Triple Negative Breast Cancer Treatment Implications

>>> Dr. Margileth: Whenever we see a breast cancer, we do testing of estrogen receptor,
progesterone receptor, and a growth regulatory gene called HER2/neu gene. One of the more
aggressive and more difficult types of breast cancer to treat is what is called the triple
negative breast cancer, that is the estrogen receptor, the progesterone receptor, and the
HER2/neu gene analyses are all negative.
The first implication of this is that triple negative breast cancer is more common in younger
women and especially more common in women that harbour what is called the BRCA 1 gene,
so that whenever we see a women, certainly under 50 and may be even under 60 with a triple
negative breast cancer, one should strongly consider seeing a genetics counselor for BRCA
gene testing.
In that the tumor is triple negative, we do not have the option of using antiestrogen
therapy, such as Tamoxifen or the aromatase inhibitors and obviously we do not have the
option of using Herceptin since the patient is HER2 negative. So we would need to rely
solely on chemotherapy as the effective treatment of that disease.
The triple negative tumors tend to be more aggressive and therefore possibly less sensitive
to chemotherapy and therefore especially, in a young woman with a triple negative tumor,
especially with positive nodes, we would generally use one of the more aggressive chemotherapy
regimens incorporating such agents as Adriamycin and Cytoxan and Taxol.
The cure rate of this, if node negative is quite good. If there are a few positive nodes,
the cure rate should be 70-80%. On the other hand, if there are over 10 positive nodes
that generally implies that the patient may do well for some period of time but her risk
of recurrence is quite high.
So after an appropriate chemotherapy regimen and appropriate local therapy, either mastectomy
or lumpectomy and radiation, these patients need to be followed very closely.
There is a lot of controversy about what is the best way to follow patients with breast
cancer. If the patient has chosen lumpectomy, obviously that patient need sequential mammograms,
often the radiotherapist will want to do a mammogram six months or so after the lumpectomy
but after that yearly mammograms would be appropriate.
Clinical followup should be done generally by the oncologist who gave the chemotherapy,
on a schedule of every three to four months for the first year or two, every six months
for the next couple of years, and then after five years when the risk of this recurrence
falls quite a bit, one can then go to yearly followup.
There is a lot of controversy about whether one should do blood tests. If you look at
the signs of it, it is generally not proven that the blood tests are helpful but many
oncologists, in the hope of picking up a recurrence early, will do such tests. In general, scanning
is not indicated, in other words getting bone scans or brain scans or PET scans on some
kind of routines sequential basis generally is not recommended. What one should do, however,
if the patient has some complaint that in fact may be indicative of recurrence then
any tests that needs to be done to determine that obviously should be performed.
So one needs to be alert for various symptoms such as shortness of breath, bone pain, weight
loss, neurologic symptoms, skin nodules on the chest wall, lymph node swelling, and anything
else that seems to persists for a month or two and is causing the patient trouble. What
I tell patients is if there is something that last for longer than a month or so and is
becoming persistent and especially if it is progressive, we will see that patient between
visits and try to ascertain what is going on?
The other big dilemma here is there have been several trials asking the question if we test
aggressively with multiple blood tests, multiple routine scans, and pick up a recurrence possibly
three to six months sooner than we might otherwise, does that imply that the ultimate survival
is better.
Unfortunately, that has not turned out to be the case. There is no evidence to date
that by picking up a recurrence three to six months sooner than what would by clinical
exam or complaints from the patient that our treatments are anymore effective. So that
doing lots of blood tests, and especially lots of scans, really is not very helpful
in the long run and in fact has its on set of problems in what is called false positive
test.
If a patient has a routine, for instance PET CT scan, often will find things on the PET
CT scan that are indeterminate. They do not necessarily look like cancer but we are not
positive whether they are cancer or not, the patient is upset, the family is upset, we
are then left in a situation of trying to determine what to do about this? Should we
biopsy it? Should we repeat the scan in two or three months? So that routine scanning
often not only is not helpful but is counterproductive. So the best thing to do is close clinical
followup and followup of any persistent complaints.
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