanced / metastatic | Standard | Curated |
Chemotherapy
| Ovarian protection: consider GnRH agonist during chemotherapy for pre… Ovarian protection: consider GnRH agonist during chemotherapy for premenopausal patients to reduce ovarian failure risk and preserve fertility. | — | Standard | Curated |
| AC-T (doxorubicin/cyclophosphamide → paclitaxel) (early/high-risk) Common adjuvant/neoadjuvant backbone; monitor cardiotoxicity and neuropathy. | — | Standard | Curated |
| TC (docetaxel/cyclophosphamide) (early) Non-anthracycline option; consider in lower cardiac reserve. | — | Standard | Curated |
| THP / TCHP (taxane ± carboplatin + trastuzumab/pertuzumab) (HER2+ neo… Preferred for stage II–III HER2+; adapt adjuvant based on pCR/residual disease. | Neoadjuvant | Standard | Curated |
| Capecitabine (post-neoadjuvant TNBC residual) Improves outcomes in residual TNBC after neoadjuvant chemo. | Neoadjuvant | Standard | Curated |
| Platinum agents Platinum agents remain valuable in TNBC (particularly HRD contexts). | — | Standard | Curated |
Targeted therapy
| Use genomic assays to decide on adjuvant chemotherapy in HR+/HER2 Use genomic assays to decide on adjuvant chemotherapy in HR+/HER2– node-negative and select 1–3 node-positive patients undergoing upfront surgery. | Adjuvant | Standard | Curated |
| Postmenopausal HR+/HER2 Postmenopausal HR+/HER2–: consider adjuvant bisphosphonates to reduce bone recurrence and fractures. | Adjuvant | Standard | Curated |
| HER2+ stage II HER2+ stage II–III: neoadjuvant taxane-based ± anthracycline + trastuzumab/pertuzumab; if residual disease, switch to adjuvant T-DM1 to complete ~1 year of anti-HER2 therapy. | Neoadjuvant | Standard | Curated |
| Small node-negative HER2+ (e Small node-negative HER2+ (e.g., T1a/b): consider paclitaxel + trastuzumab (TH) adjuvant de-escalation for appropriate candidates. | Adjuvant | Standard | Curated |
| Metastatic HER2+: first line taxane + trastuzumab + pertuzumab; secon… Metastatic HER2+: first line taxane + trastuzumab + pertuzumab; second line trastuzumab deruxtecan (T-DXd) preferred; later lines include tucatinib + trastuzumab + capecitabine (especially with brain mets), neratinib- or lapatinib-based regimens as appropriate. | Advanced / metastatic | Standard | Curated |
| gBRCA-mutated, high-risk HER2 gBRCA-mutated, high-risk HER2– (HR+ or TNBC): consider 1 year of adjuvant olaparib per criteria. | Adjuvant | Standard | Curated |
| Alpelisib for PIK3CA-mutant HR+/HER2 Alpelisib for PIK3CA-mutant HR+/HER2– after AI; start glucose monitoring and rash prophylaxis (non-sedating antihistamine). | — | Standard | Curated |
| PARP inhibitors (olaparib/talazoparib) for gBRCA/PALB2: adjuvant (sel… PARP inhibitors (olaparib/talazoparib) for gBRCA/PALB2: adjuvant (select high-risk HER2–) and metastatic; plan for anemia monitoring and contraception. | Adjuvant | Standard | Curated |
| HER2 sequence (metastatic): taxane + trastuzumab/pertuzumab → trastuz… HER2 sequence (metastatic): taxane + trastuzumab/pertuzumab → trastuzumab deruxtecan (T-DXd) → tucatinib + trastuzumab + capecitabine (brain-active) → other TKIs (neratinib/lapatinib) case-by-case. | Advanced / metastatic | Standard | Curated |
| Residual disease after neoadjuvant HER2 therapy: switch to adjuvant T… Residual disease after neoadjuvant HER2 therapy: switch to adjuvant T-DM1 to reduce recurrence risk. | Neoadjuvant | Standard | Curated |
| Extended adjuvant neratinib for high-risk HR+/HER2+ after trastuzumab… Extended adjuvant neratinib for high-risk HR+/HER2+ after trastuzumab (diarrhea prophylaxis mandatory) — center-specific use. | Adjuvant | Standard | Curated |
| T-DXd active in HER2-low (IHC 1+ or 2+/ISH T-DXd active in HER2-low (IHC 1+ or 2+/ISH–) metastatic after prior lines — emphasize ILD vigilance and early drug holds if symptomatic. | Advanced / metastatic | Standard | Curated |
