Four Key Steps In Making Treatment Decisions For Older Patients With Triple
Following initial screening and preferably a geriatric assessment, management of the older patient with triple-negative breast cancer can be broken down into four steps:
First, determine whether the medical goal of treatment is to improve the chance for cure or palliation, and convey this information to the patient and family.
Second, query the patient as to what is important to her and what her goals are for being treated. The patient and family may not always agree on these goals, and it is critical that discord be resolved early.
Third, using geriatric assessmentbased data and appropriate tools and models, including estimates of life expectancy for the individual patient, calculate the risks and benefits of treatment.
Last, present these risks-and-benefits data to the patient and family using shared decision making and in language that they can understand, to finalize the plan for care.
Should More People With Triple Negative Breast Cancer Have Genetic Testing
The current National Institute of Clinical Excellence ;guideline for treatment of people with a family history of breast or ovarian cancer on the NHS recommends that if someone has a 10% or more likelihood of having a BRCA mutation then they can be offered genetic testing. Normally, this likelihood is calculated based on a persons family history of breast and other cancers.
Although the findings from Professor Diana Eccles study agree with this recommendation they also highlight that given the number of people who were found to have inherited mutations in their study, most women aged under 40 with triple negative breast cancer do have a 10% likelihood of having a BRCA mutation, irrespective of their family history.;The researchers add to this by saying that people diagnosed with triple negative breast cancer up to age 50 with no family history of the disease have just under a 10% likelihood of having a BRCA mutation, meaning they should also be offered genetic testing. In fact, limiting testing to women aged under 40 in their study would have missed 24% of people with mutations.;
In comparison with the UK guidelines, US guidelines from the National Comprehensive Cancer Network would only miss 1% of people with mutations these guidelines recommend screening when there is a family history of cancer or a diagnosis of triple negative breast cancer under age 60.
Weight And Breast Density Play Major Factors
Moreover, researchers also report that doctors are less likely to detect triple negative breast cancers during the standard screening process. Physicians are also more likely to diagnose this form of cancer following a clean mammogram screening an occurrence researchers call interval cancers.
Meanwhile, study authors say theres a link between greater breast density and an increased risk of all four breast cancer tumor subtypes, with a particularly strong association for premenopausal women and triple negative breast cancer.
An earlier study by the same team discovered that breast density factors in to triple negative breast cancer diagnoses more than any other subtype. Similarly, obesity in general leads to greater triple negative breast cancer risk as well.
The risk prediction models available are about 60 percent accurate for predicting risk of breast cancer, says Anne Marie McCarthy, PhD, an assistant professor of epidemiology at Penn, in a university release. In our studies, we see clear differences in risk factors across these types of breast cancers, and we need to do a better job of identifying how we can accurately predict risk for women, particularly for women of color.
The study is published in Cancer Medicine.
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Obesity And Tnbc In Aa Women
Obesity is associated with increased risk of a variety of different cancer types. Of these obesity-associated cancer types, almost 13% of the cases worldwide, and nearly 20% of the cases in Europe and North America, are attributable to obesity . In the United States, obesity rates have reached epidemic proportions. More than 60% of the adult US population falls in the overweight and obese categories as determined by BMI: 2529.9 and >30 kg/m2, respectively . Results from the National Health and Nutrition Examination Survey have shown that obesity prevalence varied by sex, age, race, and socioeconomic status . The recent 2-year NHANES survey showed that in the United States, 57.2% of AA women were obese vs. 38.2% NHW women . The overall prevalence of class 3 obesity in AA women was 16.8 vs. 9.7% in NHW women . Analyses of NHANES data from 2013 to 2014 showed that in addition to race, obesity and class 3 obesity prevalence also varied by age . As shown, the prevalence of obesity in AA women vs. NHW women was on an average 150% higher at all age groups, and the prevalence of class 3 obesity from ages 2059 was 160% higher but at age 60 it was 240% higher .
Table 2. Body mass index and triple-negative breast cancer risk.
Racial Differences in Visceral Adipose Tissue and TNBC
Table 3. Breast cancer incidence by BMI and WHR.
Obesity and TNBC Development
Receptor Data And Study Population
The instructions to the tumor registrars in the Collaborative Stage Coding Manual regarding estrogen and progesterone assays were to record the pathologist’s interpretation of the assay value. However, it was noted that the College of American Pathologists had issued guidelines in late 2009 that if 1% or more of tumor cells stained positive, the ER/PR value was considered positive.
With regard to Her2 assays, the NCDB contains data on immunohistochemistry, fluorescence in situ hybridization, and chromogenic in situ hybridization, but the field we used for this study was one where the individual local tumor registrars determined the best assay result for each individual patient. The registrars were instructed to use gene amplification assays first, and then use immunohistochemistry assay for cases where the amplification assay was borderline or not performed.
