TCHP (docetaxel, carboplatin, trastuzumab, pertuzumab)

Anthracycline-free chemotherapy with dual HER2 blockade every 21 days × 6, mainly before surgery for HER2-positive early breast cancer

For clinicians and students · Regimen tutorial · Breast cancer · 9 min read · last reviewed September 30, 2026

Overview

TCHP pairs a taxane–platinum doublet with dual HER2 blockade:

• Docetaxel (T), a microtubule stabilizer.
• Carboplatin (C), dosed by the Calvert formula to a target AUC.
• Trastuzumab (H, from Herceptin), which binds HER2 subdomain IV.
• Pertuzumab (P), which binds subdomain II and blocks HER2 dimerization, especially with HER3.

The two antibodies are complementary: together they give more complete pathway blockade and add antibody-dependent cellular cytotoxicity. TCHP avoids anthracyclines, and with them the additive cardiotoxicity of anthracycline followed by trastuzumab. It is widely used as neoadjuvant therapy for stage II–III HER2-positive breast cancer, so the pathologic response can guide what comes after surgery.

Indications

• Neoadjuvant treatment of operable, locally advanced or inflammatory HER2-positive early breast cancer (eviQ ID 3736: HER2-positive by in situ hybridisation). Neoadjuvant use is generally favoured for node-positive or larger (≥ T2) tumours.
• Adjuvant use. TCH ± pertuzumab after surgery in node-positive or high-risk node-negative HER2-positive disease. BC Cancer's BRAJDCARBT (TCH) is licensed for neoadjuvant or adjuvant use in node-positive or high-risk node-negative disease, including T1b tumours.
• HER2 positivity means IHC 3+ or ISH amplification (BC Cancer: IHC 3+ or FISH ratio ≥ 2).
• Cardiac eligibility.
• eviQ excludes patients with LVEF ≤ 45%.
• BC Cancer requires LVEF ≥ 50%. Between 45% and 50%, the oncologist may treat on clinical judgement. Below 45%, or with significant cardiovascular disease, treatment is excluded.
• Grade ≥ 2 neuropathy excludes treatment (BC Cancer).

Regimen

Source: eviQ ID 3736 (current version 4). All IV drugs on day 1, every 21 days.

Cycle length: 21 days. Number of cycles: 6 before surgery.

After surgery (eviQ notes). Continue trastuzumab ± pertuzumab to a total of 17 cycles of trastuzumab. If invasive disease remains at surgery, switch to trastuzumab emtansine (T-DM1) for 14 cycles.

BC Cancer TCH comparison (BRAJDCARBT). Same doses: trastuzumab 8 mg/kg loading then 6 mg/kg, docetaxel 75 mg/m², carboplatin AUC 6, every 21 days × 6. G-CSF is filgrastim 5 mcg/kg/day starting day 3 for 5–7 doses, or pegfilgrastim 6 mg on day 3. Single-agent trastuzumab (BRAJTR) then completes 17 doses in total (51 weeks). Pertuzumab is not part of BRAJDCARBT. Whether pertuzumab is funded in the neoadjuvant or adjuvant setting, and under which protocol code, varies by province and country. Check your formulary.

Carboplatin dosing details differ between sources

• BC Cancer: prefers measured GFR (nuclear renogram). Otherwise it uses lab eGFR or Cockcroft–Gault, capped at 125 mL/min for the initial dose, and the same method is used throughout.
• eviQ: follows the ADDIKD guideline. It prefers measured GFR, or BSA-adjusted eGFR, and does not cap at 125 mL/min for the Calvert formula. For an estimated GFR > 125 mL/min (an AUC 6 dose > 900 mg), it strongly recommends direct measurement and/or dose capping.
• Recalculation: eviQ recalculates if kidney function changes by more than 20%. BC Cancer considers recalculation if creatinine changes by ±20%.

"Do not substitute"

• eviQ warns that trastuzumab must not be substituted with trastuzumab emtansine or trastuzumab deruxtecan. They are different drugs with different doses.
• Look-alike names are a known medication error risk. Some systems show these agents with distinct tall-man lettering or suffixes.

