Pelvic floor physical therapy: 5 questions answered

Triple-Negative Breast Cancer: From Diagnosis To Treatment

If you're like most people, you've likely never heard of triple-negative breast cancer. Or, for that matter, realized there were different types of breast cancer.

As Dr. Prarthna Bhardwaj, a breast medical oncologist at Baystate Regional Cancer Program explains, "There are many types and subtypes of breast cancer. They can be invasive or non-invasive. Factors like these help physicians determine the type of cancer they're dealing with and, more importantly, how it should be treated."

What is Triple-Negative Breast Cancer?

Both rare and aggressive, triple-negative breast cancer accounts for 10-15% of all breast cancers. Dr. Bhardwaj says, "TNBC tends to be faster growing. It may often present between mammograms. Its aggressive nature makes it important to begin treatment in a timely manner."

While researchers don't entirely understand what makes TNBC so aggressive, they do understand how it differs from other breast cancers.

"Determining the type of cancer a person has involves looking at the cancer cells to identify different characteristics," explains Dr. Bhardwaj. "Most breast cancer cells have different types of proteins along the edges, called receptors, that allow hormones like estrogen and progesterone to attach and feed the cancer. Another common breast cancer receptor is the HER2, or human epidermal growth factor receptor 2. Like estrogen and progesterone, HER2 feeds cancer and fuels its growth. For most types of breast cancer, treatment targets the identified receptors to help stop or slow the growth of the cancer. Here," she says, "is where TNBC differs. TNBC cells do not have estrogen, progesterone, or HER2 receptors. Hence, the triple-negative name designation."

What are the Risk Factors for TNBC?

While people of all ages can develop TNBC, some factors make people more susceptible to the disease. These include:

Mutations in the BRCA1 Gene

Normally, the BRCA1 gene helps repair damaged DNA and keep cell growth under control. However, mutations or defects to that gene are associated with an increased risk of breast cancer. Having the BRCA1 gene is associated with an up to 85% lifetime risk of developing TNBC.

Age

TNBC is most common in women and people assigned female at birth (AFAB) in their 40s and 50s, considerably lower than the average age— 62—of non-TNBC breast cancer diagnosis.

Race

Compared to other races, Black and Hispanic women are more likely to develop TNBC.

Genetics

While you can't change your genetics or race, there are things you can do to reduce your risk of developing TNBC. These include:

Maintaining a healthy weight

Getting regular moderate intensity exercise up to 120-150 minutes per week

Limiting alcohol use

In addition, Dr. Bhardwaj encourages all patients to know their family history as it relates to breast cancer. "If there's any history of breast, ovarian, pancreatic or prostate cancer, talk to your provider about your eligibility for genetic testing, which may inform how often you should be screened for breast cancer and reveal genetic mutations that could increase your risk of TNBC."

Symptoms of TNBC

While TNBC behaves differently than other breast cancers, its symptoms are the same. They include:

A lump or swelling in the breast or armpit

Pain in the breast or nipple

A dimpled or orange peel-like appearance to the skin of the breast

Abnormal nipple discharge

Nipple retraction

TNBC is often picked up on regular mammograms and/or follow-up ultrasounds.

How is TNBC Diagnosed?

As with other forms of breast cancer, a diagnosis is confirmed through a biopsy—removal of breast tissue for examination under a microscope—pathology, in which cells are tested for the estrogen or progesterone receptors and the HER2 protein.

Treatment Options for TNBC

As Dr. Bhardwaj noted, TNBC does not have the receptors present in other types of breast cancers; receptors that make many treatment options so effective for those types of cancer. But that does not mean it's untreatable. In fact, up to 50% of TNBC patients can have their tumors disappear using chemotherapy alone.

And chemotherapy is not the only option.

"Individual treatment plans for TNBC are determined by a number of factors," says Dr. Bhardwaj. "The first being what stage the cancer is in. Like other cancers, TNBC is staged by the number one through four with one indicating it's very early in the disease life and it's very contained and four indicating it's very advanced and has spread outside the breast."