The population used for this study consisted of all patients with invasive breast cancer diagnosed in 2010 and 2011 whose ER, PR, and Her2 were known to be positive or negative. This represented 88.4% of all invasive breast cancers in the database for those years. Cases were categorized as triple negative if all 3 receptors were known to be negative, and non-TNBC if any one of the receptors was known to be positive.
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Tnbc: A Different Type Of Breast Cancer
Knowing breast cancer basics can help you understand how triple-negative breast cancer is different from other types of breast cancer. To find out what type of breast cancer you have, your doctors search for the presence or absence of receptors, proteins that live inside or on the surface of a cell and bind to something in the body to cause the cell to react. You may have heard of the estrogen receptor , progesterone receptor and human epidermal growth factor receptor 2 .;In estrogen receptor-positive breast cancer, progesterone receptor-positive breast cancer and HER2-positive breast cancer, treatment includes medicines that prevent, slow or stop cancer growth by targeting those receptors. But triple-negative breast cancers need different types of treatments because they are estrogen receptor-negative, progesterone receptor-negative and HER2-negative. Medicines like tamoxifen, which targets the estrogen receptor, and trastuzumab , which targets HER2, are not helpful in treating triple-negative breast cancer. Instead, chemotherapy has been shown to be the most effective treatment for triple-negative breast cancer.
How Is Tnbc Diagnosed
Imaging tests are usually the first tests done:
- Mammography, the most common screening tool for breast cancer, uses X-rays;to take images of the breast and can uncover tumors that may be too small to feel.
- MRI uses a magnet, radio waves and a computer to make detailed images of the breast with a much greater resolution than a mammogram offers.
The next step is a biopsy to remove a sample of suspicious cells from the breast to analyze them. Techniques include:
The appropriate type of biopsy for you depends on factors such as the size and location of the tumor. You may also have a biopsy of your underarm lymph nodes at the same time to see if any cancer is there.
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Social Determinants Of Tnbc Risk In Aa Women
There is growing evidence that breast cancer patients with lower socioeconomic status are more likely to be diagnosed with advanced stages of breast cancer . The clinical outcomes in AA women with TNBC are worse when compared with European-American women who have the disease. AA patients were more likely to be diagnosed at a younger age, at a more advanced stage of the disease, to have larger tumors, to be unmarried, to live in lower SES neighborhoods, and to have public or no health insurance compared with European-American patients . A number of other contributing factors may cause the deficiencies in treatment and care among AA breast cancer patients, such as less likely to receive the standard of care , financial hardships caused by cancer care , need for time taken from work , and problems with travel , which may also disproportionally affect the cancer treatment and care of AA women. Besides socioeconomic deprivation, survival may also be influenced by patient social context disproportionately affecting AA women, at the individual or neighborhood levels, and social inequality, leading to metabolic dysfunction associated with abdominal obesity .
Figure 1. A model for the role of obesity in promoting breast cancer disparities in African American vs. Non-Hispanic White women.
How Is Triple Negative Breast Cancer Different From Other Types Of Breast Cancer
Triple negative breast cancer is different from other types of breast cancer because it does not have any of the three receptors commonly found on breast cancer cells:;
If you have triple negative breast cancer, you may notice that your treatment is slightly different from that offered to other people with breast cancer.
People with oestrogen and/or progesterone receptor positive breast cancer will usually take tamoxifen or an aromatase inhibitor as part of their treatment. People with HER2 positive breast cancer will usually take a drug called Herceptin. These drugs are not effective against triple negative breast cancer.
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Things You Need To Know About Triple Negative Breast Cancer
Today is Triple Negative Breast Cancer Day a day dedicated to raising funds and awareness for TNBC. You might be wondering why a specific type of breast cancer needs its own day? TNBC is an aggressive form of breast cancer that can be difficult to treat and targets specific populations. Read on to find out more about what you need to know.
Triple Negative Breast Cancer is not hormonally fuelled
Triple-negative breast cancer are tumours that test negative for estrogen receptors, progesterone receptors, and excess HER2 protein. These results mean the growth of the cancer is not fueled by the hormones estrogen and progesterone, or by the HER2 protein. About 10-20 percent of breast cancers are triple-negative breast cancers.;
TNBC has a different treatment pathway
TNBC does not respond to hormonal therapy medicines or medicines that target HER2 protein receptors. TNBC is typically treated with a combination of surgery, radiation therapy, and chemotherapy. The following are typical treatment pathways:
Neoadjuvant chemotherapy
PARP inhibitors for hereditary TNBC
Immunotherapy
Surgery
Most TNBC patients;undergo a mastectomy to reduce their chance of recurrence for breast cancer. Depending on your diagnosis , a unilateral or bilateral mastectomy may be recommended to reduce your risk.
TNBC targets specific populations
While TNBC can show up in anyone, researchers have found that it is more prevalent in the following populations:
;TNBC has unique features
TNBC can be scary
Diagnosing Triple Negative Breast Cancer
In many women the cancer is found during breast screening.;But symptoms such as a breast lump can be a sign of breast cancer. So it is important to get any;symptoms checked by your doctor.
