OpenOnco · Treatment Plan

Treatment plan — DIS-BREAST

PLAN-BMA-HER2_LOW_BREAST-V1 · v1 · 2026-05-04

Patient

BMA-HER2_LOW_BREAST · Algorithm: ALGO-BREAST-1L

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
BIO-HER2-LOW	IHC 1+ OR IHC 2+/ISH-negative (HER2-low by ASCO/CAP 2023 criteria)	IA	SRC-DESTINY-BREAST04-MODI-2022: Level A (Supports, Sensitivity/Response) SRC-NCCN-BREAST-2025: Level Category 1 (Supports, Sensitivity/Response) SRC-ESMO-BREAST-METASTATIC-2024: Level A (Supports, Sensitivity/Response)	Trastuzumab deruxtecan (T-DXd, DS-8201) is FDA-approved (Aug 2022) for unresectable or metastatic HER2-low (IHC 1+ or 2+/ISH-) breast cancer following prior chemotherapy. DESTINY-Breast04 (Modi et al. NEJM 2022): HR+/HER2-low — mPFS 10.1 vs 5.4 mo (HR 0.49, p<0.001); mOS 23.9 vs 17.5 mo (HR 0.64, p=0.003). HR-/HER2-low (TNBC subgroup) — mOS 18.2 vs 8.3 mo. DESTINY-Breast06 (Curigliano et al. NEJM 2024) extended indication to HER2-low and HER2-ultralow (IHC 0 with incomplete staining) HR+/HER2- endocrine-pretreated patients — mPFS 13.2 vs 8.1 mo (HR 0.62, p<0.001). T-DXd dose: 5.4 mg/kg IV q3w. Key safety: interstitial lung disease (ILD) / pneumonitis ~12% (grade ≥3 ~3%) — mandatory baseline CT and monitoring per NCCN/ESMO. HER2-low reclassification affects ~60% of previously HER2-negative metastatic breast cancer patients — large population impact.	trastuzumab deruxtecan (T-DXd) 5.4 mg/kg IV q3w monotherapy (post-chemotherapy; DESTINY-Breast04) trastuzumab deruxtecan (T-DXd) 5.4 mg/kg IV q3w monotherapy (post-endocrine HR+ disease; DESTINY-Breast06)	SRC-NCCN-BREAST-2025 SRC-ESMO-BREAST-METASTATIC-2024 SRC-DESTINY-BREAST04-MODI-2022

Treatment options (7 tracks)

Standard plan

★ DEFAULT

Indication

IND-BREAST-HR-POS-MET-1L-CDKI

Regimen

AI + ribociclib (HR+/HER2- metastatic 1L; OS-validated)

Drugs + NSZU

Letrozole (DRUG-LETROZOLE) 2.5 mg PO daily · Continuous · PO ✓ NSZU covered
Ribociclib (DRUG-RIBOCICLIB) 600 mg PO daily, days 1-21 of 28-day cycle · 21 days on, 7 days off · PO ⚠ NSZU — not for this indication

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Engine default per algorithm ALGO-BREAST-1L: {'step': 5, 'outcome': False, 'branch': {'result': 'IND-BREAST-HR-POS-MET-1L-CDKI'}, 'fired_red_flags': [], 'winner_red_flag': None}

Standard plan

Indication

IND-BREAST-HER2-POS-EARLY-NEOADJUVANT

Regimen

TCHP — docetaxel + carboplatin + trastuzumab + pertuzumab (HER2+ neoadjuvant)

Drugs + NSZU

Docetaxel (DRUG-DOCETAXEL) 75 mg/m² IV · Day 1 of 21-day cycle x 6 cycles · IV ✓ NSZU covered
Carboplatin (DRUG-CARBOPLATIN) AUC 6 IV · Day 1 of 21-day cycle x 6 cycles · IV ⚠ NSZU — not for this indication
Trastuzumab (DRUG-TRASTUZUMAB) 8 mg/kg IV loading, 6 mg/kg IV maintenance · Day 1 of 21-day cycle · IV ✓ NSZU covered
Pertuzumab (DRUG-PERTUZUMAB) 840 mg IV loading, 420 mg IV maintenance · Day 1 of 21-day cycle · IV ✓ NSZU covered

Supportive care

SUP-BONE-HEALTH-PROSTATE, SUP-G-CSF-PRIMARY-PROPHYLAXIS-PROSTATE

Reason

Alternative track presented for HCP consideration

Standard plan

Indication

IND-BREAST-HER2-POS-MET-1L-THP

Regimen

THP — docetaxel + trastuzumab + pertuzumab (HER2+ metastatic 1L)