| Sacituzumab govitecan Sacituzumab govitecan is a preferred later-line option in metastatic TNBC; early use of growth-factor support and loperamide reduces dose-limiting toxicity. | Advanced / metastatic | Standard | Curated |
| gBRCA TNBC benefits from PARP inhibitors (metastatic) and adjuvant ol… gBRCA TNBC benefits from PARP inhibitors (metastatic) and adjuvant olaparib (select early). | Adjuvant | Standard | Curated |
| HER2+ CNS disease: tucatinib-based regimens HER2+ CNS disease: tucatinib-based regimens provide intracranial responses; integrate SRS/surgery with neuro-oncology. | — | Standard | Curated |
Immunotherapy
| High-risk early TNBC: neoadjuvant anthracycline/taxane ± platinum wit… High-risk early TNBC: neoadjuvant anthracycline/taxane ± platinum with pembrolizumab; continue adjuvant pembrolizumab. If residual disease, add adjuvant capecitabine. | Neoadjuvant | Standard | Curated |
| Metastatic TNBC: PD-L1–positive → pembrolizumab + chemotherapy; later… Metastatic TNBC: PD-L1–positive → pembrolizumab + chemotherapy; later lines include sacituzumab govitecan; gBRCA mutation → PARP inhibitor considered. | Advanced / metastatic | Standard | Curated |
| Pembrolizumab for high-risk early TNBC (neoadjuvant + adjuvant) impro… Pembrolizumab for high-risk early TNBC (neoadjuvant + adjuvant) improves pCR/EFS; in metastatic TNBC, add to chemo for PD-L1–positive disease. | Neoadjuvant | Standard | Curated |
| Rare MSI-H/TMB-H/NTRK fusion Rare MSI-H/TMB-H/NTRK fusion can unlock tumor-agnostic immunotherapy/TRK inhibitors; screen with broad NGS when feasible. | — | Standard | Curated |
Hormonal therapy
| HR+/HER2 HR+/HER2– early: endocrine therapy (tamoxifen or aromatase inhibitor) ± ovarian function suppression (OFS) based on menopausal status and risk; duration typically 5 years, extend to 7–10 years for selected higher-risk cases. | — | Standard | Curated |
| High-risk, node-positive HR+/HER2 High-risk, node-positive HR+/HER2–: consider adjuvant abemaciclib + endocrine therapy per eligibility criteria. | Adjuvant | Standard | Curated |
| Metastatic HR+/HER2–: endocrine therapy + CDK4/6 inhibitor Metastatic HR+/HER2–: endocrine therapy + CDK4/6 inhibitor is standard first line. On progression, personalize by biomarkers (ESR1 → SERD; PIK3CA → alpelisib + fulvestrant; AKT1/PTEN/PIK3CA → capivasertib + fulvestrant; consider everolimus combinations). Later-line ADCs (e.g., sacituzumab govitecan) are options. | Advanced / metastatic | Standard | Curated |
| CDK4/6 + endocrine therapy (AI or fulvestrant) CDK4/6 + endocrine therapy (AI or fulvestrant) is first-line standard for metastatic HR+/HER2–; choose agent by comorbidity (e.g., ribociclib OS data; abemaciclib diarrhea but less neutropenia). | Advanced / metastatic | Standard | Curated |
| Post-CDK4/6 progression: re-profile (tumor or ctDNA) Post-CDK4/6 progression: re-profile (tumor or ctDNA). ESR1 mutation → SERD strategy (e.g., fulvestrant; oral SERDs where available). | — | Standard | Curated |
| Capivasertib + fulvestrant improves outcomes in tumors with PI3K/AKT/… Capivasertib + fulvestrant improves outcomes in tumors with PI3K/AKT/PTEN alterations; counsel on diarrhea, rash, and hyperglycemia. | — | Standard | Curated |
| Everolimus + exemestane restores endocrine sensitivity in some AI-res… Everolimus + exemestane restores endocrine sensitivity in some AI-resistant HR+; prevent stomatitis with dexamethasone mouthwash. | — | Standard | Curated |
| Adjuvant abemaciclib for high-risk node-positive HR+/HER2 Adjuvant abemaciclib for high-risk node-positive HR+/HER2– improves IDFS when added to endocrine therapy (strict eligibility). | Adjuvant | Standard | Curated |
| Later-line ADCs in HR+/HER2 Later-line ADCs in HR+/HER2–: sacituzumab govitecan after endocrine + targeted therapies; manage neutropenia/diarrhea proactively. | — | Standard | Curated |
Established care shown from OncoForge editorial curation · reviewed September 15, 2025 — authoritative citations (NCI PDQ / FDA) are being added.