|Dr Rita Nanda|
"Rita Nanda, MD, is an assistant professor of medicine and associate director of the Breast Medical Oncology Program at the University of Chicago School of Medicine. She specializes in treating triple-negative, early-onset, hereditary and locally-advanced breast cancers. Her research interests include identifying novel therapies that will improve outcomes for people with breast cancer."
Question: Are there any clinical trials available for people with early-stage triple-negative breast cancer (TNBC) undergoing chemotherapy?
Dr. Nanda: Over the past decade, the use of chemotherapy prior to surgery—neoadjuvant chemotherapy, NACT—has been increasing. Until relatively recently, NACT was primarily used for patients with large tumors that were not able to be removed through surgery at the time of diagnosis or patients with inflammatory breast cancer. However, clinical researchers are increasingly using NACT as a way to bring promising new medicines to patients faster. By using the response to a NACT regimen as a surrogate endpoint for improved patient outcomes, effective treatments can be identified more quickly.
The vast majority of treatments under study in clinical trials for people with early-stage, triple-negative breast cancer are administered in the neoadjuvant setting. Most of these trials are investigating whether a trial medicine plus the standard chemotherapy treatment can improve rates of complete pathological response, meaning no tumor remains after NACT, over the standard of care treatment alone.
Question: Are there any targeted therapies ready to be approved for triple-negative breast cancers?
Dr. Nanda: Currently, there are no targeted therapies FDA approved for TNBC. A wide variety of targeted treatments for TNBC are currently being studied, primarily in the neoadjuvant—prior to surgery—and advanced/metastatic cancer settings.
At the San Antonio Breast Cancer Symposium held in December of 2013, a presentation was given on a phase II trial evaluating the addition of the PARP inhibitor veliparib (ABT-888) and the chemotherapy drug carboplatin to standard chemotherapy—with paclitaxel, doxorubicin, and cyclophosphamide. Pathological response rates improved when veliparib and carboplatin were added to standard chemotherapy.
A phase III study testing this combination versus the standard of care in the NACT setting is currently being planned and will soon be underway. A number of other targeted therapies are currently being studied in the advanced cancer setting, including immune therapies and medicines that target pathways believed to lead to chemotherapy resistance.
Question: How are people with triple-negative disease monitored during and after treatment?
Dr. Nanda: Patients with TNBC receive the same follow-up as patients with other forms of breast cancer. After treatment is completed, patients should follow up with their physicians for physical examinations every 3 – 6 months for the first 3 years, every 6 – 12 months for years 4 – 5, and annually thereafter.
For women who have undergone breast-conserving surgery, also called lumpectomy, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Unless otherwise indicated, a yearly mammographic evaluation should be performed.
The use of complete blood counts, chemistry panels, bone scans, chest x-rays, CT scans, PET scans, MRIs, and/or tumor markers (CA 15-3 and CA 27.29) is not recommended for routine follow-up in a patient with no symptoms of cancer and no specific findings on clinical examination.
Question: Should people with triple-negative breast cancer be scanned for distant recurrence prior to treatment, even if they have early-stage disease and negative nodes?
Dr. Nanda: Performing an evaluation looking for distant spread of cancer should be reserved for patients who have significant lymph node involvement. For patients who have large tumors with greater than 3 positive lymph nodes, it is reasonable to perform a CT scan of the chest and abdomen, a bone scan, and/or a PET scan looking for distant metastases. For a metastatic tumor to be reliably picked up on a CT scan or a PET scan, it generally has to be about 1 cm in size.
For patients with lymph node-negative, early-stage breast cancer, it is highly unlikely that a CT scan, bone scan, or PET scan would show evidence of metastatic disease. Therefore, these scans are not appropriate in this setting. It is also possible that these tests could detect benign (non-cancerous) abnormalities (benign nodules, non-specific findings, etc.) unrelated to the cancer, which could lead to additional testing, unnecessary biopsies and anxiety for patients.
Question: I know medicines like tamoxifen exist for women who do not have triple-negative breast cancer and that these kinds of drugs help women avoid a recurrence of breast cancer. Are there similar medicines for women diagnosed with triple-negative breast cancer?
Dr. Nanda: Because triple-negative breast cancer lacks expression of the estrogen receptor, the progesterone receptor, and the HER2 receptor, there are currently no targeted therapies approved to help prevent recurrence. The main therapies used to prevent recurrent disease are surgery, chemotherapy, and radiation therapy.
Question: What can women who have been diagnosed with and recovered from triple-negative breast cancer do to help prevent a recurrence?
Dr. Nanda: Studies have shown that exercise (for 30 mins a day for 5 days a week), eating a healthy diet (low fat, high fiber), minimizing alcohol consumption (to under 3 alcoholic beverages a week), and maintaining a healthy body weight all help to reduce the risk of breast cancer recurrence.
Question: What are the odds of triple-negative breast cancer traveling to the colon?
