Advanced breast cancer: diagnosis and treatment

  • Clinical guideline
  • CG81
  • Published: 
  • Last updated: 
Download guidance (PDF)

Systemic anticancer therapy

1.6 Choosing systemic anticancer therapy

See also the visual summary of systemic anticancer therapy options and recommendation 1.2.1 in the section on general principles.

1.6.1

Base the decision about whether to use systemic anticancer therapy (SACT), and the choice of SACT if indicated, on factors such as:

  • the person's preferences, fitness and existing comorbidities

  • the characteristics of the cancer

  • the person's response to, and any side effects from, previous lines of therapy

  • the clinical benefits and potential side effects of any suitable SACT regimens, and how they are delivered (for example, oral or intravenous), scheduled, and fit into current treatment pathways

  • NHS funding and commissioning criteria (see the NHS England Cancer Drugs Fund list)

  • the availability of relevant clinical trials (for example, from Be Part of Research and ISCRN: The UK's clinical study registry). [2026]

Why the committee made this recommendation

The committee reviewed evidence about platinum-based chemotherapy regimens for people with triple-negative advanced breast cancer, and discussed what factors affect the choice of regimen for this group. They agreed that the factors discussed applied to all receptor subtype groups and types of SACT.

The committee agreed that the decision about which SACT regimen to use was nuanced and depended on the person's preferences and clinical judgement, taking into account many factors. For example, the characteristics of the cancer would include tumour characteristics such as receptor subtypes and genetic characteristics such as having germline BRCA1 or BRCA2 pathogenic variants. The committee also agreed that choice of regimen would depend on the previous tumour response, the person's fitness and what side effects they had experienced with any previous lines of SACT. They noted that the choice of a particular treatment could affect future treatment options, but that treatment pathways are constantly changing as new drugs become available and funding arrangements change.

Full details of the evidence and the committee's discussion are in evidence review A: platinum-containing chemotherapy regimens.

How the recommendation might affect practice

The recommendation reflects current good practice, but may help standardise it where localised variations occur.

1.7 Treatments by receptor subtype

Triple-negative advanced breast cancer

1.7.4

For medicines recommended as options for treating HER2-negative, advanced breast cancer with germline BRCA1 or BRCA2 pathogenic variants after an anthracycline and a taxane, see NICE's technology appraisal guidance on:

Chemotherapy for people with triple-negative advanced breast cancer

1.7.5

If chemotherapy is indicated for people with triple-negative advanced breast cancer, offer systemic sequential chemotherapy. [2009, amended 2026]

1.7.6

When offering systemic sequential chemotherapy for triple-negative advanced breast cancer, options include (but are not limited to) the following (in no order of preference):

  • anthracyclines

  • capecitabine

  • carboplatin

  • taxanes

  • vinorelbine. [2026]

    Eribulin and gemcitabine with paclitaxel, are recommended as chemotherapy options for treating advanced breast cancer. For full details, see NICE's technology appraisal guidance on:

  • eribulin (TA423, 2016) after at least 2 chemotherapy regimens

  • gemcitabine with paclitaxel (TA116, 2007).

1.7.7

Consider using combination chemotherapy to treat patients with advanced breast cancer for whom a greater probability of response is important and who understand and are likely to tolerate the additional toxicity. [2009]

Why the committee made the 2026 recommendation

Evidence suggested that chemotherapy regimens that contain platinums and those that do not may have similar impacts on overall survival and progression-free survival in people with triple-negative advanced breast cancer.

The committee highlighted that the evidence suggested an increased risk of some side effects (for example, neutropenia, and nausea or vomiting) with chemotherapy regimens including platinums, compared with those without. However, the evidence was very uncertain due to the studies being at a high risk of bias, and there being a large variation in results between studies for some outcomes. It also included a variety of different comparator drugs, all of which have different side-effect profiles, but only side effects most commonly expected with platinums were reported in the studies. Because of this and the evidence for overall survival and progression-free survival, the committee agreed that they were unable to recommend using platinum-based chemotherapy over non-platinum chemotherapy for people with triple-negative breast cancer (TNBC). However, they noted that the choice of the type of chemotherapy or other SACT is a complex one that needs to be tailored to the individual and agreed that for some people with triple-negative advanced breast cancer platinum-based chemotherapy would be a suitable option.

