If I Have Chemotherapy Will I Need To Take Other Medications Like Trastuzumab
If your breast cancer is HER2-positive, its recommended that you take trastuzumab for one year, Dr. Abraham says. This ensures that the HER2 growth receptor on any remaining cancer cells stays shut off. Trastuzumab is not chemotherapy. The hair you lost during chemotherapy will regrow and your energy level will improve while youre taking trastuzumab.
What Are The Side Effects Of Treatment
Generally, the side effects of hormonal therapies tend to be mild and fairly well tolerated, says Brufsky. The most common side effects are menopausal symptoms , achiness in the joints and bones, and fatigue. AIs can cause some bone loss , but that can typically be well controlled with bone-modifying medications, Brufsky notes. CDK4/6 inhibitors may cause low white blood cell counts as well as some nausea and diarrhea.
What Types Of Hormone Therapy Are Used For Breast Cancer
Several strategies are used to treat hormone-sensitive breast cancer:
Blocking ovarian function: Because the ovaries are the main source of estrogen in premenopausal women, estrogen levels in these women can be reduced by eliminating or suppressing ovarian function. Blocking ovarian function is called ovarian ablation.
Ovarian ablation can be done surgically in an operation to remove the ovaries or by treatment with radiation. This type of ovarian ablation is usually permanent.
Alternatively, ovarian function can be suppressed temporarily by treatment with drugs called gonadotropin-releasing hormone agonists, which are also known as luteinizing hormone-releasing hormone agonists. By mimicking GnRH, these medicines interfere with signals that stimulate the ovaries to produce estrogen.
Estrogen and progesterone production in premenopausal women. Drawing shows that in premenopausal women, estrogen and progesterone production by the ovaries is regulated by luteinizing hormone and luteinizing hormone-releasing hormone . The hypothalamus releases LHRH, which then causes the pituitary gland to make and secrete LH and follicle-stimulating hormone . LH and FSH cause the ovaries to make estrogen and progesterone, which act on the endometrium .
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The 2013 Asco/cap Her2 Testing Guidelines
- Always test HER2 status on newly diagnosed, invasive breast cancers .
- Ensure that at least one tumor sample is tested for either HER2 protein expression or for HER2 gene amplification.
- Discuss the role of HER2-targeted therapy if the HER2 test result is positive and if there is no apparent histopathologic discordance with HER2 testing.Delay the decision to recommend HER2-targeted therapy if the HER2 test result is equivocal.
- Mandatory re-testing should be done on the same specimen, using the alternative test if the initial HER2 test result is equivocal, or on an alternative specimen.
- Do not administer HER2-targeted therapy if the HER2 test result is negative. If there is apparent histopathologic discordance with the HER2 test result, additional HER2 testing should be considered.
- Report a HER2 test result as indeterminate if technical issues prevent one or both tests from being done in a tumor specimen, or prevent the test from being reported as positive, negative, or equivocal.
- Confirm that the testing laboratory conforms to standards set for accreditation by CAP or an equivalent accreditation authority.
- In rare cases, it may be difficult to know for sure if the result is positive or negative. If additional testing on other tissue specimens is not possible, pathologists and oncologists should consider all available clinical data on the patient prior to recommending HER2-targeted therapy.
Progesterone Receptor: Historical Perspective
Like ER, PR status is an independent predictive factor for benefit from adjuvant endocrine therapy and a prognostic indicator for early recurrence in breast cancer.3436 This discovery was preceded by observations that a subset of ER-positive breast cancers failed to respond to hormonal manipulation, indicating that ER presence alone was not a sufficient indicator of hormone dependence in breast cancer. It was shown that ER-positive/PR-positive breast cancers fared better compared with ER-positive/PR-negative tumors to adjuvant treatment.37 Studies by Horowitz and associates, the same group that extensively studied ER, suggested that the presence of PR might serve as an indicator of the functionality of the estrogen signaling pathway in the breast.38
Ligand-binding assays were the gold standard for early characterization and measurement of PR.45 With the advent of monoclonal antibodies to PR, IHC largely replaced the biochemical assays for PR measurement in the mid-1990s.46
Several studies demonstrated that IHC was superior to ligand-binding assays and enzyme immunoassays for assessing ER and PR status in primary breast cancer and had equivalent or better ability to predict response to adjuvant endocrine therapy.4650 However, reproducible and reliable IHC assays are essential with proper standardization for meaningful clinical application.
