HER-2 Positive Early Stage Breast Cancer

Juan Luna, Una Bulaquena, 1895

It used to be that when certain non-metastatic breast cancers were found to be markedly her-2 positive, they went into my "hope for the best, but expect the worst" category.

Overexpression of human epidermal growth factor receptor-2 (her-2) occurs in a third of breast cancers, and is a marker of an aggressive tumor. A gene mutation causes an excess production of this cancer growth promoter, conferring a clinical "profile" that science has begun to characterize. Myself, I obsess about occult metastases and drug resistance in these instances. When presented with her-2+(IHC+3 and/or FISH+) malignancies, the oncologist knows that certain chemo drugs are preferable, that hormonal agents aren't likely to suffice, & that the use of biologicals is optimal.

Anti-her2 monoclonal antibody surfaced years ago. As a biological "targeted therapy", it specifically seeks out the cancer promoter protein. Whether given alone or in combination with other drugs like chemotherapy, trastuzumab (Herceptin) is still finding all its indications. Its fabulous that we can now use this agent in early stage breast cancers. Did you know that herceptin use after potentially curative surgery decreases recurrence rates by half in high risk cases? I can afford to be more optimistic these days.

Not all breast cancers would benefit from the incorporation of Herceptin into a postoperative regimen, possibly not even all her-2 FISH+ cases if the risks are not sufficiently high. Discuss these points ad nauseum with your oncologist.  

Technorati Tags: metastatic breast cancers, epidermal growth factor receptor, chemo drugs, growth factor receptor, epidermal growth factor, growth promoter, gene mutation, cancer growth, curative surgery, drug resistance, clinical profile,herceptin,biologicals,oncologist

Previous Comments

After two years doing well on Herceptin and Zometa, the tumor in my sternum was growing again, so I had radiation, the results of which you can see in the photo. Subsequent scans showed that the radiation worked on the bone tumor, but that it’s now in my liver. So on to regular chemo.

Posted by Breast Cancer Stages at March 9, 2010, 6:16 pm  

Birth Control Pills and Breast Cancer

Young women who present with breast cancer are usually asked, "Are you on the Pill?"  Suspicions about causality have lain heavy in the gut of clinicians for decades.  As with hormone replacement therapy in menopause, we lacked evidence of direct malignant transformation to support our meddling in the bad old days.  By mid-2005, however, the credible folks at IARC released a monograph that classified oral contraceptives as group 1 carcinogens.  And now, a meta-analysis published in the Mayo Clinic Proceedings further validates what doctors have been warning women about for years.

To be sure, neither oral contraceptives nor hormone replacement therapy will disappear from store shelves soon.  Despite side effects, they do have applications for which a risk:benefit estimate is appropriate before use.  The aforementioned papers also have some stingers:  the IARC had noted confounding mixed effects for oral contraceptives, with risks increased for some cancers but decreased for others.  They'd also included data from now-defunct preparations that incorporated higher doses of hormones.  In its turn, the meta-analysis used case-control studies found through medical literature databases– not from the more compelling individual data from randomized trials.

Its not cancer prevention so much as risk avoidance, but consumer awareness is similarly critical:  oral contraceptives and postmenopausal estrogen therapy are now ranked up there with notorious chronic hepatitis B/C infections, asbestos, and plutonium as human carcinogens.  Consult a physician before using birth control pills and hormone replacement therapy.  There may be safer alternatives for what ails you.

 

Previous Comments

you’re killing me!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Posted by inesita at November 23, 2006, 6:57 pm

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http://www.Freebreastcancerguide.com
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Posted by Amasch Hilbert at September 19, 2008, 6:56 pm

MY 14 YEAROLD GRANDDAUGHTER WAS PRESCRIBED BIRTH CONTROL PILLS FOR HEAVY MENSES. I HAD BC AND MY DAUGHTER HAD BC AND 5 OF MY COUSINS HAD BC. ALSO ON MY DADS SIDE. I AM THE GRANDMOTHER , MY SON IS HER DADDY AND WE ARE CONCERNED ABOUT HER TAKING THE PILL. THANK YOU. LINDA ELLIS
Posted by LINDA ELLIS at December 3, 2008, 8:01 am

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Posted by hoodia gordonii at January 21, 2009, 5:48 pm

Be very careful if considering the birth control pill, Yaz. Yaz has been connected to stroke, heart attack, and other adverse events: http://www.yaz-may-cause-strokes.com/.
Posted by Cynthia at November 2, 2009, 8:09 pm

This bears repeating: The birth control pill, Yaz, has been linked to a number of adverse reactions, including strokes and lawsuits are growing over these issues. Here is some good information: http://www.yaz-may-cause-strokes.com/
Posted by Cynthia at December 22, 2009, 8:05 pm

Notes on Surgery for Breast Cancer

When buying a car, do you compare model specifications within a budget range?  If faced with breast cancer, would you similarly scrutinize the options?  Hope so.  Doctors are too fallible to bear the entire burden.  This job is tough enough as it is.

