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April 2013 Ask the Expert: Research and Treatments for Triple-Negative Breast Cancer

Editor's Note: Due to the popularity of this topic, a companion Ask the Expert session on triple-negative breast cancer will be posted in August. Please check back to see if your question has been answered.

During the month of April, Living Beyond Breast Cancer expert George Sledge, MD, answered your questions about treatment options for triple-negative breast cancer and what research is currently underway.

With TNBC, what are the general criteria for surgery first? What are the general criteria for chemo first?

When one is making a decision on lumpectomy with radiation therapy or mastectomy with radiation therapy, what are the important factors/criteria one should consider in that decision?

Is there currently any national database for TNBC information such as age, gender, medications or other illnesses, along with the patient's diagnosis, treatment and, eventually, date of death? If yes, where?

If one does not live near a National Comprehensive Cancer Network (NCCN) or National Cancer Institute (NCI) Cancer Center, how does one find oncologists knowledgeable about TNBC?

Question: With TNBC, what are the general criteria for surgery first? What are the general criteria for chemo first?

Dr.Sledge: When physicians are trying to determine whether to begin with surgery or chemotherapy for non-metastatic, triple-negative breast cancer, the first question is whether the woman has a tumor that is easily treated with surgery. Some locally advanced tumors cannot be cut out easily because of size or location, and many cannot be treated with breast-conserving surgery because the surgery required would result in a poor cosmetic outcome.

Preoperative chemotherapy, sometimes referred to as neoadjuvant therapy, can, in many cases, shrink the tumor to a size where it can be easily treated with the preferred form of surgery. In virtually all cases where it is used, it is followed with radiation to the chest wall and lymph node-bearing areas.

The overall survival of women receiving pre-operative versus standard post-operative adjuvant chemotherapy appears identical in randomized controlled trials, so a woman need not feel that she is impairing her long-term prospects with either approach.

Inflammatory breast cancers are virtually always treated with pre-operative chemotherapy, which improves local control significantly.

Question: When one is making a decision on lumpectomy with radiation versus mastectomy with radiation, what are the important factors/criteria one should consider in that decision?

Dr. Sledge: For most women with early-stage breast cancer, lumpectomy with radiation therapy and mastectomy (which may be given with or without radiation therapy depending on tumor size and lymph node status) offer similar long-term survival, a fact supported by numerous clinical trials. So for most women considered candidates for breast preservation, the choice comes down to a very personal question: Do I wish to preserve my breast?

Many personal factors may affect this decision, but in addition, some medical factors may alter a woman’s feelings, such as whether she will need post-mastectomy radiation; whether she carries a BRCA 1 or 2 mutation which predisposes her to a second breast cancer; and whether she is considered a good candidate for breast reconstruction. Ultimately, though, the decision should be the woman’s rather than the physician’s in most cases.

Question: In a recent online article of The Wall Street Journal, there was mention of the ASCO project, CancerLinQ, to collect data on the care of hundreds of thousands of cancer patients and use it to help guide treatment of other patients across the healthcare system. Is there currently any such national database for TNBC information such as age, gender, medications and other illnesses, along with the patient's diagnosis, treatment and, eventually, date of death? If yes, where?

Dr. Sledge: There is currently no national database like the one described above, which is one of the motivating factors behind ASCO’s decision to proceed with CancerLinQ. Currently, CancerLinQ is in the prototype stage, but the hope of those involved in the project (including the author) is that we will be able to develop a rapid learning system that incorporates personal medical data (up to and including modern genomic data), data from clinical trials and data from other women with similar conditions to allow rapid advances in our understanding of the disease. In theory, such a system would allow every woman’s personal data to become part of the solution for all women with TNBC and other cancer types. 

Question: If one does not live near a National Comprehensive Cancer Network (NCCN) or National Cancer Institute (NCI) Cancer Center, how does one find oncologists knowledgeable about TNBC? 

Dr.Sledge: This is a great question. Women frequently choose their physicians with less careful examination than they would require for an auto mechanic or a baby sitter. Doctors become proficient through training, practice and involvement in clinical trials.

It is reasonable to ask a physician these questions:

  • Are you board-certified in oncology?
  • How often do you see women with my condition (more is always better than fewer)?
  • Do you participate in national clinical trials that involve TNBC patients?

The last question is particularly important. Clinical trials offer women the most recent therapies for the disease (a real plus in hard-to-treat diseases); more importantly, a woman going on to a clinical trial is receiving therapy designed by experts in the disease. Such trials are available to virtually all cancer doctors through the NCI’s Cancer Trials Support Unit (CTSU) and are regularly available outside of NCI-designated cancer centers through private practitioners. If your oncologist does not participate in such trials or in other clinical trials available at many sites, consider requesting a referral to such a site.

Denver, CO  ·  September 13, 2014

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