Issam Makhoul, in, 2018
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Kaplanmeier Curves Of Os And Bcss After Psm
To minimize the imbalance of baseline clinicopathologic characteristics between groups, PSM was performed. The absolute values of standardized differences of the matched variables were < 0.1, indicating that the variables were well balanced between groups after matching. In addition, the statistical differences in the baseline characteristics between groups were reduced after PSM.
For HER2- subgroup, there were no differences in OS between ER-PR+ and ER-PR- with HR of 0.95 in a matched cohort of 1395 paired cases . However, ER+PR- showed better OS than ER-PR- with HR of 1.44 in a matched cohort of 9626 paired cases . Patients with ER+PR- showed better OS than patients with ER-PR+ with HR of 1.32 . ER+PR+ showed better OS than ER+PR- with HR of 1.52 , and better OS than ER-PR+ with HR of 2.25 . We further found that there was no difference in OS between ER+PR+HER2+ and ER+PR+HER2-with HR of 0.99 . BCSS showed the same trend as OS. However, patients with ER+PR+HER2+ predicted better BCSS than those with ER+PR+HER2- with HR of 0.86 .
Figure 2 KaplanMeier curves of overall survival after propensity score matching in HER2- subgroup. Comparison between ER-PR+ and ER-PR-. Comparison between ER+PR- and ER-PR-. Comparison between ER-PR+ and ER+PR-. Comparison between ER+PR+ and ER+PR-. Comparison between ER+PR+ and ER-PR+. Comparison between ER+PR+HER2- and ER+PR+HER2+. ER, estrogen receptor PR, progesterone receptor HER2, human epidermal growth factor Receptor 2.
Progesterone Receptor Mrna Tends To Be Expressed At Low
We performed a genome-wide analysis to determine the relative level of PGR expression and variability of PGR expression in ER- and ER+ breast cancer . To determine cut-points for ER and PR positivity based on the ESR1 and PGR mRNA data, we fit a mixture of two Gaussians to the ESR1 mRNA data and PGR mRNA data , which produced a positivity cut-point of 1.3 for ESR1 and 0.4 for PGR. Based on these cut-points, we classified each of 3,666 cancers as ER+ or ER- based on mRNA expression levels. We then computed the standard deviation of each gene separately in the ER+ and ER- cancers. This analysis demonstrates that PGR‘s variability is strongly dependent on ER status . PGR shows highly variable expression levels in ER+ breast cancer . In contrast, PGR expression is highly invariable in ER- breast cancer . These data are concordant with the observation that measurement of PR expression can be used to aid in the stratification of ER+ breast cancer into more- and less-aggressive disease subtypes . The lack of variation of PGR expression in ER- breast cancer suggests that it is unlikely PR will provide clinically or biologically useful information for the stratification of ER- breast cancer.
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What This Means For Patients
Because the results of ER and PR testing can make a difference in a persons treatment and chance of recurrence, it’s important that these tests are accurate. This guideline was developed to help both doctors and laboratories know how to improve the accuracy of ER and PR testing for those with breast cancer. Understanding the ER/PR status of the primary tumor and any distant or recurrent tumors can help doctors make sure that patients receive the appropriate treatment and avoid side effects of a treatment that may not work. Use this guideline to talk with your doctor about the accuracy of your ER and PR test results and what that means for your treatment.
