American Society of Clinical Oncology (ASCO)/

College of American Pathologists (CAP)

Guideline Recommendations for
Immunohistochemical Testing of
Estrogen/Progesterone Receptors in Breast
Cancer
www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved
INTRODUCTION
• ASCO and the College of American Pathologists (CAP)
previously collaborated on a guideline on HER2 testing,
published in 2007
• Subject: Estrogen (ER) and Progesterone (PgR) testing
• Rationale: Evidence of wide variability in test
performance and inaccurate results
• ASCO and CAP decided to produce the first ever
evidence-based ER-PgR testing guideline, based on a
systematic review

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Background
• Hormone receptor-positive is the most
common breast cancer phenotype worldwide
• Access to accurate and reliable ER/PgR
testing and to established and relatively
affordable endocrine therapies could have a
profound impact on breast cancer outcomes
in high and low/middle income countries
across the globe

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Guideline Methodology:
Systematic Review
• ASCO and Cancer Care Ontario jointly conducted a
systematic review of the medical literature available from
1990-May 2008
– Ovid (Medline)
– EMBASE
– Cochrane Database of Systematic Reviews
• Primary outcome: correlation of hormone receptor status and
outcome of endocrine treatment
• ASCO/CAP Expert Panel made recommendations based on
this review

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Clinical Questions
1. What is the optimal testing algorithm for testing ER
and PgR status?
1.1 What are the clinically validated methods that can
be used in this assessment?
2. What strategies can ensure optimal performance,
interpretation, and reporting of established assays?
2.1 What are the preanalytic, analytic and postanalytic
variables that must be controlled to ensure that assay
results reflect tumor ER and PgR status?

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Clinical Questions, cont’d
2.2. What is the optimal internal quality management
regimen to ensure ongoing accuracy of ER and
PgR testing?
2.3. What is the regulatory framework that permits
application of external controls such as
proficiency testing and on-site inspection?
2.4. How can internal and external control efforts be
implemented and their effects measured?

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Special Questions
1. Should ER/PgR be done in DCIS or recurrent
tumor?
2. Does PgR influence the choice of endocrine
therapy?

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Clinical Question 1. What is the optimal testing algorithm for testing ER and PgR
status?
Optimal algorithm for ER/PgR testing
• Positive - if finding of ≥ 1% of tumor cell nuclei are
immunoreactive
• Negative - if finding of < 1% of tumors’ cell nuclei are
immunoreactive in the presence of evidence that the
sample can express ER or PgR (positive intrinsic controls
are seen)
• Uninterpretable - finding that no tumor nuclei are
immunoreactive and that internal epithelial elements
present in the sample or separately submitted from the
same sample lack any nuclear staining

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Clinical Question 2. What strategies can ensure optimal performance,
interpretation, and reporting of established assays?

Clinical Question 2.1 What are the preanalytic, analytic, and postanalytic variables
that must be controlled to ensure that assay results reflect tumor ER and PgR
status?

Optimal testing conditions

• Large, preferably multiple core biopsies of tumor
are preferred for testing if they are representative
of the tumor (grade and type) at resection
• Interpretation follows guideline recommendation
• Accession slip and report must include guideline-
detailed elements

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Required reporting elements
1. Percent/proportion of tumor cells staining
positively. Percentage either by:
1. Estimation
2. Quantitation (counting cells or image analysis)
3. If cytology specimen, count ≥100 cells
2. Intensity of staining – weak, moderate, or strong –
representing an estimate of average of intensity of
positive cells relative to positive controls on same
batch
3. Interpretation of the assay (+, -, or uninterpretable)

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

 Two optional report elements
are recommended
1. If negative ER and PgR interpretations when the
histopathology of the tumor is almost always associated
with ER+ and PgR+ results, including: tubular, lobular,
and mucinous histological types or Nottingham grade 1
tumors
Then an optional cautionary statement should indicate
that while the patient’s tumor tested as ER-negative,
tumors with the same histological type or Nottingham
grade almost always test +

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Optional report elements, cont’d
2. -Pathologist may also provide a composite
score e.g. the H score, Allred score, or Quick
score
-Using the percent and intensity measurements
provided
-Since each of these is somewhat differently
calculated and may lead to confusion across
institutions
-Scoring is not required

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Clinical Question 2.1 What are the preanalytic, analytic, and postanalytic
variables that must be controlled to ensure that assay results reflect tumor ER
and PgR status?
Optimal tissue handling requirements
• Time from tissue acquisition to start of fixation process
should be as short as possible
• Samples for ER and PgR testing are fixed in 10% neutral
buffered formalin (NBF) for 6-72 hours
• Samples should be sliced at 5 mm intervals after
appropriate gross inspection and margins designation and
placed in sufficient volume of NBF formalin of a sufficient
volume to allow adequate tissue penetration