Premedication and supportive care

Docetaxel premedication

• BC Cancer: dexamethasone 8 mg PO BID for 3 days, starting the day before docetaxel, with at least 3 doses before treatment. This reduces fluid retention and hypersensitivity.
• eviQ: dexamethasone 8 mg BID the day before, 8 mg on day 1, then day 2–3 doses.

Antiemetics

• BC Cancer treats the combination as highly emetogenic.
• eviQ classifies carboplatin AUC ≥ 4 as MODERATE, but still recommends NK1 antagonist + 5-HT3 antagonist + dexamethasone (e.g. netupitant/palonosetron + dexamethasone).
• In practice, give triple prophylaxis.

Growth factor

• Built in. BC Cancer states that febrile neutropenia risk is > 20% without G-CSF.

Nail and skin protection

• BC Cancer suggests frozen gloves from 15 min before until 15 min after the docetaxel infusion to prevent onycholysis and hand skin toxicity. Change the gloves after 45 min.

Diarrhea plan

• Diarrhea is the most common non-hematologic toxicity of TCHP. eviQ cites neutropenia and diarrhea as the most clinically significant toxicities, and pertuzumab adds to it.
• Supply loperamide and teach patients when to call.

Infusion reactions

• Trastuzumab: chills and fever occur in about 40% at the first infusion (BC Cancer). Treat with acetaminophen, diphenhydramine and/or meperidine, and slow the infusion.
• Serious reactions are rare.
• Observation periods: BC Cancer observes for 1 h after the first trastuzumab dose and 30 min after the next doses. Observation is no longer required after 3 uneventful doses.

Key toxicities

• Hematologic. Neutropenia and febrile neutropenia; anemia (TRYPHAENA arm C had notably more grade ≥ 3 anemia); and thrombocytopenia from carboplatin.
• Gastrointestinal. Diarrhea (very common with dual HER2 blockade), nausea, and mucositis.
• Docetaxel-specific.
• Fluid retention (peripheral edema, effusions), which is cumulative and reduced by steroids.
• Nail changes and onycholysis, and hand-foot skin reactions.
• Peripheral neuropathy.
• Hypersensitivity, which can occur with the first or second infusion.
• Interstitial pneumonitis (rare).
• Epiphora (tear duct stenosis) with prolonged use.
• Hepatic impairment (particularly raised AST/ALT with raised alkaline phosphatase or bilirubin) sharply increases the risk of toxic death. Check liver tests before cycle 1.
• Carboplatin. Myelosuppression, which is cumulative for platelets. Hypersensitivity becomes more likely with increasing cycle number (eviQ). Hypomagnesemia.
• HER2-directed cardiotoxicity. Usually an asymptomatic fall in LVEF, less often heart failure. It is largely reversible and not dose-dependent, unlike anthracycline cardiomyopathy. The risk is higher after anthracyclines and with pre-existing cardiac disease.
• Trastuzumab and warfarin. BC Cancer notes a possible interaction that raises the INR. Monitor the INR every 2 weeks for the first 3 months.

Monitoring

• Baseline:
• CBC and differential, creatinine (with GFR for carboplatin), liver panel (bilirubin, ALT/AST, alkaline phosphatase, GGT).
• LVEF by echocardiogram or MUGA.
• Hepatitis B serology (eviQ).
• Pregnancy test where relevant.
• Before each cycle: CBC and differential, creatinine, and electrolytes including magnesium where indicated. Liver tests if they were previously abnormal. Assess symptoms of neuropathy, diarrhea, edema and heart failure.
• LVEF during treatment.
• eviQ: baseline, then every 3 months.
• BC Cancer: before the first trastuzumab dose, then every 3–4 months, with no more than 4 months between assessments, until trastuzumab is complete.

