Patient information and resources

Latest advances in Breast cancer treatment

  1. Node preservation reduces lymphedema cases-Can be done by Sentinal lymph node biopsy.
  2. Genomic testing minimizes chemotherapy exposure-In detail described below.
  3. Better identification of hereditary cancer syndromes.
  4. An oral option for targeted therapy.
  5. New drug combination makes estrogen-blocking agents more effective.
  6. The next generation of monoclonal antibodies.
  7. Immunotherapy in Triple negative Breast cancer.

Breast cancer is a curable disease in majority of patients.

Before describing about treatment of breast cancer we need to not only look at the stage of breast cancer but also at different prognostic and predictive biomarkers.

Apart from the stage, these biomarkers tell us about the probability of relapse

So, we divide breast cancer according to stage and according to the hormone receptor status and genomics. (By looking at genes we can also say that what kind of genes are driving cancer and how aggressive these genes are).

Classification of Breast cancer

A, As per Stage- Stage I, Stage II, Stage III, Stage IV.

B, As per Biomarkers-

Estrogen Receptor (ER)

Progesterone Receptor (PR)

Her2 Neu

C, Genomic test for Breast recurrence score-That measures the expression of cancer related genes in patients tumor.

Oncotype DX Breast recurrence score

Mammaprint

PAM 50

EndoPredict

Breast cancer can be divided   into subtypes   that respond differently to various types of treatment.

Subtypes according to Hormone receptor status

A, Hormone receptor positive – Estrogen receptor positive (ER-Positive), Progesterone receptor positive (PR-Positive) and Her2 Neu receptor negative are good biology tumors where chances of recurrence are less because they are good biology tumors. These breast cancers are 98% curable if diagnosed at early stage.

Can we avoid chemotherapy for such patients suffering from breast cancer?

Does that mean treating breast cancer without chemotherapy-Yes but not for all breast cancer patients

Yes, more breast cancer patients can avoid chemotherapy. With the help of genomic recurrence scores in breast cancer we can tell now who will benefit from chemotherapy. Not only in early-stage breast cancer, we can avoid chemotherapy in node positive breast cancer as well. From last 3 years 30% of our patients did not not receive chemotherapy after surgery for breast cancer. Now we can have better informed discussion with patients explaining why they are unlikely to benefit from chemotherapy in early-stage breast cancer.

This allows women suffering from Breast cancer to get through their cancer treatment faster and back to their lives sooner.

Cost remains a concern for such tests but in coming times it would go down so everyone can afford these tests.

In young breast cancer patients with advanced stage who are high risk for relapse ovarian suppression 

 B, Her2Neu positive Breast cancer – These are more aggressive that hormone receptor positive breast cancers. Such types of breast cancers are driven by Her2 Neu gene.

How are breast tumors tested for HER2?

By simple method called immunohistochemistry-IHC

If the IHC result is 0 or 1+, the cancer is considered HER2-negative. These cancers do not respond to treatment with drugs that target HER2.

If the IHC result is 3+, the cancer is HER2-positive. These cancers are usually treated with drugs that target HER2.

If the IHC result is 2+, the HER2 status of the tumor is not clear and is called “equivocal.” This means that the HER2 status needs to be tested with FISH to clarify the result.

If IHC report is 2-equivocal, it should be confirmed with FISH- Fluorescent in situ hybridization.

How to treat Her2 Neu positive breast cancer?

Chemotherapy cannot be avoided for such type of breast cancer unless tumor is less that 1cm. These are aggressive types of breast cancer and need targeted therapy along with chemotherapy.

Now different types of targeted therapies are available for such type of breast cancer and prognosis has improved with  advent of targeted therapies like Trastuzumab, Pertuzumab, Trstuzumab Emtasine (TDM-1), Lapatinib, Fam-Trastuzumab, Tucatinib, Enhertu (chemical name: fam-trastuzumab-deruxtecan etc.

C, TNBC-Triple negative Breast cancer- Tumor which is ER Negative, PR Negative and Her2Neu negative are called triple negative breast cancer. Triple negative Breast cancer is an aggressive cancer and has more like spread at the time of diagnosis and is more likely to come back after treatment.

In early stage 5 year survival rate is 90%, for breast cancer patients who are locally advanced (Stage II, Stage III) 5 year survival is 60% and for stage IV triple negative breast cancer patient 5 year survival is 10%.

These cancers are usually associated with BRCA 1 and BRCA 2 genes and other hereditary syndromes as well. So such breast cancer patients are diagnosed at early age. Some body diagnosed with Triple negative breast cancer should be screened for Hereditary syndromes after proper genetic counselling.

