As awareness of triple negative breast cancer has grown, so has the fear associated with it. Women whose tumors are hormone receptor positive can take follow-up drugs like tamoxifen or aromatase inhibitors after initial treatment. If the tumor is Her2neu positive, they receive targeted therapies like Herceptin. So part of the fear related to triple negative breast cancer (TNBC) is that once the initial treatment is over, a women isn’t getting the kind of follow-up care that her friend who is estrogen-receptor positive receives. Doctors have also learned that TNBC tends to be more aggressive with a higher recurrence rate.
A recent presentation at the Miami Breast Cancer Conference by Dr. Lisa Carey, professor of medicine at the University of North Carolina, will help allay the fears of the 15% of breast cancer patients diagnosed with TNBC. I found Anna Azvolinsky’s summary of Dr. Carey’s presentation full of information that was new to me.
Dr. Carey pointed out that most Stage I breast cancers are cured, including those that are triple negative. So Stage I TNBC patients should be optimistic about their chances for a cure. “There is no breast cancer biology that is predestined to recur,” said Dr. Carey.
Treatment for TNBC can include the same kind of breast conserving treatment that women with other types of breast cancer receive. Lumpectomy with radiation or mastectomy are both good choices, and each woman can discuss with her doctors if one is better for her based on her medical history.
Because of the aggressive nature of TNBC, some oncologists treat even small tumors with chemotherapy. Dr. Carey thinks that this is not always necessary. She believes patients with very small (less than 5 millimeter) node-negative tumors may not need chemo while acknowledging that there is not yet much research data on how safe it is to skip chemo. Another issue facing oncologists is whether to use different chemo drugs for TNBC patients. Dr. Carey says there is currently no data to support a different drug regimen just because the tumor is triple negative.
For laypeople, the subsets of breast cancer seem carved in stone. But to oncologists looking at pathology reports, it is not always so clear. If the pathologist finds that less than 10% of the cells respond to estrogen, the tumor is classified as ER negative. But there is that small percentage of cells that are ER positive. Each breast cancer patient’s tumor profile is unique. There is a whole range of how strongly a tumor responds to estrogen and the other factors the pathologist is checking. Dr. Carey thinks that oncologists should consider hormone therapy for those TNBC patients who have even a small response to estrogen.
Reading reports like this one reminds me how fast cancer research can change treatments and attitudes. When I was diagnosed in 1998, testing for Her2neu was not yet routine. I had to ask for it. I had heard about a new drug called Herceptin that was showing excellent results in clinical trials, and I wanted to get it if I was eligible. When the news came in that I was Her2neu positive, I was delighted until I saw the glance the oncologist exchanged with his nurse. I could see he was trying to decide whether to tell me something.
“Actually, it’s not good to be Her2neu positive,” he said. “Those tumors are more aggressive.” I learned that I had the worst combination possible known at the time. I was hormone receptor negative and Her2neu positive. Because Herceptin was still in clinical trials for Stage IV patients, there would be no follow-up drugs for me. We would need to hit my cancer with the biggest hammers available. Once I finished chemo, surgery, and radiation, I was on my own. My own immune system would have to vanquish any stray cancer cells that had survived.
Between my unpromising tumor profile and my dismal pathology report showing 16 positive lymph nodes, I lived in Panic City for a while. Depending on which prognostic factor I was looking at, my long-term survival chances ranged from 25-45%. What I eventually came to terms with was that fact that in my worst-case scenario, one out of four people would get well and be fine. There was no reason to believe that I could not be that person. I quickly rounded up my best-case prognosis of 45% to fifty-fifty. I had as many chances to get well as to die.
Today, Herceptin and other targeted therapies make the Her2neu positive tumor less scary, even though it is aggressive. Since my diagnosis, research has shown the triple negative tumors also tend to recur more frequently than other types.
When people learn that their cancer has a worse prognosis than their friend’s, it is easy to let fear get the upper hand. I know. I have been there. Dr. Carey’s research shows that the stage of your cancer is more relevant to your chances of survival than the words “triple negative.” Even if you do have an advanced stage TNBC tumor, these tumors often respond well to chemotherapy. It is time to put away the fear that the words “triple negative” can ignite.
Azvolinsky, Anna. Management Insights for Triple-Negative Breast Cancer. March 9, 2013. Retrieved from http://www.cancernetwork.com/conference-reports/mbcc2013/content/article/10165/2131856