Treatment options for TNBC at the different stages typically include:

Stage 1: Surgery, sometimes followed by radiation, and mostly followed by chemotherapy

Stage 2 & 3: Six months of a combination of chemotherapy and immunotherapy (medication that boosts your immune system and stimulates it to fight and kill the cancer cells), followed by surgery that is sometimes followed by radiation, and always followed by six months of immunotherapy and sometimes chemotherapy based on response

Stage 4: Chemotherapy, targeted therapy, and antibody-drug conjugates

Dr. Bhardwaj explains, "Unlike chemotherapy, which is essentially a medicinal cocktail that kills both good and bad cells, antibody-drug conjugates, a new type of treatment for TNBC, targets specific proteins on cancer cells and preferentially dumps chemotherapy into those cells, sparing healthy cells. The result is very promising outcomes for many, many patients."

The latest current five-year survival rates for TNBC, which don't reflect the relatively new introduction of immunotherapy, are as follows:

Stages 1-2: 91%

Stage 3: 66%

Stage 4: 12%

What to Do If You're Diagnosed with TNBC

When it comes to a diagnosis of TNBC, knowledge is power. "Asking questions is the best way to learn what you're up against," says Dr. Bhardwaj. Among the must-ask questions she thinks patients should put to their provider are:

What is the goal of treatment – curative or palliative?

Is immunotherapy an option?

What are the possible side effects of treatment?

Are clinical trials an option?

Beyond their provider, patients can tap other resources, including other TNBC patients, for information and support.

"The TNBC Foundation is an amazing resource for patients," says Dr. Bhardwaj. "They have lots of information on treatment options, support groups, publications, and online forums where patients can share experiences and insights about different treatment options, after-surgery tips, palliative care, dealing with family, and more. Much of it is also available in Spanish.

"Locally, Rays of Hope, a program offered through the Baystate Health Breast Network, supports patients throughout their cancer journey and raises much needed funds for clinical trials and other work done at the nearby Rays of Hope Center for Breast Cancer Research."

In addition, Baystate Health lends ongoing support for patients who've completed treatment via the Breast Cancer Survivorship Program.

Dr. Bhardwaj adds, "Breast cancer of any kind is no longer a journey anyone must go through alone. There are a lot of good resources out there—even for cancers as unique as TNBC. Finding answers and support can help you manage every stage of the disease with a clearer mind and help you feel more confident and in control of the decisions you make."

Understanding Why Chemotherapy Is A Lifeline In Cancer Care

The story so far:

On November 13, at a government hospital in Tamil Nadu, the son of a woman who was receiving chemotherapy for Hodgkin Lymphoma, stabbed her doctor, disturbed by the suffering that his mother was undergoing. Notably, the family had been to other hospitals and were advised everywhere that one of the side effects of the chemotherapy the woman was undergoing would affect her lungs. As his mother found it difficult to breathe, her son decided to attack the doctor who was offering her the treatment.

Understanding cancer

Cancer is one of the leading causes of death in India and the world. India registers over 1.4 million new cancer cases annually as per the national cancer registry, and the numbers are expected to rise due to ageing populations, lifestyle changes, and environmental factors. Common cancers in India include those of the breast, lung, cervix, and stomach, with tobacco use contributing significantly to oral and lung cancers.

Cancer is not a single disease but a term used for various illnesses, just like the word "vehicle" can refer to cars, trains, or planes. Similarly, cancers can vary greatly depending on the type, location, and their behaviour in the body. It is a disease caused by a breakdown in the body's normal processes that control how cells grow, divide, and develop into specialized types.

Cancer cells that have undergone abnormal changes (known as neoplastic transformation), often display markers on their surfaces that resemble those found in immature or foetal cells. These cells may also show chromosomal abnormalities like structural rearrangements (translocations). Research has shown that within a tumour, there is often a small group of cells called tumour stem cells. These cells can multiply repeatedly and may contribute to the growth and spread of cancer.

What is chemotherapy?

Treating cancer usually requires one or more of three main approaches: surgery, radiotherapy, and chemotherapy. Surgery involves removing the tumour from the body through surgery. Radiotherapy uses high-energy rays to target and destroy cancer cells. Chemotherapy, which means chemical therapy, refers to using medicines to treat cancer, targeting cells that grow and divide quickly.

