HR-Positive, HER2-Negative Breast Cancer in Algeria: Beyond Endocrine Therapy Alone

Hormone receptor-positive, HER2-negative breast cancer remains the most common biological subtype of breast cancer. In Algeria, endocrine therapy remains a central component of treatment, but therapeutic decisions increasingly depend on individual risk factors, endocrine sensitivity, and the availability of targeted therapies.
The 2026 Algerian therapeutic guidelines increasingly integrate risk, endocrine sensitivity and targeted treatment into the management of these patients.

Endocrine therapy remains the backbone

For early HR-positive, HER2-negative breast cancer, adjuvant endocrine therapy remains fundamental. The intensity of systemic treatment is adapted according to tumour size, nodal status, grade, proliferation and, when available, genomic risk.
The 2026 Algerian framework therefore does not treat every HR-positive tumour in the same way. Some patients may require endocrine therapy alone, while others may benefit from chemotherapy followed by endocrine therapy.
The practical challenge is identifying who really needs more than endocrine therapy.

In metastatic disease, the paradigm has changed

For HR-positive, HER2-negative metastatic breast cancer without an indication for urgent chemotherapy, the Algerian 2026 guideline places an aromatase inhibitor combined with a CDK4/6 inhibitor at the centre of first-line treatment.
This is an important shift from the traditional sequence of endocrine therapy followed by chemotherapy.
For premenopausal patients, ovarian function suppression is also an important part of the endocrine strategy.

Over time, many tumours develop resistance to endocrine therapy, raising an important clinical question:

What mechanisms are driving endocrine resistance?

Resistance is becoming a molecular question

International practice is increasingly using tumour or circulating DNA to identify alterations that can guide subsequent treatment. In particular, ESR1 mutations can emerge during endocrine treatment, while PIK3CA alterations may identify patients for specific targeted approaches. Current ASCO guidance recommends testing for ESR1 mutations at progression on endocrine therapy, with or without a CDK4/6 inhibitor, and also recommends PIK3CA testing when relevant.
This creates an important question for Algeria:

How much molecular information can we realistically obtain when a patient progresses?

Access to molecular testing will increasingly determine whether patients can benefit from biomarker-guided treatment strategies.

The Algerian perspective

The 2026 Algerian guideline already provides a structured approach to endocrine-sensitive and endocrine-resistant disease and includes CDK4/6 inhibition within the national treatment framework.
The next step is not simply adding more drugs.
It is ensuring that the right patient receives the right endocrine backbone, the appropriate targeted therapy, and—when clinically relevant—the molecular test that can explain resistance and guide the next decision.
For Algerian RCPs, this means that a metastatic HR-positive, HER2-negative case should increasingly be discussed not only in terms of “which line of treatment?”, but also:

• What treatment has the patient already received?
• Is the disease still endocrine-sensitive?
• Is there a molecular alteration that could change the next step?
• And is the required test and treatment accessible?

Breast cancer precision medicine is therefore not only about discovering new targets.
It is about making sure that biology can actually inform treatment decisions in the patient sitting in front of us.