Starting With Neoadjuvant Therapy
Most often, these cancers are treated with neoadjuvant chemotherapy. For HER2-positive tumors, the targeted drug trastuzumab is given as well, often along with pertuzumab . This may shrink the tumor enough for a woman to have breast-conserving surgery . If the tumor doesnt shrink enough, a mastectomy is done. Nearby lymph nodes will also need to be checked. A sentinel lymph node biopsy is often not an option for stage III cancers, so an axillary lymph node dissection is usually done.
Often, radiation therapy is needed after surgery. If breast reconstruction is planned, it is usually delayed until after radiation therapy is done. For some, additional chemo is given after surgery as well.
After surgery, some women with HER2-positive cancers will be treated with trastuzumab for up to a year. Many women with HER2-positive cancers will be treated first with trastuzumab followed by surgery and then more trastuzumab for up to a year. If after neoadjuvant therapy, any residual cancer is found at the time of surgery, ado-trastuzumab emtansine may be used instead of trastuzumab. It is given every 3 weeks for 14 doses. For women with hormone receptor-positive cancer that is in the lymph nodes, who have completed a year of trastuzumab, the doctor might also recommend additional treatment with an oral targeted drug called neratinib for a year.
A Number Of Clinical Studies Provided Evidence
Since the development and usage of trastuzumab, the international field of breast cancer study has carried out a number of large scale classic adjuvant therapy in clinical studies, including NSABP B-31, NCCTG9831, HERA, FinHer and BCIRG006, etc. , all having explored the efficacy, the treatment time and the best treatment modality using trastuzumab in HER2-positive breast cancer patients. The results of these studies have subsequently confirmed that the adoption of trastuzumab for HER2-positive breast cancer can reduce the risk of recurrence of early breast cancer by about 50% and lower the risk of death by about 30%.
N9831 and NSABP B-31 studies have compared the adjuvant treatment efficacy in HER2-positive breast cancer patients with AC-T program with or without trastuzumab, jointly analysing the patient overall survival and disease-free survival . The results showed that the DFS rate of patients with trastuzumab had significantly improved over the group of patients without trastuzumab treatment , the OS rate was also significantly increased . The cumulative incidences of distant metastasis in the trastuzumab usage group had an absolute reduction of 9.6%.
A Disease No One Gets
Sadly, people donât âgetâ mets. In fact, a recent survey sponsored by Pfizer Oncology shows just how misunderstood it is. Sixty percent of the 2,000 people surveyed knew little to nothing about MBC while 72 percent believed advanced breast cancer was curable as long as it was diagnosed early. Even more disheartening, a full 50 percent thought breast cancer progressed because patients either didnât take the right treatment or the right preventive measures.
âTheyâve built an industry built on four words â early detection equals cure â and that doesnât even begin to define breast cancer,â said Schoger, who helped foundBreast Cancer Social Media, a virtual community for breast cancer patients, caregivers, surgeons, oncologists and others. âWomen are blamed for the fate of bad biology.â
The MBC Alliance, a consortium of 29 cancer organizations including the biggest names in breast cancer , addressed this lack of understanding and support as well as what many patient advocates term the underfunding of MBC research in a recently published landmark report.
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What Are The Goals Of Treatment
The goals of treatment depend on the stage of breast cancer you have at diagnosis. For those with stage 0 to 3 breast cancer, the goal of treatment is to cure the cancer and prevent future recurrence.
Stage 4 breast cancer means the cancer has spread beyond the breast and local lymph nodes. At this stage, the goal of treatment is to control the growth of the cancer and prevent any organ damage or pain.
Unfortunately, stage 4 breast cancer cannot be cured. But with the advent of new and innovative drugs, its possible to stay in a period of stable disease for long periods of time.
Understanding Her2+ Status And Survival
Doctors use three markers to help define breast cancers and guide treatment. One of those is the HER2 protein. The other two are hormone receptors . When a cancer has none of these, doctors call it triple negative. Until recently, there wasnât much information about how these markers changed survival rates for breast cancer.