While each of these treatments can work alone in some cases, they are often used in combination depending on the type of cancer and how far it has spread. Based on this understanding, chemotherapy is designed to disrupt the cell cycle. By targeting specific stages of the cycle, chemotherapy drugs aim to stop cancer cells from growing and dividing.

Cancer cells grow through a sequence called the cell cycle, which consists of phases where the cell grows, duplicates its DNA, and divides. Cancer cells divide uncontrollably, unlike healthy cells, making them particularly vulnerable to treatments that interfere with DNA replication or cell division. Chemotherapy drugs target specific stages of this cycle. Some drugs disrupt DNA synthesis during the 'S' phase; others prevent cell division in the 'M' phase, while certain drugs attack cancer cells regardless of stage, making them versatile tools in cancer therapy.

How is it delivered?

Chemotherapeutic agents are administered through different routes, including oral pills, intravenous infusions, or injections into the tumour site. Depending on the cancer's stage and type, chemotherapy can serve as the main treatment. Primary chemotherapy means that chemotherapy is the main treatment used to fight cancer, especially in blood cancers like leukaemia or lymphoma, where other treatments like surgery or radiation are not as effective. On the other hand, neoadjuvant chemotherapy means it plays a supportive role with other therapies like surgery or radiation.

Chemotherapy, while effective, faces challenges like drug resistance and toxicity that necessitate careful planning and management. Drug resistance occurs when cancer cells adapt to evade the effects of chemotherapy, either by mutating, repairing damage more effectively, or expelling the drugs.

To combat resistance, combination therapy is often employed, using multiple drugs with different mechanisms of action to target cancer cells. The key principles of combination therapy include balancing efficacy and toxicity, ensuring optimum scheduling to maximise impact during sensitive phases of the cancer cell cycles. The complications of chemotherapy range from acute toxicities like nausea, vomiting, and immune suppression to delayed toxicities such as pulmonary fibrosis, organ damage, or secondary cancers. These side effects can significantly affect the patient's quality of life.

Why does chemotherapy cause side effects?

All cancer treatments—surgery, radiotherapy, and chemotherapy—have side effects because they do not exclusively target cancer cells.

Chemotherapy is a form of systemic cancer treatment, meaning it travels through the bloodstream to attack cancer cells throughout the body. Since some healthy cells -- such as those in the hair follicles, bone marrow, and digestive tract -- also divide quickly, and since chemotherapy drugs exploit the rapid division of cancer cells, these healthy can be inadvertently harmed, leading to side effects.

The inability of chemotherapeutic agents to differentiate between cancerous and healthy rapidly dividing cells leads to its most common side effects. Damage to hair follicle cells results in hair loss, while suppression of bone marrow activity reduces red blood cell production, leading to fatigue. The gastrointestinal lining is also affected, causing nausea and vomiting, and the immune system becomes compromised due to decreased white blood cell production, increasing susceptibility to infections. Anti-nausea (vomiting) medications, growth factors to stimulate white blood cell production, and improved drug formulations have significantly reduced the treatment's impact on healthy cells, making it more tolerable for patients.

Innovations in chemotherapy have led to improved safety, efficacy, and precision. Advances in targeted drug delivery, such as liposomal formulations, ensure that chemotherapy drugs attack cancer cells while sparing healthy tissue. Pharmacogenomics tailors chemotherapy regimens based on a patient's genetic makeup, enhances treatment effectiveness and minimises side effects.

While chemotherapy may be feared for its side effects, its role in saving lives cannot be overstated. With ongoing advancements in drug design, delivery methods, and supportive care, chemotherapy continues to evolve as a more precise and effective treatment.

Chemotherapy plays a critical role in managing the growing epidemic of cancer. Despite its reputation for severe side effects, chemotherapy remains an essential treatment modality, especially for cancers that cannot be addressed by surgery or radiation. While innovations such as immunotherapy and precision medicine are gaining attention, chemotherapy remains a primary line of defence.

(Dr. C. Aravinda is an academic and public health physician. The views expressed are personal. Aravindaaiimsjr10@hotmail.Com)

Published - November 22, 2024 10:00 pm IST

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