Drugs + NSZU

Docetaxel (DRUG-DOCETAXEL) 75-100 mg/m² IV · Day 1 of 21-day cycle x 6-8 cycles, then HP maintenance · IV ✓ NSZU covered
Trastuzumab (DRUG-TRASTUZUMAB) 8 mg/kg loading, 6 mg/kg maintenance IV · Day 1 of 21-day cycle, continuous until progression · IV ✓ NSZU covered
Pertuzumab (DRUG-PERTUZUMAB) 840 mg loading, 420 mg maintenance IV · Day 1 of 21-day cycle, continuous until progression · IV ✓ NSZU covered

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Alternative track presented for HCP consideration

Standard plan

Indication

IND-BREAST-HER2-POS-MET-2L-TDXD

Regimen

T-DXd monotherapy (HER2+ metastatic 2L+, also HER2-low metastatic)

Drugs + NSZU

Trastuzumab deruxtecan (T-DXd) (DRUG-TRASTUZUMAB-DERUXTECAN) 5.4 mg/kg IV · Day 1 of 21-day cycle, continuous until progression · IV ✓ NSZU covered

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Alternative track presented for HCP consideration

Standard plan

Indication

IND-BREAST-TNBC-EARLY-NEOADJUVANT

Regimen

Pembrolizumab + chemo (TNBC neoadjuvant)

Drugs + NSZU

Pembrolizumab (DRUG-PEMBROLIZUMAB) 200 mg IV q3 weeks · Days 1 of cycles 1-8 (4 cycles each phase) · IV ⚠ NSZU — not for this indication
Paclitaxel (DRUG-PACLITAXEL) 80 mg/m² IV weekly · Cycles 1-4 (12 weekly doses) · IV ✓ NSZU covered
Carboplatin (DRUG-CARBOPLATIN) AUC 5 IV · Cycles 1-4 q3 weeks (or weekly AUC 1.5) · IV ⚠ NSZU — not for this indication
Doxorubicin (DRUG-DOXORUBICIN) 60 mg/m² IV · Cycles 5-8 q3 weeks · IV ✓ NSZU covered
Cyclophosphamide (DRUG-CYCLOPHOSPHAMIDE) 600 mg/m² IV · Cycles 5-8 q3 weeks · IV ✓ NSZU covered

Supportive care

SUP-G-CSF-PRIMARY-PROPHYLAXIS-PROSTATE, SUP-BONE-HEALTH-PROSTATE

Reason

Alternative track presented for HCP consideration

Standard plan

Indication

IND-BREAST-BRCA-POS-MET-PARPI

Regimen

Olaparib monotherapy (BRCA-mutant HER2- breast: metastatic OR adjuvant high-risk early)

Drugs + NSZU

Olaparib (DRUG-OLAPARIB) 300 mg PO BID continuous · Until progression (metastatic) or 1 year (OlympiA adjuvant) · PO ⚠ NSZU — not for this indication

Supportive care

SUP-BONE-HEALTH-PROSTATE

Reason

Alternative track presented for HCP consideration

IND-BREAST-TNBC-METASTATIC-1L-PEMBRO-CHEMO

Indication: IND-BREAST-TNBC-METASTATIC-1L-PEMBRO-CHEMO
Regimen: —
Reason: Alternative track presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CECT-CAP	CECT chest/abdomen/pelvis	Critical	imaging	—	standard
TEST-ER-PR-IHC	ER + PR immunohistochemistry on tumor	Critical	—	CSD Lab ✓ (code TBC)	standard
TEST-HER2-IHC-FISH	HER2 IHC + reflex FISH on tumor	Critical	—	CSD Lab ✓ (code TBC)	standard
TEST-GERMLINE-BRCA-PANEL	Germline BRCA1/2 + HRR panel sequencing	Standard	—	CSD Lab: M089	standard
TEST-PIK3CA-NGS	PIK3CA mutation testing (tumor or ctDNA)	Standard	—	CSD Lab: M065	desired (standard)

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Age ≥75 + ECOG ≥2 + significant comorbidity — anthracycline + dose-dense regimens poorly tolerated; consider TC, weekly paclitaxel, single-agent endocrine, or trastuzumab + chemo of reduced intensity.RF-BREAST-FRAILTY-AGE
Cardiac dysfunction (LVEF <50%) — anthracycline + trastuzumab/pertuzumab + T-DM1/T-DXd all carry cardiotoxicity risk; baseline echo + serial monitoring required.RF-BREAST-ORGAN-DYSFUNCTION

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · AI + ribociclib (HR+/HER2- met

28-day cycles × Continuous until progression

Standard plan

Induction · TCHP — docetaxel + carboplatin

21-day cycles × 6 (then surgery → adjuvant trastuzumab + pertuzumab to complete 1 year HER2-targeted therapy; T-DM1 if residual disease)

Standard plan

Induction · THP — docetaxel + trastuzumab

21-day cycles × Docetaxel × 6-8; HP continues until progression

Standard plan

Induction · T-DXd monotherapy (HER2+ metas

21-day cycles × Continuous until progression or unacceptable toxicity

Standard plan

Induction · Pembrolizumab + chemo (TNBC ne

21-day cycles × 8 (paclitaxel/carbo+pembro phase 1-4, then AC+pembro phase 5-8)

Standard plan

Induction · Olaparib monotherapy (BRCA-mut

28-day cycles × Adjuvant: 12; Metastatic: continuous until progression

MDT brief

Data quality

Unevaluated RedFlags: RF-BREAST-AKT1-E17K-ACTIONABLE, RF-BREAST-AKT1-E17K-CAPIVASERTIB-CANDIDATE, RF-BREAST-BRCA-GERMLINE-ACTIONABLE, RF-BREAST-CDH1-LOBULAR-CANDIDATE, RF-BREAST-ESR1-MUT-ACTIONABLE, RF-BREAST-ESR1-Y537S-D538G-CANDIDATE, RF-BREAST-FRAILTY-AGE, RF-BREAST-HER2-AMP-ACTIONABLE, RF-BREAST-HER2-LOW-ACTIONABLE, RF-BREAST-HER2-ULTRALOW-CANDIDATE, RF-BREAST-HIGH-RISK-BIOLOGY, RF-BREAST-INFECTION-SCREENING, RF-BREAST-ORGAN-DYSFUNCTION, RF-BREAST-OVARIAN-HRD-ASSAY-DISTINCTION, RF-BREAST-PIK3CA-COALT-INAVOLISIB-CANDIDATE, RF-BREAST-PIK3CA-MUT-ACTIONABLE, RF-BREAST-TRANSFORMATION-PROGRESSION, RF-PAN-ATM-CHEK2-CDK12-PARPI-CANDIDATE, RF-PAN-BRCA-SOMATIC-PARPI-CANDIDATE, RF-PAN-PALB2-PARPI-CANDIDATE

Skill catalog (0/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-DESTINY-BREAST03-CORTES-2022: Trastuzumab Deruxtecan versus Trastuzumab Emtansine for Breast Cancer (2022)
SRC-ESMO-BREAST-EARLY-2024: ESMO Clinical Practice Guideline on Early Breast Cancer (2024)
SRC-ESMO-BREAST-METASTATIC-2024: ESMO Clinical Practice Guideline on Metastatic Breast Cancer (2024)
SRC-HER2CLIMB-MURTHY-2019: Tucatinib, Trastuzumab, and Capecitabine for HER2-Positive Metastatic Breast Cancer (2019)
SRC-KEYNOTE-355-CORTES-2020: Pembrolizumab plus chemotherapy versus placebo plus chemotherapy for previously untreated locally recurrent inoperable or metastatic triple-negative breast cancer (KEYNOTE-355) (2020)
SRC-MONALEESA-2-HORTOBAGYI-2016: Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer (2016)
SRC-MONALEESA-3-SLAMON-2018: Phase III Randomized Study of Ribociclib and Fulvestrant in Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer (MONALEESA-3) (2018)
SRC-MONALEESA-7-TRIPATHY-2018: Ribociclib plus endocrine therapy for premenopausal women with hormone-receptor-positive, advanced breast cancer (MONALEESA-7) (2018)
SRC-NCCN-BREAST-2025: NCCN Clinical Practice Guidelines — Breast Cancer (2025.v4)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-04.

