Abstract PO4-25-12: Improving HER2 Low Scoring Consistency and Accuracy: Insights from the Australian HER2 Low Concordance Study for Invasive Breast Cancer
Authors: Farshid Gelareh , Kumar Beena , Pathmanathan Nirmala , Mahajan Hema , Dessauvagie Ben , Armes Jane , Snell Cameron , Gilhotra Amardeep 
Published: May 2024

Abstract
Introduction: The Destiny Breast-04 Trial (DB-04) demonstrated the survival benefits of Trastuzumab Deruxtecan (T-DXd) for women with metastatic HER2 Low breast cancer, characterised by 1+ or 2+ IHC staining without amplification. While the DB-04 study applied the standard 2018 ASCO CAP IHC scoring criteria, in clinical practice, distinguishing HER2 0 from 1+ cancers is challenging as i) HER2 Low is not a biologically distinct subset of breast cancer, ii) there are no reference standards for HER2 Low cancers, iii) second-tier test, like ISH, are not applicable, and iv) there are no known controls for cases that have 0 or 1+ HER2 scores. For two decades this distinction was clinically immaterial, but now differentiating between HER2 0 and 1+ has now become crucial for determining patient eligibility for T-DXd therapy. Concerns regarding the subjectivity, imprecision and poor concordance between pathologists in scoring IHC in HER2 Low cancers raise the potential for misalignments in patient treatment. Ensuring pathologists have access to focused training for interpreting IHC scores at the low end of the HER2 expression spectrum, quality assurance procedures and reference sets are essential steps to help pathologists assess HER2 Low breast cancers more accurately and consistently.
Design: In this study, a group of 9 experienced breast pathologists compiled a deidentified set of 60 breast cancer core biopsies from 3 laboratories. The Ventana 4B5 HER2 assay had been used for evaluation and the local laboratories had scored the samples as HER2 0 or 1+. We teased out the ASCO CAP 2018 criteria and used our collective expertise of reporting HER2 IHC for many years to specify HER2 Low-focused scoring conventions, including some potential pitfalls. Subsequently, using these conventions, each pathologist reviewed digitized whole slide images of the IHC slides and scored HER2 expression for each case. At a consensus workshop, the cases were jointly reviewed to establish consensus scores and determine the percentage of HER2-expressing tumor cells in each case. We then evaluated the concordance between individual pathologists' HER2 scores and the consensus opinion and ascertained reasons for discordance.
Results: Among the cases discussed during the consensus conference, 43 out of 60 (71.7%) were classified as HER2 Low, with 40 cases designated as 1+ and three as 2+ (known to be not amplified). The consensus score matched the majority opinion of the pathologists' independent scores in 93.3% (56 out of 60) of the cases. Utilizing the HER2 Low-focused IHC scoring conventions, 7 out of 17 (41.2%) cases locally reported as HER2 0 were reclassified as HER2 Low. Conversely, among the 32 cases with local scores of 1+, 7 (21.8%) were reclassified as ultralow or null. When compared to the consensus score, individual pathologists' scores demonstrated concordance levels ranging from 71.7% to 91.7%, with a mean concordance rate of 81.3%. Cases with less than 20% of tumor cells expressing HER2 had lower inter observer concordance.
This reference set of cases with expert consensus HER2 scores obtained through our study will be invaluable for peer training and the development of external quality assurance programs for HER2 Low cancers, including the quality assurance program of the Royal College of Pathologists of Australasia.
Conclusion: This study revealed that when breast pathologists were provided explicit instructions on scoring pitfalls and HER2 Low-focused scoring conventions, their HER2 scores were concordant with expert consensus scores in 71.7% to 91.7% of cases. Discordant cases primarily involved cases with less than 20% of tumor cells expressing HER2. Utilising such an approach, peer training and quality assurance procedures will improve the accuracy and consistency of HER2 IHC assessment for better patient care. Reassessing older cases using HER2 Low focused scoring conventions may result in revisions of HER2 scores from HER2 Low to zero, and vice versa.
Table. Individual pathologists' concordance with the consensus HER2 IHC score Applying our HER2 Low-focused IHC scoring conventions in a set of 60 core biopsies of invasive breast cancer with low or 0 HER2 protein expression.
Citation Format: Gelareh Farshid, Beena Kumar, Nirmala Pathmanathan, Hema Mahajan, Ben Dessauvagie, Jane Armes, Cameron Snell, Amardeep Gilhotra. Improving HER2 Low Scoring Consistency and Accuracy: Insights from the Australian HER2 Low Concordance Study for Invasive Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-25-12.