April 2014 Ask the Expert: Medical Updates, Treatment Options and Follow-Up Care for Triple-Negative Breast Cancer
During the month of April, Living Beyond Breast Cancer expert Rita Nanda, MD, answered your questions about treatment options for triple-negative breast cancer, what research is currently underway and how it applies to you.
Remember: We cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.
Dr. Nanda: Over the past decade, the use of chemotherapy prior to surgery — neoadjuvant chemotherapy, NACT — has been increasing. Until relatively recently, NACT was primarily used for patients with large tumors that were not able to be removed through surgery at the time of diagnosis or patients with inflammatory breast cancer. However, clinical researchers are increasingly using NACT as a way to bring promising new medicines to patients faster. By using the response to a NACT regimen as a surrogate endpoint for improved patient outcomes, effective treatments can be identified more quickly.
The vast majority of treatments under study in clinical trials for people with early-stage, triple-negative breast cancer are administered in the neoadjuvant setting. Most of these trials are investigating whether a trial medicine plus the standard chemotherapy treatment can improve rates of complete pathological response, meaning no tumor remains after NACT, over the standard of care treatment alone.
Dr. Nanda: Currently, there are no targeted therapies FDA approved for TNBC. A wide variety of targeted treatments for TNBC are currently being studied, primarily in the neoadjuvant — prior to surgery — and advanced/metastatic cancer settings.
At the San Antonio Breast Cancer Symposium held in December of 2013, a presentation was given on a phase II trial evaluating the addition of the PARP inhibitor veliparib (ABT-888) and the chemotherapy drug carboplatin to standard chemotherapy — with paclitaxel, doxorubicin, and cyclophosphamide. Pathological response rates improved when veliparib and carboplatin were added to standard chemotherapy.
A phase III study testing this combination versus the standard of care in the NACT setting is currently being planned and will soon be underway. A number of other targeted therapies are currently being studied in the advanced cancer setting, including immune therapies and medicines that target pathways believed to lead to chemotherapy resistance.
Dr. Nanda: Patients with TNBC receive the same follow-up as patients with other forms of breast cancer. After treatment is completed, patients should follow up with their physicians for physical examinations every 3–6 months for the first 3 years, every 6–12 months for years 4–5, and annually thereafter.
For women who have undergone breast-conserving surgery, also called lumpectomy, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Unless otherwise indicated, a yearly mammographic evaluation should be performed.
The use of complete blood counts, chemistry panels, bone scans, chest x-rays, CT scans, PET scans, MRIs, and/or tumor markers (CA 15-3 and CA 27.29) is not recommended for routine follow-up in a patient with no symptoms of cancer and no specific findings on clinical examination.
Dr. Nanda: Performing an evaluation looking for distant spread of cancer should be reserved for patients who have significant lymph node involvement. For patients who have large tumors with greater than three positive lymph nodes, it is reasonable to perform a CT scan of the chest and abdomen, a bone scan, and/or a PET scan looking for distant metastases. For a metastatic tumor to be reliably picked up on a CT scan or a PET scan, it generally has to be about 1 centimeter in size.
For patients with lymph node-negative, early-stage breast cancer, it is highly unlikely that a CT scan, bone scan, or PET scan would show evidence of metastatic disease. Therefore, these scans are not appropriate in this setting. It is also possible that these tests could detect benign (non-cancerous) abnormalities (benign nodules, non-specific findings, etc.) unrelated to the cancer, which could lead to additional testing, unnecessary biopsies and anxiety for patients.
Dr. Nanda: Because triple-negative breast cancer lacks expression of the estrogen receptor, the progesterone receptor, and the HER2 receptor, there are currently no targeted therapies approved to help prevent recurrence. The main therapies used to prevent recurrent disease are surgery, chemotherapy, and radiation therapy.
Dr. Nanda: Studies have shown that exercise (for 30 minutes a day for 5 days a week), eating a healthy diet (low fat, high fiber), minimizing alcohol consumption (to under three alcoholic beverages a week), and maintaining a healthy body weight all help to reduce the risk of breast cancer recurrence.
Dr. Nanda: If triple-negative breast cancer spreads outside of the breast and axilla to other parts of the body, the most common places it spreads to are the lungs, the liver, the bones and the brain. While not impossible, the colon would be a very unusual location of spread.
Dr. Nanda: In general, radiation is used when patients opt for breast conservation therapy (a lumpectomy or partial mastectomy as opposed to a mastectomy). Radiation is also typically recommended for patients who have lymph nodes that are positive for breast cancer or have tumors that are larger than 5 centimeters, even if they undergo a mastectomy (because the risk of local recurrence when radiation therapy is not administered is high in these situations). In your case, if you opted for a mastectomy, you do not likely need radiation therapy. However, I would suggest you consult with a radiation oncologist for a thorough review of your case and a discussion of your treatment options.
Dr. Nanda: It is very natural for a survivor to be concerned about recurrence. The peak incidence of recurrence for TNBC occurs approximately 3 years after diagnosis and decreases from that point. While there is no guarantee that your cancer could not return, given that you are 6 years out from diagnosis, the risk is quite low. If you feel that your fear is negatively impacting your quality of life, I would encourage you to consider counseling to help manage your fears. There are many healthcare professionals who specialize in cancer survivorship concerns and seeking help if you feel that your fear is taking over your life may very helpful.
Dr. Nanda: The American Society of Clinical Oncology (ASCO) has guidelines for follow-up care of breast cancer patients. After treatment is completed, patients should follow up with their physicians for physical examinations every 3–6 months for the first 3 years, every 6–12 months for years 4–5, and annually thereafter.
For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Unless otherwise indicated, a yearly mammographic evaluation should be performed.
The use of complete blood counts, chemistry panels, bone scans, chest x-rays, CT scans, PET scans, MRIs, and/or tumor markers (CA 15-3 and CA 27.29) is not recommended for routine follow-up in a patient with no symptoms and no specific findings on clinical examination. Some medical oncologists perform follow-up scans and tumor markers after the completion of treatment to monitor for a recurrence.
Intense surveillance, however, has not been shown to improve outcomes for women with breast cancer, and I personally follow the ASCO guidelines. In fact, in many cases, intense surveillance can be quite detrimental as it can increase anxiety and lead to additional and oftentimes invasive and unnecessary testing.
Dr. Nanda: The current standard of care for patients with TNBC is chemotherapy. Based on your question, it appears that you had early-stage breast cancer that was treated aggressively and appropriately with a combination of chemotherapy, surgery and radiation therapy. The goal of your treatment was to cure you of the cancer.
For patients with advanced TNBC, treatment is primarily palliative, with the goals of helping women live longer and better. However, there are countless clinical trials seeking to identify new targeted therapies for patients with TNBC, and every reason to be hopeful that we will be able to identify promising new therapies in the future. I encourage women with advanced TNBC to consider participating in clinical trials if possible to increase their treatment options.
Dr. Nanda: It is unlikely that the fatigue you are feeling now is related to your treatment from several years ago, although every patient is different, and it can certainly take some time to recover from the side effects of breast cancer treatment. I would encourage you to see your medical oncologist or primary care physician to discuss your concerns. There are a variety of medical causes which can lead to fatigue, including hypothyroidism (underactive thyroid gland), anemia, poor sleep, medication side effects and mood disorders. Your physician should be able to help identify factors contributing to your fatigue, work with you to address them and get you feeling better.