Proteins For Targeted Cancer Drugs
Testing cancer cells for particular proteins can help to show whether targeted drug treatments might work for your breast cancer.
Targeted cancer drugs are treatments that change the way cells work and help the body to control the growth of cancer.
Some breast cancers have large amounts of a protein called HER2 receptor . They are called HER2 positive breast cancers. About 15 out of every 100 women with early breast cancer have HER2 positive cancer.
Targeted cancer drugs such as trastuzumab can work well for this type of breast cancer. These drugs attach to the HER2 protein and stop the cells growing and dividing.
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Assessment Of Agreement Between Gene Expression
To assess inter-assay reproducibility, we computed the proportion of cases in each diagnostic category as determined from the protein expression data in the medical record that were classified into the same diagnostic category using the mRNA expression data. For each binary diagnostic classification schema , we computed Cohens Kappa statistic . The Kappa score is widely used in studies of diagnostic agreement and interpretation can be aided by published guidelines: . Kappa statistics were implemented in R using the Kappa function in the vcd package.
The Overall Hormone Receptor Status Of A Breast Tumor Helps Predict Behaviour And Responsiveness To Treatment
Indeed, specialists consider the hormone-receptor status of a tumor to be more of a predictive factor rather than a prognostic factor. It helps determine what you are up against, and how best to treat it.
However, research shows that the outlook for a particular breast cancer is more likely to be influenced by the histological type and grade of the breast cancer tumor at the time of discovery.
Also, whether or not there is lymphatic involvement is another important factor, and not the hormone receptor status.
It is true, however, that breast cancer tumors with a positive hormone receptor status have a more indolent course than do hormone receptor-negative tumors.
Indolent is kind of a strange term to use, but it means that a tumor is less responsive or lazy in response to treatment than hormone negative receptor status tumors. Some kind of extra intervention or boost is often necessary to really get a positive healing response from cancer.
However, the good news is that certain kinds of hormone-receptor-positive tumors are actually more responsive to endocrine therapy. So, there is a positive aspect to this as well.
In fact, there is often a kind of inverse relationship between the HER-2 hormone receptor status, and the ER and PR status of a tumor.
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How To Read Hormone Receptor Test Results
Most testing labs use a special staining process that makes the hormone receptors show up in a sample of breast cancer tissue. The test is called an immunohistochemical staining assay, or ImmunoHistoChemistry . Not all labs use the same method for analyzing the results of the test, and they do not have to report the results in exactly the same way. So you may see any of the following on your pathology report:
- A percentage that tells you how many cells out of 100 stain positive for hormone receptors. You will see a number between 0% and 100% .
- An Allred score between 0 and 8. This scoring system is named for the doctor who developed it. The system looks at what percentage of cells test positive for hormone receptors, along with how well the receptors show up after staining . This information is then combined to score the sample on a scale from 0 to 8. The higher the score, the more receptors were found and the easier they were to see in the sample.
- The word positive or negative.
Keep in mind that a test should be done for both estrogen receptors and progesterone receptors. If your result is reported as just the word positive or negative, ask your doctor for a more definite percentage, rating, or other number. You also can ask about how these more precise results might influence treatment decisions for your particular situation.
What Are The Stages Of Breast Cancer
Breast cancer is staged by the size of the tumor and extent of spread. Breast cancers are also graded from one to three, based on how abnormal the cancer cells look and how fast they grow. One is low grade cancer and three is high grade cancer that grows and spreads rapidly.
The four stages of breast cancer are:
- Stage I: The tumor is relatively small and localized to the original site, with possible spread to the sentinel lymph nodes, which are the first lymph nodes the cancer is likely to spread to.
- Stage II: The tumor has grown and spread to a few nearby lymph nodes.
- Stage III: The tumor has grown into many lymph nodes and other tissue in the breast.
- Stage IV: The cancer has spread to distant parts of the body.
