Immunotherapy As An Emerging Treatment
Immunotherapy is a relatively new treatment option, and while it hasnt been approved by the Food and Drug Administration for breast cancer yet, its a promising area.
Immunotherapy works by raising the bodys natural defenses to fight off the cancer. It has fewer side effects than chemotherapy and is less likely to cause resistance.
Pembrolizumab is an immune checkpoint inhibitor. Its a type of immunotherapy that has shown particular promise in the treatment of metastatic breast cancer.
It works by blocking specific antibodies that make it harder for the immune system to fight the cancer. This allows the body to fight back more efficiently. A 2016 study found 37.5 percent of patients with triple-negative breast cancer saw a benefit from the therapy.
Because immunotherapy isnt FDA approved yet, treatment is mostly available through clinical trials at this time.
Breast Cancer Cell Lines
Part of the current knowledge on breast carcinomas is based on in vivo and in vitro studies performed with cell lines derived from breast cancers. These provide an unlimited source of homogenous self-replicating material, free of contaminating stromal cells, and often easily cultured in simple standard media. The first breast cancer cell line described, BT-20, was established in 1958. Since then, and despite sustained work in this area, the number of permanent lines obtained has been strikingly low . Indeed, attempts to culture breast cancer cell lines from primary tumors have been largely unsuccessful. This poor efficiency was often due to technical difficulties associated with the extraction of viable tumor cells from their surrounding stroma. Most of the available breast cancer cell lines issued from metastatic tumors, mainly from pleural effusions. Effusions provided generally large numbers of dissociated, viable tumor cells with little or no contamination by fibroblasts and other tumor stroma cells.Many of the currently used BCC lines were established in the late 1970s. A very few of them, namely MCF-7, T-47D, MDA-MB-231 and SK-BR-3, account for more than two-thirds of all abstracts reporting studies on mentioned breast cancer cell lines, as concluded from a Medline-based survey.
Metabolic markers
Systemic Treatments For Stage 1 Breast Cancer
Systemic treatments, often termed add-on or adjuvant treatments, treat breast cancer throughout your body and not just at the site of the tumor.
These treatments help destroy cancer cells that have spread beyond your breast but are still too small to be spotted. They include the therapies outlined below.
Chemotherapy
Doctors may recommend chemotherapy, also called chemo, after surgery to help destroy any undetected cancer cells. Chemotherapy may also lower your risk of the cancer coming back at a later stage.
Chemotherapy may be recommended for a smaller tumor if:
- Any cancer cells were found in the lymph nodes.
- You score high on a gene test such as Oncotype DX, which shows whether chemotherapy could help treat your breast cancer and if its likely to come back after surgery.
- The cancer cells are progesterone receptor- and estrogen receptor-negative.
- The breast cancer cells are positive for human epidermal growth factor receptor 2 various therapies can target these receptors.
Hormone therapy
Hormone therapy can be used to help slow down the growth of cancer cells in people with estrogen receptor-positive or progesterone receptor-positive cancer cells. Hormone therapy works by blocking hormone receptors on the cancer cells or by lowering the amount of estrogen produced in your body.
Its important to ask your doctor about the potential side effects of hormone therapy before you begin this treatment, so can you know what to expect.
Targeted therapy
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Side Effects Of Breast Cancer Chemotherapy
Chemotherapy usually works by attacking rapidly dividing cells. This means that chemotherapy can harm not only cancer cells but also healthy cells that are dividing rapidly, like the ones that cause your hair to grow.
Whether you have side effects from breast cancer chemotherapy will depend on the details of your treatment plan. The care teams at MSK are committed to helping you feel your best during and after treatment. During treatment, well watch carefully for your reaction to the drugs and adjust the drugs or dose as necessary. Well also continue to monitor you for possible long-term effects after your treatment ends.
We offer a variety of other specialized services to support you during your treatment. Many MSK patients find that our Integrative Medicine Service can be a valuable part of their treatment plan. Programs include massage, acupuncture, hypnotherapy, meditation, visualization, music therapy, and nutritional counseling.
One side effect of chemotherapy can be hair loss. MSK offers scalp cooling to help minimize hair loss. Learn more about scalp cooling, or ask your care team for more information.
Neoadjuvant Chemotherapy Neoadjuvant Her2
With neoadjuvant chemotherapy, all the chemotherapy to treat the breast cancer is usually given before surgery . If the tumor doesnt get smaller with the first combination of chemotherapy drugs, other combinations can be tried.
If your tumor is HER2-positive, you may get neoadjuvant trastuzumab and neoadjuvant pertuzumab , but not at the same time as the chemotherapy drug doxorubicin .