A recent study looked at the National Cancer Institute data to see if there were differences in survival for women based on these markers. The study shows there are. Overall, women who have HR+ and HER2- breast cancer do best. But in the later stages, those who have the HER2+ type have better survival rates than those with HER2-. Breast cancers that are triple negative have the lowest survival rates. The 4-year survival rates are as follows:
- HR+/HER2-: 92.5%
- HR-/HER2-: 77.0%
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Summary Of Treatment Options For Metastatic Breast Cancer
Hormone receptor-positive, HER2-negative breast cancer
Hormonal therapy is considered the standard initial treatment for HER2-negative metastatic breast cancer that is also hormone receptor-positive, and is often given in combination with targeted therapy. However, chemotherapy may also be given. A clinical trial may also be an option for treatment at any stage.
Hormone receptor-negative, HER2-negative breast cancer
In general, chemotherapy or targeted therapy is given for treatment of triple-negative breast cancer. A clinical trial may also be an option for treatment at any stage.
HER2-positive breast cancer that has spread to parts of the body other than the brain
In general, HER2-targeted therapy is regularly added to treatment for HER2-positive breast cancer that has spread. The drugs used depend on the treatments already given and whether the cancer is hormone receptor-positive. The treatment recommendations for first-line, second-line, and third-line or higher treatment are listed below. A clinical trial may also be an option for treatment at any stage.
First-line treatment
Second-line treatment
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Second-line treatment is used for people with early-stage breast cancer who had the cancer either spread during initial treatment with trastuzumab or return within 12 months after stopping treatment with trastuzumab. It is also used for people whose cancer worsens while receiving first-line treatment.
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The preferred second-line treatment is the drug T-DM1.
From Cured To Stage 4
Others, like Teri Pollastro, a 54-year-old stage 4 patient from Seattle, respond surprisingly well.
Diagnosed with early stage ductal carcinoma in situ in 1999, Pollastro underwent a mastectomy but did not receive chemotherapy, radiation or tamoxifen, since her cancer was ER negative.
âThey used the C-word with me, they told me I was cured,â she said. âEvery time I went back to my oncologist, he would roll his eyes at me when I had questions.â
In 2003, Pollastro switched to Seattle Cancer Care Alliance where she saw Dr. Julie Gralow, a breast cancer oncologist and clinical researcher at Fred Hutchinson Cancer Research Center. Gralow discovered Pollastroâs cancer had metastasized to her liver.
âMy husband and I were in shock,â said Pollastro of her mets diagnosis. âYou donât go from being cured to stage 4.â
Pollastro went on Herceptin, a type of immunotherapy for women with HER2-positive metastatic breast cancer, and did six months of chemotherapy.
âI felt better right away with the treatment,â she said. âBut the problem is, it stopped . Thatâs what you can expect with mets. And thereâs always some residual cancer. And that starts percolating.â
And along with mets, she also had to deal with many misconceptions regarding her disease.
The Mercer Island, Washington, mother of two, who often counsels newly diagnosed patients, sometimes even found it difficult to relate to early stage breast cancer survivors.
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Taking Care Of Yourself
Having breast cancer can be overwhelming. Remember, though: You’re in control of your treatment decisions and how you live your life.
These tips can help you stay healthy while you get treatment:
- Get the support you need. This could be information about breast cancer, talking with someone, or help with daily tasks. It can all make a huge difference in how you feel. Listen to your body. Exercise can help you feel better, but only when you’re up for it.
- Stay nourished. If you don’t have much of an appetite, eat smaller meals every few hours rather than three big meals.
Targeted Therapy For Her2
In about 1 in 5 women with breast cancer, the cancer cells make too much of a growth-promoting protein known as HER2 . These cancers, known as HER2-positive breastcancers, tend to grow and spread more aggressively than HER2-negative breast cancers. Different types of drugs have been developed that target the HER2 protein.
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Taxol/herceptin Effective In Stage I Her2
The combination of Taxol® and Herceptin® followed by Herceptin alone showed benefit and was well tolerated by women with stage I HER2-positive, node-negative breast cancer.
The APT study included 406 women with HER2-positive, node-negative tumors that measured less than 3 cm. The study was a nonrandomized prospective trial to define the outcomes in a uniformly treated cohort. Patients received Taxol/Herceptin for 12 weeks followed by 9 months of Herceptin.