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations- Optimal tissue
handling requirements, cont’d
• If tumor comes from remote location, it
should be bisected on removal and sent to
the laboratory immersed in a sufficient
volume of NBF
• Cold ischemia time, fixative type, and time
sample placed in NBF must be recorded

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations-Optimal tissue
handling requirements, cont’d
• Storage of unstained slides for more than 6
weeks prior to analysis is not recommended
• Time tissue is removed from patient, time
tissue is placed in fixative (cold ischemia
time), duration of fixation, and fixative type
must be recorded and noted on accession
slip or in report

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Additional information in re:
Clinical Question 2.1
Standardization of Analytical Variables
Antibody Selection
• Antibodies should have well-established specificity and sensitivity and
have been clinically validated (good correlation with patient outcomes)
• Alternatively, results of lab-selected antibodies should be ≥90%
concordant with clinically validated antibodies for ER and PgR-positive
category and ≥95% concordant with clinically validated antibodies for
ER or PgR negative category
• Include: ER: 1D5, 6F11, SP1, 1D5; PgR: 1294, 312

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Clinical Question 1.1 What are the clinically validated methods that can be
used in this assessment?

Optimal internal validation procedure

• Validation of any test must be done before test is
offered
• Validation must be done using a clinically validated
ER or PgR test method
• Revalidation should be done whenever there is a
significant change to the test system, such as a
change in the primary antibody clone or introduction
of new antigen retrieval or detection systems.

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

 Recommendations
Clinical Question 2.3. What is the optimal internal quality management regimen
to ensure ongoing accuracy of ER and PgR testing?
Optimal internal QA procedures
• Initial test validation
• Ongoing quality control and equipment maintenance
• Initial and ongoing laboratory personnel training and competency assessment
• Use of standardized operating procedures including routine use of external
control materials with each batch of testing and routine evaluation of internal
normal epithelial elements or the inclusion of normal breast sections on each
tested slide, wherever possible.
• Regular, ongoing assay reassessment should be done at least
semiannually. Revalidation is needed whenever there is a significant
change to the test system.
• Ongoing competency assessment and education of pathologists

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Clinical Question 2.4. What is the regulatory framework that permits
application of external controls such as proficiency testing and on-site
inspection?
Clinical Question 2.5. How can internal and external control efforts be
implemented and their effects measured?

Optimal external proficiency assessment

• Mandatory participation in external proficiency testing program
with at least two testing events (mailings)/year
• Satisfactory performance requires at least 90% correct responses
on graded challenges for either test
• Unsatisfactory performance will require laboratory to respond
according to accreditation agency program requirements

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Recommendations
Optimal laboratory accreditation
• On-site inspection every other year with annual
requirement for self-inspection
• Reviews laboratory validation, procedures, QA
results and processes, results and reports
• Unsuccessful performance results in suspension
of laboratory testing for ER or PgR

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

 Special Questions
1. Should ER/PgR be done in DCIS or recurrent tumor?
• ER and PgR status should be determined on all newly
diagnosed invasive breast cancers (primary and/or metastatic
site)
• Lack of validation studies on testing for people with DCIS.
Panel saw value, but could not make formal recommendation.
• Women with breast recurrences accessible to biopsy should
also always be tested
– To check prior negative results not false negative
– To check specimen for emergence of negative clones

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Special Questions
2. Does PgR correlate with or influence the
choice of endocrine therapy?
• The precise role of PgR in patient management
has not been strongly established
• Do not withhold endocrine treatment from
women w/ ER-rich, PgR poor tumor
• Women w/ ER-/PgR+ tumors may respond to
endocrine therapy

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

How can these efforts be implemented
and the effects measured?
• Educational opportunities from ASCO and CAP
• CAP certification program for pathologists
• Coordination of recommendations with NCCN, Commission of
Cancer of the American College of Surgeons, the American
Joint Committee on Cancer, and patient advocacy groups
• CAP will:
– Review and publish results of proficiency testing and laboratory
accreditation
– Inclusion of quality monitoring activities on ER/PgR testing in ongoing
quality assessment programs

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Guideline Methodology:
Panel Members
Panel Member Institution
Intermountain Health Care, University of Utah School of
M. Elizabeth H. Hammond, MD, Co-Chair*
Medicine, UT
University of Michigan Comprehensive Cancer Center,
Daniel F. Hayes, MD, Co-Chair*
University of Michigan Health and Health System, MI
Mitch Dowsett, PhD* Royal Marsden Hospital, UK