If your tumor is estrogen receptor-negative, progesterone receptor-negative and HER2-negative with a high risk of recurrence, you may get neoadjuvant pembrolizumab . Pembrolizumab is an immunotherapy drug.
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Treatment For Stage 2 Breast Cancer
The most common for stage 2 breast cancer is surgery.
Surgery
In most cases, treatment involves removing the cancer. The person may undergo a lumpectomy or mastectomy. The doctors and the individual can decide based on the size and location of the tumor. The surgeon may also remove one or more lymph nodes.
Combination therapy
A doctor may recommend a combination of radiation therapy, chemotherapy, and hormone therapy to people with stage 2A or 2B breast cancer.
Neoadjuvant therapy
In some cases, a doctor may recommend neoadjuvant therapy, which is chemotherapy before surgery to reduce the size of a tumor.
are 3A, 3B, and 3C.
3A breast cancer is an invasive breast cancer where:
- There is no tumor in the breast, or a tumor of any size is growing alongside cancer found in four to nine axillary lymph nodes or the lymph nodes by the breastbone.
- A person has a tumor greater than 5 cm. They also have clusters of breast cancer cells in the lymph nodes that are between 0.22 mm in diameter.
- The tumor is larger than 5 cm. The cancer has also spread to one to three axillary lymph nodes or the lymph nodes near the breastbone.
Stage 3B breast cancer is invasive breast cancer where:
- A tumor of any size has spread into the chest wall or skin of the breast, causing swelling or an ulcer to develop.
- Cancer cells may also be present in to up to nine axillary lymph nodes.
- They may be present in lymph nodes by the breastbone.
When Is Chemotherapy Used To Treat Early
The first treatment for early-stage breast cancer usually includes surgery and sometimes radiation. Your doctor may also talk to you about added treatment, such as chemotherapy and hormone therapy, that may help keep cancer from coming back.
It isn’t possible for all women to know for sure who will benefit from added treatment. But if you have early-stage, estrogen receptor positive breast cancer with no cancer in the lymph nodes, you may have a gene test. Gene tests, such as the Oncotype DX, may be done on the cancerous tissue that was removed to look for tumor markers. These tests can give your doctor important information about whether chemotherapy will help you.
The type of added treatment you have depends on the stage and classification of your breast cancer:
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Treatment For Stage 0 Breast Cancer
Not everyone with stage 0 breast cancer needs treatment. If tests suggest that treatment is a good idea, include:
Surgery
A lumpectomy involves removing cancerous cells from the breast. It is an option when the cells remain in one area. This is a relatively short and simple procedure, and a person should be able to go home after the surgery on the same day.
If cancerous cells appear throughout the breast, the doctor may recommend a mastectomy, which involves removing the entire breast. Plastic surgeons can rebuild the breast at the same time or a later date.
Hormone therapy
The hormone estrogen, found naturally in the body, can impact some types of breast cancer. If a person has estrogen receptor-positive or progesterone receptor-positive breast cancer, a doctor may suggest hormone treatment in addition to surgery.
, the cancerous cells have invaded the surrounding breast tissue. Stage 1 breast cancer has two subcategories 1A and 1B.
Checking The Lymph Nodes
The usual treatment is surgery to remove the cancer. Before your surgery you have an ultrasound scan to check the lymph nodes in the armpit close to the breast. This is to see if they contain cancer cells. If breast cancer spreads, it usually first spreads to the lymph nodes close to the breast.
Depending on the results of your scan you might have:
- a sentinel lymph node biopsy during your breast cancer operation
- surgery to remove your lymph nodes
You may have other treatments after surgery.
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Is The Cancer In My Lymph Nodes
Whether your breast cancer has spread to your lymph nodes the filtering mechanisms in your armpits and elsewhere in the body that are part of the immune system is one of the most important predictors of the severity of your disease.
Involvement of the lymph nodes changes the treatment plan, says Dr. Abraham. When breast cancer cells have spread to the lymph nodes, we tend to discuss more aggressive treatment options, such as chemotherapy.
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.
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Chemotherapy Regimens For Early
At some point, your medical oncologist will recommend a chemotherapy plan for you. Also called a chemotherapy regimen, the plan will have important details about your treatment, including:
- which drugs youre receiving
- the order in which you receive them
- the amount of each drug
- how often and how long you will need chemotherapy
Most women with early-stage breast cancer receive chemotherapy for approximately three to six months. Theres time in between treatments to allow your body to recover. If you are receiving targeted therapy for early HER2-positive breast cancer, treatment could last up to a year.