Another highly detailed classification system is the TNM classification system based on tumor size, lymph node involvement and metastatic spread.
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Nurses Health Study Cohort
The Nurses Health Study cohort was established in 1976 when 121,701 female US registered nurses ages 30 to 55 responded to a mail questionnaire that inquired about risk factors for breast cancer . Every two years, women are sent a questionnaire and asked whether breast cancer has been diagnosed, and if so, the date of diagnosis. All women with reported breast cancers are contacted for permission to review their medical records so as to confirm the diagnosis. Pathology reports are also reviewed to obtain information on ER and PR status. Informed consent was obtained from each participant. This study was approved by the Committee on the Use of Human Subjects in Research at Brigham and Womens Hospital.
The Following Statistics Are A Little Old Now They Are Much Better
There are of course many factors that contribute to the survival of breast cancer. However, some older studies show that only about 60%of patients with HER-2 positive status invasive breast cancer are disease free after 10 years.
In addition, about 65% survive overall .
And, a greater number of HER-2 positive patients succumb to the illness during the first five years than those who are negative for HER-2 overexpression.
At the same time, all other factors assumed to be equal, patients with negative HER-2 status tumors tend to be disease free at a rate of 75% over 10 years and have a slightly higher overall survival rate.
From this, we can informally estimate that women with breast cancer which overexpresses HER-2 are about 10% more likely to have significant difficulties and ultimately succumb to the disease within the first five years, than those who do not.
Because some of the Incidence and Prognosis rates are a little old now check out our brand new Index of Posts on Survival Rates.
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Epidemiology Of Breast Cancer
Globally, breast cancer is the most common cancer in women and the second most common cancer in the world. More than 1.67 million new breast cancer cases were diagnosed in 2012 . Incidence rates range from 27 per 100,000 in developing areas to 92 in more developed areas .4 Several epidemiologic studies have linked these different rates to reproductive and breastfeeding differences5 in addition to lower screening rates and incomplete reporting.6 If women in developed countries had the average number of births and lifetime duration of breastfeeding that women in developing countries have had until recently, the cumulative incidence of breast cancer would be reduced by more than half, from 6.3 to 2.7 per 100 women by age 70. The protective effect of parity was restricted to estrogen receptor -positive/progesterone receptor -positive breast cancer with each birth reducing the risk of ER-positive PR-positive cancer by 11% .7
Even though incidence rates are much lower in developing countries, mortality rates are practically equal across the world due to less favorable health conditions and limited access to care in the developing countries .4 Worldwide, the incidence of breast cancer has been going up in most regions but at faster rates in developed than developing countries. Trends in mortality from breast cancer, however, show steady decrease in most developed countries and stagnation or slight increase in developing countries.4
JoEllen Welsh, in, 2017
Limitations Of Her2 Testing
Before the implementation of the first 2007 ASCO/CAP HER2 testing guidelines, the number of patients with equivocal HER2 test results was rather large.
Since 2007, the quality of HER2 testing has improved the frequency of equivocal and inaccurate results has decreased. These improvements are believed to be due in part to the implementation of the testing guidelines since 2007.
With the increasing number of laboratories performing HER2 testing, uniform standards and quality control are mandatory.
The updated 2013 ASCO/CAP guidelines contain even more detailed recommendations on what physicians should discuss with their patients regarding HER2 status reasons for HER2 testing types of tests used interpretation of test results, and any potential need for re-testing in the case of disease recurrence .
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Should I Enroll In A Clinical Trial
Clinical trials are definitely worth considering, according to the Susan G. Komen organization. They offer the chance to try and possibly benefit from new treatments. The best time to join a trial is before starting treatment or, if your provider is considering changing treatments, before you switch to a new treatment. Ask your doctor if there are any trials that would suit your circumstances. You can also search the clinical trial database at ClinicalTrials.gov or use the Susan G. Komen Metastatic Trial Search, a personalized tool to match you with clinical trials.