The committee recognised that clinical practice has changed greatly over time and that a single sequence of chemotherapies for everyone with advanced breast cancer is no longer relevant. However, they noted that chemotherapies in the 2009 recommendation are still in use, and they agreed to add carboplatin to this list of potential options for TNBC. They agreed that the 2009 recommendation on offering systemic sequential chemotherapy also remained relevant.

The committee were unable to recommend a different chemotherapy regimen for people who have TNBC with, or without, germline BRCA1 or BRCA2 pathogenic variants because of the limited number of included trials and small number of participants in them. Therefore, they drafted a recommendation for research on platinum-containing chemotherapy regimens to try to fill these gaps in the evidence base.

Full details of the evidence and the committee's discussion are in evidence review A: platinum-containing chemotherapy regimens.

How the recommendation might affect practice

The recommendation reflects current practice and is not expected to result in significant changes.

HER2-positive advanced breast cancer

Chemotherapy for people with HER2-positive advanced breast cancer
1.7.13

If chemotherapy is indicated for people with HER2-positive advanced breast cancer, offer systemic sequential chemotherapy. [2009, amended 2026]

1.7.14

When offering systemic sequential chemotherapy for HER2-positive advanced breast cancer, options include (but are not limited to) the following (in no order of preference):

  • anthracyclines

  • capecitabine

  • taxanes

  • vinorelbine. [2026]

    Eribulin, and gemcitabine with paclitaxel, are recommended as chemotherapy options for treating advanced breast cancer. For full details, see NICE's technology appraisal guidance on:

  • eribulin (TA423, 2016) after at least 2 chemotherapy regimens.

  • gemcitabine with paclitaxel (TA116, 2007).

1.7.15

Consider using combination chemotherapy to treat patients with advanced breast cancer for whom a greater probability of response is important and who understand and are likely to tolerate the additional toxicity. [2009]

Why the committee made the 2026 recommendation

The committee used the same process for updating the chemotherapy recommendations for people with HER2-positive advanced breast cancer as was used with triple-negative breast cancer (TNBC), based on the same rationale. However, platinum chemotherapy was excluded as the effectiveness of this was not reviewed as part of this update for people who did not have TNBC.

How the recommendation might affect practice

The recommendation reflects current practice and is not expected to result in significant changes.

Hormone-receptor-positive, HER2-negative advanced breast cancer

1.7.20

Elacestrant is recommended as an option for treating oestrogen receptor-positive, HER2-negative, advanced breast cancer with ESR1 pathogenic variants that has progressed after at least 1 line of endocrine treatment plus a CDK4/6 inhibitor. For full details, see NICE's technology appraisal guidance on elacestrant (TA1036, 2025).

1.7.21

For medicines recommended as options for treating HER2-negative, advanced breast cancer with germline BRCA1 or BRCA2 pathogenic variants after endocrine therapy or an anthracycline and a taxane, see NICE's technology appraisal guidance on:

Chemotherapy for people with hormone-receptor-positive, HER2-negative advanced breast cancer
1.7.22

If chemotherapy is indicated for people with hormone-receptor-positive, HER2-negative advanced breast cancer, offer systemic sequential chemotherapy. [2009, amended 2026]

1.7.23

When offering systemic sequential chemotherapy for hormone-receptor-positive, HER2-negative advanced breast cancer, options include (but are not limited to) the following (in no order of preference):

  • anthracyclines

  • capecitabine

  • taxanes

  • vinorelbine. [2026]

    Eribulin, and gemcitabine with paclitaxel, are recommended as chemotherapy options for treating advanced breast cancer. For full details, see NICE's technology appraisal guidance on:

  • eribulin (TA423, 2016) after at least 2 chemotherapy regimens

  • gemcitabine with paclitaxel (TA116, 2007).

1.7.24

Consider using combination chemotherapy to treat patients with advanced breast cancer for whom a greater probability of response is important and who understand and are likely to tolerate the additional toxicity. [2009]

Why the committee made the 2026 recommendation

The committee used the same process for updating the chemotherapy recommendations for people with hormone-receptor-positive, HER2-negative advanced breast cancer as was used with triple-negative breast cancer (TNBC), based on the same rationale. However, platinum chemotherapy was excluded as the effectiveness of this was not reviewed as part of this update for people who did not have TNBC.

Full details of the evidence and the committee's discussion are in evidence review A: platinum-containing chemotherapy regimens.

How the recommendation might affect practice

The recommendation reflects current practice and is not expected to result in significant changes.

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours