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UK recommendations for HER2 assessment in breast cancer: an update
  1. Emad A Rakha1,
  2. Puay Hoon Tan2,
  3. Cecily Quinn3,
  4. Elena Provenzano4,
  5. Abeer M Shaaban5,
  6. Rahul Deb6,
  7. Grace Callagy7,
  8. Jane Starczynski8,
  9. Andrew H S Lee9,
  10. Ian O Ellis 11,
  11. Sarah E Pinder10
  1. 1 Cellular Patthology Department, School of Medicine, University of Nottingham, Nottingham, UK
  2. 2 Luma Medical Centre, Singapore
  3. 3 Department of Histopathology, St Vincent's University Hospital, Elm Park and and UCD School of Medicine, Dublin, Ireland
  4. 4 Department of Histopathology, Addenbrookes Hospital, Cambridge, UK
  5. 5 Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trusts and Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
  6. 6 Cellular Pathology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
  7. 7 Discipline of Pathology, School of Medicine, Lambe Institute for Translational Research, University of Galway, Galway, Ireland
  8. 8 Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trusts, Birmingham, UK
  9. 9 Cellular Pathology Department, City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
  10. 10 School of Cancer & Pharmaceutical Sciences, Kings College London, London, UK
  1. Correspondence to Emad A Rakha, Cellular Pathology Department, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK; emad.rakha{at}


The last UK breast cancer (BC) human epidermal growth factor receptor 2 (HER2) testing guideline recommendations were published in 2015. Since then, new data and therapeutic strategies have emerged. The American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) published a focused update in 2018 that reclassified in situ hybridisation (ISH) Group 2 (immunohistochemistry (IHC) score 2+and HER2/chromosome enumeration probe 17 (CEP17) ratio ≥2.0 and HER2 copy number <4.0 signals/cell), as well as addressed other concerns raised by previous guidelines. The present article further refines UK guidelines, with specific attention to definitions of HER2 status focusing on eight key areas: (1) HER2 equivocal (IHC 2+) and assignment of the ASCO/CAP ISH group 2 tumours; (2) the definition of the group of BCs with low IHC scores for HER2 with emphasis on the distinction between IHC score 1+ (HER2-Low) from HER2 IHC score 0 (HER2 negative); (3) reporting cases showing HER2 heterogeneity; (4) HER2 testing in specific settings, including on cytological material; (5) repeat HER2 testing, (6) HER2 testing turnaround time targets; (7) the potential role of next generation sequencing and other diagnostic molecular assays for routine testing of HER2 status in BC and (8) use of image analysis to score HER2 IHC. The two tiered system of HER2 assessment remains unchanged, with first line IHC and then ISH limited to IHC equivocal cases (IHC score 2+) but emerging data on the relationship between IHC scores and levels of response to anti-HER2 therapy are considered. Here, we present the latest UK recommendations for HER2 status evaluation in BC, and where relevant, the differences from other published guidelines.

  • In Situ Hybridization

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  • Handling editor Vikram Deshpande.

  • Twitter @RahulADeb

  • Collaborators ER drafted the manuscript. All authors reviewed the manuscript and approved the final version. This manuscript is prepared on behalf of the UK National Coordinating Committee for Breast Pathology. No conflict of interests.

  • Contributors ER: drafted and reviewed the manuscript and approved the final version. PHT, CQ, EP, AMS, RD, GC, JS, AHSL, IOE and SEP: reviewed and amended the manuscript and approved the final version

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests The authors attended meetings sponsored by Roche and AstraZeneca on HER2 low and HER2 positive breast cancer. No other relevant conflict of interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.