After a median follow-up of 3.6 years, disease-free survival was 98.7 percent and recurrence or death occurred in 2.5 percent of patients. There were no new contralateral primary breast cancers. Distant recurrences were observed in two patients. By hormone receptor status, disease-free survival rates were 98.5 percent in receptor-positive patients and 99.2 percent in receptor-negative patients.
Two patients developed symptomatic congestive heart failure. Few other adverse events were noted.
The limitations of the study were that it was a non-randomized, single-arm study and about 20 percent of patients had T1a tumors, which are already associated with a favorable prognosis. Still, the researchers concluded that this adjuvant regimen should be considered a standard strategy to prevent recurrence in stage I HER2-positive, node-negative breast cancer.15
Targeted Therapy: Herceptin Biosimilars
Generic drugs donât exist for brand-name biologics. Biologics are made of large, complex molecules and produced — thanks to the magic of biotechnology — in a living system, such as an animal or plant cell. You canât replicate that.
But you can create a similar version. These drugs are called biosimilars. They have âno clinically meaningful differencesâ in terms of safety, purity, or potency.
Trastuzumab and hyaluronidase is another type of trastuzumab treatment that is injected underneath the skin.
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The Course Of Epidermal Growth Factor Receptor 2
Breast cancer is one of malignant tumors affecting womens health. The Global Cancer Statistics published in February 2015 showed that there were around 1.67 million women suffering from breast cancer, more than 500,000 patients died of breast cancer, and the incidence and mortality all ranked first among cancers in women . According to the latest published data on cancer incidence and mortality by our National Cancer Center, the number of cases of breast cancer ranks first in female cancers, while the number of deaths of women with breast cancer ranks only sixth , indicating preliminarily, that, through the tireless efforts of scholars in the field of breast cancer for decades, our breast cancer treatment has accomplished an international standard.
Thus, at the 10th Shanghai International Forum on Breast Cancer recently organized by the Chinese Anti-Cancer Association Breast Cancer Committee , Fudan University Cancer Hospital, and the Shanghai Cancer Institute, experts and scholars in the field of breast cancer from China and the United States had an discussion and exploration on the current status of HER2-positive breast cancer treatment to promote the development of anti-HER2 targeted therapy.
Side Effects Of Her2 Targeted Drug Therapy
The side effects of HER2 targeted drugs are often mild, but some can be serious. Discuss what you can expect with your doctor. If you are pregnant, you should not take these drugs. They can harm and even cause death to the fetus. If you could become pregnant, talk to your doctor about using effective birth control while taking these drugs.
Monoclonal antibodies and antibody-drug conjugates can sometimes cause heart damage during or after treatment. This can lead to congestive heart failure. For most women, this effect lasts a short time and gets better when the drug is stopped. The risk of heart problems is higher when these drugs are given with certain chemo drugs that also can cause heart damage, such as doxorubicin and epirubicin . Other factors that can increase your risk of heart problems are being older than 50, being overweight or obese, having heart problems, and taking medicines for high blood pressure.
Because these drugs can cause heart damage, doctors often check your heart function before treatment, and regularly while you are taking the drug. Let your doctor know if you develop symptoms such as shortness of breath, a fast heartbeat, leg swelling, and severe fatigue.
Lapatinib, neratinib, tucatinib, and the combination of pertuzumab with trastuzumab can cause severe diarrhea, so its very important to let your health care team know about any changes in bowel habits as soon as they happen.
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What Is The Outlook For Her2
The outlook for HER2-positive breast cancer depends on a few different factors. This includes the stage of the cancer, your ability to tolerate treatments, your age, and your current health status.
The advent of many new and effective targeted drugs working in combination with other therapies continue to improve outlooks for women with HER2-positive breast cancer.
What Exactly Does Her2
HER2-positive stands for human epidermal growth factor receptor 2. Cells in the body typically receive messages to grow and spread from receptors located on the outside of the cell. These receptors are sensitive to different enzymes, or messengers, that are produced in the body. The receptors regulate different cells and tell them what to do .