Dose-modification principles

• HER2 antibodies are not dose-reduced. eviQ and BC Cancer both state that trastuzumab (and pertuzumab) doses are not reduced for hematologic toxicity. Continue the antibodies even if chemotherapy is held. Stop pertuzumab if trastuzumab is stopped (eviQ).
• Chemotherapy for cytopenias.
• BC Cancer BRAJDCARBT: on day 1, give 100% if ANC ≥ 1.0 and platelets ≥ 100. Otherwise delay 1 week. Give 75% if the platelets were < 100.
• Febrile neutropenia: 1st episode → 75%; 2nd → 50% of the original dose; 3rd → discontinue the protocol.
• eviQ uses delays plus consideration of 25% reductions of docetaxel and carboplatin.
• Diarrhea or mucositis (eviQ). Grade 2 → delay until grade ≤ 1, with escalating 25% then 50% reductions on repeat episodes. Grade 3–4 → delay, then a 50% reduction; on recurrence, omit docetaxel and carboplatin.
• Neuropathy (eviQ). Grade 2 persisting at the next cycle → reduce docetaxel by 25%, then 50%. Grade 3–4 → omit docetaxel.
• Hepatic impairment (eviQ). Reduce docetaxel by 25% (minimal), 50% (mild), or omit it (moderate or severe).
• LVEF.
• eviQ. LVEF 40–45% and/or a fall of ≥ 10 points from baseline: delay both antibodies and repeat LVEF within 3 weeks. Consider stopping if LVEF has not recovered to within 10 points of baseline. LVEF < 40%: delay, and discontinue if confirmed. Symptomatic heart failure: discontinue.
• BC Cancer. Uses a grid of LVEF relative to the lower limit of normal and the absolute fall from baseline. For example, a fall of ≥ 16 points means hold even if the LVEF is still normal. Repeat in 3–4 weeks. Stop trastuzumab after 2 consecutive holds or 3 holds in total.
• Missed doses (eviQ; BC Cancer similar for trastuzumab).
• Delay ≤ 6 weeks: give the maintenance dose as soon as possible.
• Delay > 6 weeks: reload trastuzumab 8 mg/kg and pertuzumab 840 mg, then resume every 3 weeks.

Key trials and evidence

• BCIRG 006 (Slamon, NEJM 2011). Adjuvant TCH was about as effective as AC→TH, with fewer cardiac events and less leukemia. This established the anthracycline-free carboplatin backbone.
• NeoSphere (Gianni, Lancet Oncol 2012). Adding pertuzumab to trastuzumab plus docetaxel roughly doubled the rate of pathologic complete response before surgery.
• TRYPHAENA (Schneeweiss, Ann Oncol 2013). A phase II cardiac safety study. Anthracycline-free TCHP produced a high pCR rate (66.2% ypT0/is in arm C) with low rates of symptomatic LV dysfunction. It was the main evidence eviQ used for the protocol.
• TRAIN-2 (van Ramshorst, Lancet Oncol 2018). With dual HER2 blockade, a carboplatin–paclitaxel backbone without anthracyclines gave pCR rates similar to regimens containing anthracyclines, with less febrile neutropenia.
• APHINITY (von Minckwitz, NEJM 2017). Adjuvant pertuzumab added a small invasive disease-free survival benefit, concentrated in node-positive disease.
• KATHERINE (von Minckwitz, NEJM 2019). For residual invasive disease after neoadjuvant HER2-directed therapy, T-DM1 cut the risk of recurrence or death roughly in half compared with trastuzumab.

Clinical pearls

• Loading doses reset after long gaps. Any delay of more than 6 weeks needs reloading. Track the dates of the last antibody doses, not just cycle numbers.
• Steroids start the day before. Missing dexamethasone before docetaxel raises the risk of hypersensitivity and fluid retention. Confirm the doses were taken before the chair appointment.
• Carboplatin math. Check which GFR method your protocol uses, and whether it is capped. An uncapped high eGFR can push the AUC 6 dose above 900 mg.
• Diarrhea is the "P" toxicity. It is usually worst in early cycles. Proactive loperamide keeps patients out of hospital and on schedule.
• Neoadjuvant response changes the plan. Book surgical and pathology review so that pCR (continue HER2 antibodies to a year) and residual disease (switch to T-DM1) are identified quickly after surgery.
• Cardio-oncology early. For borderline LVEF or significant risk factors, involve cardiology at baseline rather than at the first LVEF drop. Cardioprotective therapy (e.g. an ACE inhibitor or beta-blocker) may allow trastuzumab to continue, per cardio-oncology advice.

Educational material for health professionals and students. Not a prescribing order; it does not replace your institution's approved protocol, pharmacy verification or clinical judgement.

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