Triple Negative Breast Cancer Treatment Implications

Learn from oncologist Dr. Margileth what it means to be diagnosed with triple-negative breast cancer and how that diagnosis affects your treatment options.

David A. Margileth, MD: 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.

Dr. David A. Margileth practices medical oncology at St. Joesph Hospital in Orange, CA specializing in oncology, hematology, and internal medicine (board certified). His selected area of interest is breast cancer. Dr. Margileth graduated from Baylor College of Medicine in 1971 and has since spent time treating patients at the National Cancer Institute and Methodist Hospital in Houston, TX.
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