For some people, doctors may recommend a dose-dense chemotherapy regimen. Dose-dense chemotherapy means there is less time between treatments. You will not need to have a larger dose of chemotherapy.
Research has shown that dose-dense chemotherapy can improve survival and lower the risk of the breast cancer coming back compared to a traditional chemotherapy schedule. Dose-dense chemotherapy does not result in more side effects.
How The Breast Cancer Staging Process Starts
The breast cancer staging process begins with diagnostic testing. Depending on previous screening results, if any breast cancer symptoms are present, and other factors, your doctor may recommend one of the following tests:
- Diagnostic mammogram A mammogram involves using an X-ray to take photos of your breast tissue at different angles. To do this, your breasts are gently compressed between two plates so the X-ray can be taken.
- Ultrasound An ultrasound is a non-invasive imaging test that bounces soundwaves of your breast tissue to create a picture of the inside of your breast.
- MRI An MRI is another non-invasive imaging test that uses radio waves and a magnetic field to create an image of your breast tissue. This can help doctors determine the size and placement of tumors.
- Biopsy A biopsy removes small masses and growths from your breast so they can be examined under a microscope by a pathologist and determine if theyre cancerous.
If cancer is detected, a CT scan may be ordered to look for any distant metastasis or local invasion to other organs. And youll likely be connected with a breast surgeon right away, either through a nurse navigator or your doctor.
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How Big Is My Tumor
Tumor size is another factor that will determine your course of treatment. Your doctor uses the size of your tumor to stage, or further categorize your cancer .
The tumors dimensions are estimated by a physical exam, a mammogram, an ultrasound or an MRI of the breast. The precise size wont be known until a pathologist studies the tumor after surgical removal.
Factoring In Side Effects
Given that metastatic breast cancer is almost universally fatal, there is a great interest in not under-treating patients which is why most of them currently receive some form of chemotherapy. But the downside of this approach is that it means there is a group of women who are probably over-treated, getting chemotherapy when they dont really need it and experiencing a decreased quality of life as a result.
Although not all chemotherapy drugs carry serious side effects, many of them do. Dr. Baselga rattles off a list of potential issues, including an increased risk of developing leukemia, hair loss, menopause, potential risk of heart damage, risk of ending up in the hospital with a low blood count, and infections.
These potential drawbacks, he says, represent an important counterbalance to the potential benefits of chemotherapy and must be seriously considered by both the doctor and the patient when making a treatment decision.
For some women, these risks may be worth it to improve their overall chances of survival. There is evidence in the literature that women will do a lot for small benefits, says Dr. Dickler. Theyll take chemotherapy for even a 2 to 3 percent improvement in outcome. For others, quality of life may be more important.
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Stage 1 Or 2 Early Breast Cancer
Stage 1 and 2 breast cancer refers to invasive breast cancer that is contained within the breast, and may or may not have spread to the lymph nodes in the armpit. These stages are also known as early stage breast cancer.
At Stage 1 and 2, some cancer cells may have spread outside the breast and armpit area, but at this stage these cannot be detected.
Prognosis Of Late Vs Early Cancer Recurrence
Late recurrence is associated with a better prognosis than early recurrence in estrogen receptor-positive breast cancer. A 2018 study in Clinical Breast Cancer found that survival after recurrence was significantly longer in people with a late versus early recurrence . In this study, the lungs were the most common site of late distant recurrence.
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Will I Need Surgery And What Kind Should I Have
This is an important question but the answer may be less than definitive. It will vary from patient to patient and you may have more than one choice.
According to the American Cancer Society, most women with breast cancer have some type of surgery. But some breast cancers cant initially be surgically removed. In other cases, whether to operate and the type of surgery may depend on the cancers stage, the tumors size and location, the size of your breast and your personal preference.
In women whose breast cancers are operable, the choices are breast-conserving surgery or mastectomy. Mastectomy is the removal of most or all breast tissue and possibly nearby lymph nodes. Within each of those two broad categories are further options. Talk with your oncologist and breast surgeon. If you have any doubts, you may choose to seek a second opinion.
For Metastatic Breast Cancer
Chemo can be used as the main treatment for women whose cancer has spread outside the breast and underarm area to distant organs like the liver or lungs. Chemo can be given either when breast cancer is diagnosed or after initial treatments. The length of treatment depends on how well the chemo is working and how well you tolerate it.
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General Indications For Chemotherapy
We outline below some of the more common indications for needing chemotherapy. The decision to undergo chemotherapy also involves being healthy enough to tolerate the treatment. Deciding who needs chemotherapy and what type of chemotherapy to administer is one of the most difficult decisions made in medicine. Your medical oncologist will guide you.