NCT	Title	Phase	Status	Sponsor	UA
NCT06903468	Novel Cavity Marking Technique in Breast Cancer Patients Undergoing Breast Conservation Surgery With Oncoplastic Reconstruction for the Delivery of Adjuvant Radiotherapy and Accuracy of Recommended Re-excisions	NA	RECRUITING	University of Florida	—
NCT02422641	Prospective Evaluation Of High-Dose Systemic Methotrexate In Patients With Breast Cancer And Leptomeningeal Metastasis	PHASE2	RECRUITING	Wake Forest University Health Sciences	—
NCT06781281	NabPE With or Without Serplulimab for Early-stage HR+/HER2- Breast Cancer.	N/A	RECRUITING	Henan Cancer Hospital	—
NCT05919108	Neoadjuvant Neratinib in Stage I-III HER2-Mutated Lobular Breast Cancers	PHASE2	RECRUITING	Vanderbilt-Ingram Cancer Center	—
NCT04437160	Adjuvant Chemotherapy for Triple Negative Breast Cancer Patients With Residual Disease After Neoadjuvant Chemotherapy	PHASE2	RECRUITING	Chinese Academy of Medical Sciences	—
NCT03827317	HERPET- A Novel PET Imaging Study of HER2 in Breast Cancer	NA	RECRUITING	Imperial College London	—
NCT05196087	Non-Invasive Artificial Intelligence-Based Platform MonIToring Program (NIP IT!)	N/A	RECRUITING	University Health Network, Toronto	—
NCT04891068	BRE-04: Window of Opportunity Trial of Preoperative Low Dose Azacitidine in High-Risk Early Stage Breast Cancer	PHASE2	RECRUITING	University of Illinois at Chicago	—
NCT04553770	Trastuzumab Deruxtecan Alone or in Combination With Anastrozole for the Treatment of Early Stage HER2 Low, Hormone Receptor Positive Breast Cancer	PHASE2	RECRUITING	Jonsson Comprehensive Cancer Center	—
NCT04368702	CONFIRM: Magnetic Resonance Guided Radiation Therapy	NA	RECRUITING	Brigham and Women's Hospital	—

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan AI + ribociclib (HR+/HER2- metastatic 1L; OS-validated) (REG-AI-RIBOCICLIB)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan TCHP — docetaxel + carboplatin + trastuzumab + pertuzumab (HER2+ neoadjuvant) (REG-TCHP-NEOADJUVANT)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan THP — docetaxel + trastuzumab + pertuzumab (HER2+ metastatic 1L) (REG-THP-METASTATIC)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan T-DXd monotherapy (HER2+ metastatic 2L+, also HER2-low metastatic) (REG-TDXD-METASTATIC)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Pembrolizumab + chemo (TNBC neoadjuvant) (REG-PEMBRO-CHEMO-TNBC-NEOADJUVANT)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Olaparib monotherapy (BRCA-mutant HER2- breast: metastatic OR adjuvant high-risk early) (REG-OLAPARIB-BREAST)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
IND-BREAST-TNBC-METASTATIC-1L-PEMBRO-CHEMO — No regimen components on this track — availability unknown	— unknown	— unknown	₴-? — verify pathway	not recorded
Trial · NCT06903468 Novel Cavity Marking Technique in Breast Cancer Patients Undergoing Breast Conservation Surgery With Oncoplastic Reconstruction for the Delivery of Adjuvant Radiotherapy and Accuracy of Recommended Re-excisions No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT02422641 Prospective Evaluation Of High-Dose Systemic Methotrexate In Patients With Breast Cancer And Leptomeningeal Metastasis No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06781281 NabPE With or Without Serplulimab for Early-stage HR+/HER2- Breast Cancer. No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05919108 Neoadjuvant Neratinib in Stage I-III HER2-Mutated Lobular Breast Cancers No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04437160 Adjuvant Chemotherapy for Triple Negative Breast Cancer Patients With Residual Disease After Neoadjuvant Chemotherapy No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03827317 HERPET- A Novel PET Imaging Study of HER2 in Breast Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05196087 Non-Invasive Artificial Intelligence-Based Platform MonIToring Program (NIP IT!) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04891068 BRE-04: Window of Opportunity Trial of Preoperative Low Dose Azacitidine in High-Risk Early Stage Breast Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04553770 Trastuzumab Deruxtecan Alone or in Combination With Anastrozole for the Treatment of Early Stage HER2 Low, Hormone Receptor Positive Breast Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04368702 CONFIRM: Magnetic Resonance Guided Radiation Therapy No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-04.

plan_id: PLAN-BMA-HER2_LOW_BREAST-V1 | version: 1 | generated: 2026-05-04T14:13:16.628790+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.