Dr. Nanda: If triple-negative breast cancer spreads outside of the breast and axilla to other parts of the body, the most common places it spreads to are the lungs, the liver, the bones, and the brain. While not impossible, the colon would be a very unusual location of spread.
Question: How do you know when radiation therapy is absolutely necessary? I started with a 3 cm breast tumor, which chemo shrunk to 1.5mm, and no cancer found in nodes post chemo as well. My surgeon stated I went from a stage 3 to stage 1, but would not give me any advice on radiation. Am I in the grey zone?
Dr. Nanda: In general, radiation is used when patients opt for breast conservation therapy (a lumpectomy or partial mastectomy as opposed to a mastectomy). Radiation is also typically recommended for patients who have lymph nodes that are positive for breast cancer or have tumors that are larger than 5 cm, even if they undergo a mastectomy (because the high risk of local recurrence when radiation therapy is not administered is high in these situations). In your case, if you opted for a mastectomy, you do not likely need radiation therapy. However, I would suggest you consult with a radiation oncologist for a thorough review of your case and a discussion of your treatment options.
Question: Where and when is recurrence most likely to occur in triple-negative breast cancer?
Dr. Nanda: The most common sites of recurrence of triple-negative breast cancer include the lungs, the liver, and the brain. Triple-negative breast cancer can also metastasize to the bones, but the incidence is lower for triple-negative breast cancer as compared to other forms of breast cancer.
Question: I am a 6-year survivor of BRCA1-related, triple-negative breast cancer. When will the fear go away? It has improved a lot but is not gone.
Dr. Nanda: It is very natural for a survivor to be concerned about recurrence. The peak incidence of recurrence for TNBC occurs approximately 3 years after diagnosis and decreases from that point. While there is no guarantee that your cancer could not return, given that you are 6 years out from diagnosis, the risk is quite low. If you feel that your fear is negatively impacting your quality of life, I would encourage you to consider counseling to help manage your fears. There are many healthcare professionals who specialize in cancer survivorship concerns and seeking help if you feel that your fear is taking over your life may very helpful.
Question: Why is follow-up care so different from woman to woman? I am in a support group and every triple-negative participant has a different follow-up care regimen, even though we all were stage 2 or 3 at diagnosis. We are scared our doctors may be missing recurrences.
Dr. Nanda: The American Society of Clinical Oncology (ASCO) has guidelines for follow-up care of breast cancer patients. After treatment is completed, patients should follow up with their physicians for physical examinations every 3 – 6 months for the first 3 years, every 6 –12 months for years 4 – 5, and annually thereafter.
For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Unless otherwise indicated, a yearly mammographic evaluation should be performed.
The use of complete blood counts, chemistry panels, bone scans, chest x-rays, CT scans, PET scans, MRIs, and/or tumor markers (CA 15-3 and CA 27.29) is not recommended for routine follow-up in a patient with no symptoms and no specific findings on clinical examination. Some medical oncologists perform follow-up scans and tumor markers after the completion of treatment to monitor for a recurrence.
Intense surveillance, however, has not been shown to improve outcomes for women with breast cancer, and I personally follow the ASCO guidelines. In fact, in many cases, intense surveillance can be quite detrimental as it can increase anxiety and lead to additional and oftentimes invasive and unnecessary testing.
Question: I read in the fall 2013 Cure Magazine article “Divide and Conquer” (pg.34) that treatment options are limited and average survival drops to 1 year for patients with metastatic TNBC. This was very disturbing to me and I don't know what this means for sure. Can you elaborate? I am 20 months clear from stage 2 ILC and was treated with 6 rounds of TAC and radiation therapy after lumpectomy.
Dr. Nanda: The current standard of care for patients with TNBC is chemotherapy. Based on your question, it appears that you had early stage breast cancer that was treated aggressively and appropriately with a combination of chemotherapy, surgery and radiation therapy. The goal of your treatment was to cure you of the cancer.
For patients with advanced TNBC, treatment is primarily palliative, with the goals of helping women live longer and better. However, there are countless clinical trials seeking to identify new targeted therapies for patients with TNBC, and every reason to be hopeful that we will be able to identify promising new therapies in the future. I encourage women with advanced TNBC to consider participating in clinical trials if possible to increase their treatment options.
Question: I am several years post-treatment for triple-negative breast cancer. I experience significant fatigue on a regular basis, which affects my quality of life. Is this a common problem and do you have any thoughts regarding how to deal with this issue?
Dr. Nanda: It is unlikely that the fatigue you are feeling now is related to your treatment from several years ago, although every patient is different, and it can certainly take some time to recover from the side effects of breast cancer treatment. I would encourage you to see your medical oncologist or primary care physician to discuss your concerns. There are a variety of medical causes which can lead to fatigue, including hypothyroidism (underactive thyroid gland), anemia, poor sleep, medication side effects, and mood disorders. Your physician should be able to help identify factors contributing to your fatigue, work with you to address them and get you feeling better.
April 2014 Ask the Expert: Medical Updates, Treatment Options and Follow-Up Care for Triple-Negative Breast Cancer