If you have symptoms and see your GP they refer you to a;specialist breast clinic. At the breast clinic the doctor or breast care nurse takes your medical history and examines your breasts. They also feel for any swollen lymph nodes under your arms and at the base of your neck.
You have some of the following tests:
- a mammogram
- an ultrasound
- a biopsy your doctor or nurse take a small sample of cells or tissue from your breast to look at under a microscope
Depending on your age and whether other family members have had breast cancer, your doctor might refer you for gene testing. This is to find out if there is a fault in the BRCA cancer gene.
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The Signs Of Triple Negative Breast Cancer
Symptoms of triple negative breast cancer arent different from other types of breast cancer, Dr. Mayer says. According to the ACS, these symptoms include:
- A new breast lump that may be hard, soft, painful, or painless
- Swelling of the breast
- Skin peeling, thickening, or redness
- Skin that resembles an orange peel
- Nipple discharge
- Swollen lymph nodes
Risk Factors For Triple
Doctors aren’t sure what makes you more likely to get triple-negative breast cancer. Not many women do — it only affects up to 20% of those who have breast cancer. You’re most at risk for triple-negative breast cancer if you:
- Are African-American or Latina
- Are under 40
- Have what your doctor will call a BRCA mutation , especially the gene BRCA1
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Treatment Options For Triple Negative Breast Cancer
Since triple negative breast cancer doesnt respond to targeted treatments used for other types of breast cancer, it raises complicated questions about treatment.
For now, experts typically rely on removing as much of the tumor as possible in addition to chemotherapy, according to the Mayo Clinic. Experts are testing immunotherapy options that may attack triple negative breast cancer tumors as well. Ongoing research could lead to new targeted treatments for triple negative breast cancer, Dr. Nanda says. If youre interested in learning more, you might consider speaking to your doctor about participating in a clinical trial, Dr. Mayer says.
No matter the treatment strategy that you and your doctor decide is best, self-care is an essentialand easy to overlookpart of dealing with triple negative breast cancer. Heres how four women with this condition practice self-care. They may give you a few ideas for coping, too.
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Trials For Advanced Triple Negative Breast Cancer
Trials are comparing different types of chemotherapy to see which are;better at treating advanced disease. For example, researchers are waiting for the results of the Triple Negative Trial to find out whether it is better to use carboplatin or docetaxel.;
Research is looking at using;targeted cancer drugs;alongside other treatments. For example, a trial is using a drug called atezolizumab;in combination with chemotherapy.;Some trials are testing a drug called pembrolizumab.;Researchers think that these targeted drugs on their own might help to control the growth of the cancer.
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National Institute for Health and Care Excellence , July 2018
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Biology and management of patients with triple negative breast cancerP;SharmaThe Oncologist. 2016, Volume 21, Issue 9
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4th ESOESMO International Consensus Guidelines for Advanced Breast CancerF Cardoso and othersAnnals of Oncology,2018, Volume 29, pages 16341657
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Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-upF Cardoso and others;
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Why It Matters For Patients
As well as being important for preventing, or catching cancer earlier in people with a family history of breast cancer, testing for genetic mutations is becoming increasingly important in helping to shape treatment plans for people who already have breast cancer.
In the first instance this is because people with a genetic mutation may also opt for more drastic surgery to reduce the risk of developing breast cancer a second time around, for example having a double mastectomy instead of a lumpectomy. In addition, drugs including PARP inhibitors that target cancers with BRCA mutations, and other genetic faults, are currently in clinical trials and so knowing how many people with triple negative disease are likely to have a genetic mutation could change whether they are automatically offered genetic testing, and ultimately change their treatment plan if they do have a mutation.
What Tests And Exams Diagnose Triple
The diagnosis of triple-negative breast cancer requires a sampling of tissue from the breast, known as a breast biopsy. Medical professionals may perform the biopsy using imaging techniques, such as mammography or others, for guidance. If the biopsy shows cancer, they may perform other tests on the biopsy sample to determine the precise type of cancer. In particular, they commonly perform tests for expression of the estrogen receptor , progesterone receptor , and HER2 protein as a first step. If these tests are all negative, they classify the cancer as triple-negative breast cancer.
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Breast Cancer Gene Mutations
Everyone has BRCA1 and BRCA2 genes, which we get from our mother and father. When they work properly, these genes prevent the development of cancers. But only a small percentage of people with breast cancer are born with a mutation, a change in DNA, in BRCA1 or BRCA2.;
If you are born with a BRCA1 or BRCA2 gene mutation, you are at increased risk for developing breast, ovarian and other cancers throughout your life. The BRCA1 mutation puts you at higher risk for developing a basal-like breast cancer. Scientists are still trying to find out why BRCA1 mutations increase the risk of developing triple-negative breast cancer. Keep in mind, not all breast cancers from BRCA mutations are triple negative. In fact, BRCA2 mutations are more likely to be present in estrogen receptor-positive breast cancer.