These receptors are also on the outside of cancer cells. But, cancer cells may have a lot more receptors than a normal cell. This increased number, along with other changes around the cancer cell, allows them to receive more messages to grow and spread when compared to normal, noncancerous cells. We call these receptors oncodrivers, meaning they drive the cancer to grow.
In these cases, the cancer can be very dependent on those receptors to continue to grow and spread. When these receptors are blocked and not allowed to receive messages, the cell cannot grow or spread.
In HER2-positive breast cancer, the number of HER2-positive receptors on the outside of the cell is greater than it would be in a normal, noncancerous cell. This helps drive the cancer to grow and spread.
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Treatment Of Her2 Positive Early Stage Breast Cancer
Breast cancer is diagnosed in over 200,000 women annually in the US alone. Early breast cancer refers to cancer that has not spread outside the breast and regional lymph nodes. Standard treatment for early breast cancer typically includes the surgical removal of the cancer, followed by systemic treatment with chemotherapy, precision cancer medicines and/or hormonal therapy and radiation.
The addition of Herceptin to chemotherapy has demonstrated improved outcomes, including survival, in patients with HER2-positive metastatic breast cancer.
The first trial reported in the New England Journal of Medicine was an international, multi-center trial called the HERA trial. It included nearly 5,100 women with early-stage, HER2-positive breast cancer who had completed surgery with or without radiation therapy and chemotherapy. Patients then received either one year of treatment with Herceptin, two years of treatment with Herceptin, or no further treatment .
Herceptin significantly improved outcomes at a median follow-up of one year:
- Patients treated with Herceptin had a 46% reduced risk of death, a cancer recurrence, cancer in the other breast, or cancer other than breast cancer.
- At two years, cancer-free survival was improved by 8.4% overall in the patients treated with Herceptin.
- Severe side effects affecting the heart occurred in 0.5% of patients treated with Herceptin.
What Does Testing Involve
If a doctor confirms an unusual growth, they will take a biopsy. To collect a sample, they may perform one of the following procedures:
- Use a fine needle to remove a sample of breast cells or a liquid in fine-needle aspiration.
- Use a larger needle in a core needle biopsy.
- Carry out minor surgery as an outpatient procedure.
According to the American Cancer Society , a core needle biopsy is often the preferred option.
The doctor will send the tissue samples to a laboratory to test whether or not breast cancer is present. If it is, the pathologist will test to see if the cancer is HER2-positive.
The two main tests for determining whether or not HER2-positive cancer is present are the fluorescent in situ hybridization test and the immunohistochemistry test.
The FISH test looks for additional copies of the HER2 gene in breast cancer cells. It uses special labels that attach to the HER2 proteins that glow in the dark.
The IHC test uses a chemical dye to stain HER2 proteins and can determine how much HER2 protein is present in breast cancer cells.
Often, the pathologist will carry out the IHC test and then the FISH test. IHC testing is faster and less costly than FISH testing. However, if the results of the IHC test are unclear, a person will need a FISH test to determine whether or not a tumor is HER2-positive.
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Treating Aggressive Breast Cancers
Women diagnosed with breast cancer undergo testing to determine the form of the disease and whats driving its growth. This information is key to developing an individualized treatment strategy. Choice of treatment also depends on how extensive the cancer is within the breast, whether it has metastasized, and whether the patient is menopausal.
When either HER2-positive or triple-negative breast cancer is diagnosed early, surgery is often performed to remove the tumor and its surrounding tissue or the entire breast . Nearby lymph nodes sometimes are removed as well.
Neoadjuvant therapy, a treatment given as a first step before the primary treatment, is standard for both HER2-positive and triple-negative breast cancers if the tumor can be surgically removed. Chemotherapy is often used as a neoadjuvant therapy before surgery to shrink the tumor. The goal is to reduce the area that needs to be removed so the surgery can be less extensive, possibly avoiding a mastectomy. For HER2-positive cancer, chemotherapy may be combined with targeted therapy, medication that acts on the specific cause of the cancer.
After neoadjuvant therapy and surgery, the treatment strategies for HER2 and triple-negative breast cancers differ.