Progress in Treating Inflammatory Breast Cancer
"But IBC is fatal," a doctor once told me when I mentioned that I am an inflammatory breast cancer survivor as she took my medical history. An article titled "Inflammatory Breast Cancer: What Progress Have We Made?" by Shaheenah Dawood and Massimo Cristofanilli reviews thirty years of progress that proves just how wrong that doctor was. Here are some highlights of their article published March 21, 2011, on-line at Cancer Network.
Better imaging techniques are leading to better diagnosis and treatment of IBC. You may have heard of IBC as the breast cancer that does not show up on a mammogram. Although it is true that most IBC patients do not have a lump, the new digital mammograms are better at identifying the skin thickening and changes in breast density that are often present in IBC. Breast MRI's can help the doctor determine where to biopsy, a problem when there is no solid lump. Improved sonograms, MRI's, PET and CT scans are picking up the problems with lymph nodes and distant metastases common in IBC much earlier leading to more effective treatment.
Preoperative chemotherapy is saving lives. While Dawood and Christofanelli want to see more studies to determine the best chemotherapy drugs for IBC, the switch from doing chemo after surgery to doing it before surgery has been a major factor in increasing the average median overall survival from 15 to 40 months. First, it helps doctors to be able to see whether the chemo is working by gauging changes in the breast over the course of the treatment. The doctor can change drugs if the first does not work. It is also important to start chemo before surgery because the cancer is already in the lymph system where it may easily travel to other parts of the body. A systemic treatment like chemo helps to kill any cancer cells that have already metastasized.
So far the data show that IBC patients should have their chemo drugs chosen from two families: the anthracyclines and the taxanes. Combining these types of drugs has significantly improved survival rates with many more patients now living for years past the median survival rate.
Targeted therapies are often helpful for IBC patients. As scientists learn more about the molecular differences in types of tumors, they are devising drugs that target specific factors. Dawood and Cristofanilli say, "Our deeper understanding of the molecular biology of IBC has led to the identification of several prime molecular targets that may help with the development of therapeutic agents, with the goal of further improving prognostic outcomes."
Having a Her2 positive tumor is more common among IBC patients, so trastuzumab (Herceptin) has improved survival among those IBC patients who overexpress Her2. In one study, researchers found a 3-year event-free survival of 71% in the women who received trastuzumab and of 56% in those who did not. Trastuzumab also seems to make pre-operative chemotherapy drugs more effective.
Lapatinib (Tykerb) and Bevacizumab (Avastin) may be more effective for IBC than other types of breast cancer because the factors they address are more common in IBC. Scientists are at work identifying more possibilities for targeted therapy. These drugs won't work for everyone with IBC. Each one is designed for a specific issue.
Surgery remains an important part of IBC treatment. Now that chemotherapy is given before surgery, surgeons are able to get clean margins more frequently. Unfortunately, sentinel node biopsies have not proved effective for IBC patients because the cancer is already in the lymphatic system and it is impossible to trace which lymph nodes the cancer might have gone to first. So for IBC patients, surgery means a modified radical mastectomy that includes removing quite a few lymph nodes.
Researchers are studying the best way to deliver radiation to IBC patients. Radiation is almost always a part of IBC treatment after chemo and surgery. Because IBC tumor cells tend to be especially fast growing, researchers are studying whether twice-a-day radiation might work better with IBC patients. One study at MD Anderson Cancer Center found that the twice-a-day treatments seemed most effective in patients who had a poor response to chemo, who had positive margins at the time of surgery and who were younger than 45 years.
Many challenges remain in treating IBC. One major challenge is understanding exactly how IBC differs from other forms of breast cancer. Yes, more IBC tumors overexpress Her2, but not all do, and many non-IBC tumors also overexpress Her2. So far researchers have not found a specific feature of IBC that is present in all IBC patients and not present in other forms of breast cancer. Because IBC is relatively rare, it can be hard to find enough patients to study.
As I read this article summarizing progress in treating inflammatory breast cancer, I had mixed feelings. Yes, more people survive today than thirty years ago; however, progress seems so slow and incremental. We need another big breakthrough like pre-operative chemo.
Yet in the thirteen years since my diagnosis, I can see change. When I was diagnosed, most breast cancer studies systematically excluded IBC patients because of fear we would skew the results. Now researchers are starting to see that advances in understanding this most aggressive form of breast cancer will help all breast cancer patients. Maybe thirty years from now breast cancer will be a dimly remembered scourge like smallpox.