Fighting HER2 in Gastric Cancer: Current Approaches and Future Landscapes

Gastric cancer (GC) remains a major cause of cancer-related mortality worldwide, with human epidermal growth factor receptor 2 (HER2)-positive disease representing a clinically relevant subset. Trastuzumab combined with chemotherapy is the standard first-line treatment in advanced settings, following the landmark ToGA trial. However, resistance to trastuzumab has emerged as a significant limitation, prompting the need for more effective second-line therapies. Trastuzumab deruxtecan, a novel antibody–drug conjugate (ADC) composed of trastuzumab linked to a cytotoxic payload, has demonstrated promising efficacy in trastuzumab-refractory, HER2-positive GC, including cases with heterogeneous HER2 expression. Other HER2-targeted ADCs are also under investigation as potential alternatives. In addition, strategies to overcome resistance include HER2-specific immune-based therapies, such as peptide vaccines and chimeric antigen receptor T cell therapies, as well as antibodies targeting distinct HER2 domains or downstream signaling pathways like PI3K/AKT. These emerging approaches aim to improve efficacy in both HER2-high and HER2-low GC. As HER2-targeted treatments evolve, addressing resistance mechanisms and optimizing therapy for broader patient populations is critical. This review discusses current and emerging HER2-directed strategies in GC, focusing on trastuzumab deruxtecan and beyond, and outlines future directions to improve outcomes for patients with HER2-positive GC across all clinical settings.