There have been a lot of developments in the breast cancer arena in the last several years, some of which have been in the field of early breast cancers and other advances in advanced or metastatic breast cancer.
For women with early stage breast cancer who are being treated with the intent of curing their breast cancer, many of the recent advances have centered around improving outcomes for patients with high risk breast cancer subtypes. These would be women who have HER2-positive or triple-negative breast cancers, which are less common variants of breast cancer that often require a treatment with not only surgery, but often chemotherapy.
For women with both triple-negative breast cancer and HER2-positive breast cancer, we have known for a long time that chemotherapy improves their outcomes and cures more women but what we have discovered in the last several years is that by administering chemotherapy prior to surgery, we’re able to personalize cancer treatment for those women.
We can identify women who are excellent responders to standard chemotherapy regimens who have a great response and at the time of surgery their cancer has been completely destroyed within the breast tissue. We know that those women have excellent odds as being cured.
We can also identify women who, following chemotherapy, still have a significant amount of residual cancer in the breast tissue that’s removed. For those women, their odds of cure are not quite as high. For that subset of women, there have been several trials looking at how to improve their survival rates and cure more women.
Both in the triple-negative arena with a drug called Xeloda, which is an oral chemotherapy medication, and in the HER2-positive arena with an intravenous HER2 blocking therapy called T-DM1 or Kadcyla, both of those combinations have been shown to improve rates of disease control for women who are not total responders for their neoadjuvant treatment. That’s been an exciting advance.
Incorporating Immunotherapy as a Treatment Option
Immunotherapy has really revolutionized the treatment for many cancer subsets. Melanoma is the one that comes to mind that was sort of the first cancer that immunotherapy was shown to be effective in, but it’s recently really come to light in the triple-negative breast cancer arena.
In the last year there has been the approval by the FDA of the use of Tecentriq, which is atezolizumab. That is a PDL-1 or checkpoint inhibitor that can be used in combination with a chemotherapy agent, known as Abraxane, for women with advanced or metastatic breast cancer.
In that setting, it was actually shown that for women who have a specific marker in their tumor called PDL-1, when they’re treated with the combination of immunotherapy plus chemotherapy as compared to women who receive only chemotherapy, their survival rates were dramatically improved.
The survival rate was 25 months with the addition of the immunotherapy agent versus 15 months for women who received chemotherapy alone. That’s a huge improvement in survival. That was really exciting news.
There has also been a lot of recent evaluation looking at bringing immunotherapy into the early stage breast cancer arena. There have been a series of trials looking at administering immune therapy for women with potentially curable higher risk triple-negative breast cancers pre-surgery. So prior to them undergoing surgical intervention where they would typically be receiving chemotherapy, there have been a lot of trials looking at chemotherapy plus the addition of immunotherapy.
One trial is the KEYNOTE trial. This was a large phase 3 trial looking at more than a thousand women and it was recently announced that the interim analysis is showing an improvement in response rates for women who receive a combination of chemotherapy plus Keytruda in the pre-surgery setting versus women who were just receiving chemotherapy alone. That’s really exciting and we’re waiting to see the analysis on that. But according to report, that was seen regardless of PDL1 status, which is an exciting development.
There are still a lot of data that we’re waiting on in the early stage breast cancer field but it’s exciting to see that immunotherapy is impacting the treatment for women with these more aggressive subtypes of breast cancer.
The unknown is whether we can also see benefit in other breast cancer subtypes. In HER2-positive tumors, which are also aggressive types of breast cancer, will there be some benefit with using these agents there? I think there is a lot more to come in the immunotherapy arena with breast cancer.
The Importance of Screening, Prevention, and Managing and Comorbidities
We know that breast cancer is still the most common cancer in women and the use of mammography does help us to identify women in earlier and more treatable states. Every woman should know their risk factors for breast cancer, and I think highlighting the importance of that. The United States preventative services task force just came out with a new recommendation for women who are at high risk for breast cancer to be considered for preventative medication with Tamoxifen or an aromatase inhibitor to reduce their risk for breast cancer.
I think you are going to hear a lot more following that recommendation about how to really identify women who are at higher risk so that they, for starters, can be undergoing screening that is appropriate for the level of their risk. How early to start screening and how aggressive to screen really depends on what a person’s risk factor is for breast cancer. That includes family history as a very strong component, but other risk factors as well. Then how to identify and refer appropriate patients who should be considered for medications to reduce their risk for breast cancer. Everyone should talk to their primary care physician or their gynecologist about their particular risk factors for breast cancer. It’s very important to know your family history.
Breast cancer is a highly curable cancer. The cure rates are very high for women who identified with breast cancer and a lot of that is because of early detection. But because of that we do want to be very cognizant about side effects of any of the agents that we’re using. Many women are on endocrine therapy with either Tamoxifen or an aromatase inhibitor for longer and longer periods of time, initially five years, but now we’re extending to 10 years with many women with higher risk cancers.
We know that there is some additional screening that needs to happen for those women. We know there’s a higher risk for developing osteoporosis. There is a risk for cholesterol abnormalities that need to be screened for and so we do need to work closely with the primary care physicians or the oncologists who are following these patients to make sure that we’re looking for side effects of our treatments.
For women who received chemotherapy, we can see problems that can develop with the heart or the blood system that can happen many years down the road. Survivorship care is important with all subsets of cancer, but specifically for breast cancer treatments because many of the complications that we can see can occur, such as five and 10 years down the road as opposed to immediately following their breast cancer treatments. Patients need to be aware of their risk factors and make sure that their primary care physicians are also aware of what kind of treatments they’ve had in the past so that they can be appropriately monitored into the future.
The Multidisciplinary Approach at TriHealth
At TriHealth we really believe in multidisciplinary care for our breast cancer patients. We have a multidisciplinary panel where patient cases are presented and we get input from various fields including radiology, pathology, medical oncology, surgery, and radiation oncology. We also have multiple genetic counselors and research coordinators who come together to review our patient care and provide input. Then we have specific multidisciplinary clinics where we often see the patients together so that we’re really coordinating a coordinated care plan for that patient.
I think to be providing standard of care in 2019 you really need to be considering the future of cancer care. That’s true in breast cancer as it is in other fields. We have several institutional but also national clinical trials available for breast cancer patients to try to advance the standard of care that’s currently being offered.
The Patient Experience
I think patients appreciate the sub-specialization and the coordinated care at TriHealth. I think more and more, the oncology world is becoming very complex and that’s a great thing. There are so many new treatments being approved each year. With that, I think the increasing specialization is an important factor. I see primarily breast cancer patients because that allows me to focus and make sure that I’m providing the best care for those patients that I see. I think patients appreciate that sub-specialization and the personal approach and tailored approach that we offer.