Treatment has not changed much as no targeted therapy is available for treatment of TNBC breast cancer patients. Immunotherapy is a new tool which is showing promise.

Immunotherapy for Triple negative Breast Cancer-Immunotherapy has changed the way we look at triple negative breast cancer. Different drugs called immune checkpoint inhibitors are available and are in early phase trials, have shown promising results

Immunotherapy for breast cancer can be combined with chemotherapy especially for locally advanced breast cancer. In neo adjuvant settings   it has shown good results in disease control for the first time in history. Research is going on and different clinical trials are addressing this issue.

Sofa we have seen more complete pathological responses with this approach.

C, TNBC-Triple negative breast cancer;-  Tumor which is ER-Negative,PR-Negative and Her2Neu-Negative.  -Aggressive type of breast cancer with high relapse rates .Now different drugs are available to cure this type of cancer. Immunotherapy is now a major tool to fight breast cancer.

Treatment of metastatic Breast cancer

Stage 4 breast cancer means that it is not curable, but that does not mean that breast cancer patients do not survive longer.

With newer drugs, better diagnostic techniques and better imaging modalities majority patients with stage 4 breast cancer survive beyond 5 years .

Again before starting treatment, we need to look at Estrogen receptor, Progesterone receptor and Her2Neu receptor status.

For ER, PR positive cancer patients and HerNeu negative   there is no need for chemotherapy, these patients can forgo chemotherapy and can be treated with hormonal therapy (Tamoxifen, Letrazole, Anastrazole, Exemestene) and other newer drugs called CDK4,6 Inhibitors (Palbociclib, Abemaciclib, Everolimus, Fulvestrant  etc) .

For Her2 Neu metastatic breast cancer patient newer drugs have shown promise in increasing survival.

For TNBC -Triple negative breast cancer survival remains poor and immunotherapy has shown promising results and more research is needed in this field.

Want to read to more about Breast cancer

1, Early detection of Breast cancer

2, Breast cancer screening

3, Sub types of Breast cancer

4, Treatment of high-risk breast cancer patients

5, Surgery for Breast cancer

Research

https://www.cureus.com/articles/17222-harnessing-the-immunomodulatory-effects-of-radiation-in-urinary-bladder-cancer#:~:text=Extensive%20preclinical%20data%20supports%20the,the%20systemic%20anti%2Dtumor%20effect.

https://www.ojionline.org/article.asp?issn=2589-1871;year=2020;volume=4;issue=3;spage=110;epage=114;aulast=Patil

https://ijmio.com/cardiotoxicity-in-patients-on-trastuzumab-in-her2-positive-breast-cancer-a-retrospective-analysis-from-a-center-in-north-india/

https://www.crstonline.com/article.asp?issn=2590-3233;year=2020;volume=3;issue=1;spage=146;epage=147;aulast=Abbas

https://www.researchgate.net/publication/343512692_Predictors_of_Occult_Neck_Metastasis_and_Extra_Capsular_Spread_in_Early_Oral_Cancers

https://pubmed.ncbi.nlm.nih.gov/30050778/

https://pubmed.ncbi.nlm.nih.gov/31607695/

https://pubmed.ncbi.nlm.nih.gov/31807489/

https://www.proquest.com/openview/d26bb79fb4948a5db6724295f88156a5/1.pdf?pq-origsite=gscholar&cbl=226512

https://pubmed.ncbi.nlm.nih.gov/31489291/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498714/

https://www.journalofcurrentoncology.org/article.asp?issn=2589-8892;year=2018;volume=1;issue=2;spage=97;epage=100;aulast=Patil

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348784/

https://www.researchgate.net/publication/334632035_Cancer_Awareness_amongst_Nurses_in_a_Tertiary_Care_Hospital_in_North_Delhi_India

https://www.crstonline.com/article.asp?issn=2590-3233;year=2021;volume=4;issue=1;spage=55;epage=60;aulast=Abbas

https://www.crstonline.com/article.asp?issn=2590-3233;year=2020;volume=3;issue=1;spage=146;epage=147;aulast=Abbas

 

Dr. Waseem Abbas

Director research @MAX institute of cancer care.

Senior consultant medical and Hemato-oncology @MAX cance centre shalimarbagh.

Clinical lead in Medical oncology from MAX cancer centre shalimarbagh.

Dr. Abbas is the Director of research at MAX Institute of cancer care and is one of the best breast cancer specialists in Delhi/India. He has treated more than 1000 breast cancer cases successfully till date. He also has done some breakthrough research in this field and is dedicated to research in the field of breast cancer. He is expert in treating aggressive breast cancers. Has received multiple national and international awards for his research.