Washington University School of Medicine , St. Louis,

D. Craig Allred, MD*
MO
Jared N. Schwartz, MD, PhD, FACP, Co-Chair* Presbyterian Hospital, NC
The Sidney Kimmel Comprehensive Cancer Center at
Antonio C. Wolff, MD, FACP, Co-Chair*
Johns Hopkins University, MD

Sunil Badve, MD ECOG, Indiana University, IN

US Food and Drug Administration, Center for Devices
and Radiological Health, Office of In Vitro Diagnostic
Robert L. Becker, MD, Ex-Officio
Device Evaluation and Safety

Patrick L. Fitzgibbons, MD, FACP St. Jude Medical Center, CA

Glenn Francis, MBBS, FRCPA, MBA Princess Alexandra Hospital, Australia

*Steering Committee Member
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Guideline Methodology:
Panel Members, cont’d
Panel Member Institution
Neal S. Goldstein, MD Advanced Diagnostics Laboratory, MI

Malcolm Hayes, MD University of British Columbia, Canada

David G. Hicks, MD, FCAP University of Rochester, NY

Susan Lester, MD Brigham and Women’s Hospital, MA

Richard Love, MD Ohio State University, OH

Lisa McShane, PhD NCI, Biometric Research Branch, DCTD

Keith Miller, MD UK NEQAS

C. Kent Osborne, MD Baylor College of Medicine, TX

Soonmyung Paik, MD National Surgical Adjuvant Breast and Bowel Project, PA

Jane Perlmutter, PhD, Patient Representative Gemini Group, MI

Anthony Rhodes, PhD University of the West of England, Bristol, UK NEQAS

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Guideline Methodology:
Panel Members, cont’d
Panel Members Institution
Hironobu Sasano, MD Tohoku University School of Medicine, Japan

Fred C. G. J. Sweep, PhD Radboud University, Nijmegen, Netherlands

Sheila Taube, PhD ST Consulting, MD

Emina Emilia Torlakovic, MD, PhD Royal University Hospital, Saskatoon, Canada

Paul Valenstein, MD, FCAP St. Joseph Mercy Hospital, Ann Arbor, MI

Giuseppe Viale, MD, FRCPath European Institute of Oncology, Milan, Italy

Daniel Visscher, MD University of Michigan, Ann Arbor, MI

Thomas Wheeler, MD, FCAP Baylor College of Medicine, TX

R. Bruce Williams, MD, FCAP The Delta Pathology Group, Shreveport, LA

James L. Wittliff, MD, PhD University of Louisville, KY

Judy Yost, MA, MT (ASCP), Ex Officio CMS, Division of Laboratory Services (CLIA)

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Guideline Methodology:
Guests invited to open portion of meeting
Invited Guests Affiliation
Richard Bender, MD Agendia Inc

Kenneth J. Bloom, MD Clarient

Allen M. Gown, MD PhenoPath Laboratories, Seattle, WA

David L. Rimm, MD, PhD Yale University

Patrick Roche, PhD Ventana Medical Systems

Steven Shak, MD Genomic Health

Roseanne Welcher DAKO

Hadi Yaziji, MD Ancillary Pathways, Miami, FL

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

Additional ASCO Resources
•The full text of the guideline, an abridged
version of the guideline, an Executive
Summary, this slide set, and additional
clinical tools and resources can be found at:
http://www.asco.org/guidelines/erpr

•A patient guide, “What to Know” about this

guideline, is available at:
http://www.cancer.net/whattoknow

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved

ASCO Guidelines
It is important to realize that many management questions have not been
comprehensively addressed in randomized trials and guidelines cannot always
account for individual variation among patients. A guideline is not intended to
supplant physician judgment with respect to particular patients or special clinical
situations and cannot be considered inclusive of all proper methods of care or
exclusive of other treatments reasonably directed at obtaining the same results.
Accordingly, ASCO considers adherence to this guideline to be voluntary, with
the ultimate determination regarding its application to be made by the physician
in light of each patient’s individual circumstances. In addition, the guideline
describes administration of therapies in clinical practice; it cannot be assumed to
apply to interventions performed in the context of clinical trials, given that clinical
studies are designed to test innovative and novel therapies in a disease and
setting for which better therapy is needed. Because guideline development
involves a review and synthesis of the latest literature, a practice guideline also
serves to identify important questions for further research and those settings in
which investigational therapy should be considered.

www.asco.org/guidelines. ©American Society of Clinical Oncology 2010. All rights reserved