Biopsy of a suspicious breast mass may be accomplished by needle sampling or by open excisional biopsy.  When needle sampling is done, a "fine" aspiration biopsy will confirm the presence of malignant cells while a "core" can diagnose invasion and provide tissue for further processing.  As to open biopsy, if ever excision is contemplated within the context of a possible cancer, marking of margins or the inclusion of a rim of normal tissue around the mass must be done where feasible (in effect, a lumpectomy).  This is to minimize the need for further radical surgery.

If the breast mass biopsy is positive, staging is done & treatments are planned accordingly.  (How I hate it when stage IV patients have wasted time & money on pointless radical surgery before they get the treatment they really need!)  The staging tests ordered would depend on a thorough history & physical examination, but chest x-rays, mammography, a bone scan, liver ultrasound, or CT scans may be requested.  Special stains are sometimes done on the biopsy specimen at this point for hormone receptor assays & her2/neu (cerbB2) growth factor receptor, especially if preoperative treatments are contemplated.

In non-metastatic invasive breast cancer of the non-inflammatory type, an operation is always a component of cure.  For stages I & II, Breast Conserving Surgery is ideal in the absence of any compelling contraindication.  BCS, aka "lumpectomy" or "partial mastectomy", involves a wide excision of tumor with a cuff of normal tissue around it.  It entails subsequent radiotherapy but affords the same control rates as a standard modified radical mastectomy with better cosmetic results.  A better feel & shape than an implant in most cases anyway.  (By the way, while there are additional technical considerations, BCS is not prohibited for tumors near the nipple or where implants are in place.)  Axillary lymph node sampling is also done with BCS, through a separate armpit incision.  This sample extent depends upon whether you've presented with apparent node involvement or not.  If none are clinically evident, just a biopsy of the "sentinel node" may be done.  Axillary node status is just prognostic and not all nodes need to be removed.  The extent of their involvement gives your docs added staging information to guide postoperative treatments.

What should make you think twice about lumpectomy?  When is a modified radical mastectomy the better option?  Well, BCS requires re-excision should the margins of the lumpectomy specimen remain positive.  Radiotherapy is a necessary component, so those who can't take that treatment are best served by breast removal (eg. early pregnancy).  BCS is also suboptimal if tumors are multiple. The same is true if the mass is large relative to the breast's size, although preoperative (neoadjuvant) chemotherapy may be considered to enable BCS in such cases.

Where all things are equal and no contraindications to BCS exist, the important factor is the fully informed patient's preference.

As for surgeons… I know of a busy one who said that breast cancer operations are glorified excisions to sleepwalk through.  For a minute there, I'd thought that I was talking with God (or a neurosurgeon) but… no; This doc still comes alive for each hair-raising Whipple's procedure.  Would that all constructive thrill-seekers have that level of experience & expertise, not to mention stamina.  In reality, what may be almost reflexive & forthright for some is an uncommonly complex job for others.  Find yourself an oncology team with a great surgeon!

Previous Comments

Hi OncoDoc,
Good greetings. My wife was diagnosed of breast cancer wherein her tumor was located near her left nipple recently.
Her’s was diagnosed of still, on early stage II (2cmx2cm lump).
Upon reading your notes about surgery on breast cancer, I’m very much interested of having her done a breast conservation surgery.
Could you recommend anyone who can treat my wife here in the Philippines? Maybe you can help us.
I shall wait for your reply soon.
Thank you very much and God bless.
Posted by Jake Olano at November 18, 2006, 1:38 am

It depends upon the geographical location. Her medical oncologist would know a suitable breast surgeon for second opinion purposes.
Posted by oncodoc at November 25, 2006, 5:26 pm

Primary Liver Cancer: Prevention

Most liver cancers are metastatic, i.e., they involve the liver secondarily after initial development & growth in a distant site. Of those few malignancies that are native or primary to the liver, the most common is hepatocellular carcinoma ("hepatoma"). 

Risk factors for hepatoma include cirrhosis, diabetes, BRCA 1 & 2 gene mutations, aflatoxin exposure, alcohol abuse, & smoking but worldwide, the most common cause of hepatoma is chronic hepatitis virus infection. Of 6 known types, hepatitis B (HBV) & C (HCV) viruses are the main culprits & they are usually acquired via contaminated blood or needles in the context of tranfusions, tattooing, or drug abuse. Further, HBV is endemic in Asia and may also be sexually-transmitted, infecting even fetuses in utero. Once malignant transformation has set in, only surgery can provide a possible cure. Sadly, this is possible only for a few, since the infected liver may not have enough reserves to sustain a complete tumor resection (matched organ donors are hard to find), the tumors may be too numerous, involve more than one lobe, or are already affecting blood supply. All other treatments– chemotherapy, experimental targeted therapy, chemo-embolization, tumor ablation by RFA (unless tiny), radioisotopes etc– are in the realm of palliation.

How to protect yourself from hepatoma? Well, common sense says that one should avoid the risk factors under our control, including most substances that can damage the liver– drugs, excessive alcohol, pesticides, toxins. Use only sterile needles with your meds, insist upon properly screened blood products when transfusions are prescribed, and think hard before tattooing/piercing. Know the virus status of a sexual partner (tough without screening). Most important of all: vaccines exist for HBV that provide almost total protection for years. Even infants can be immunized– and they should be.

The easiest kind of "cancer treatment" is always prevention.

  

Previous Comments

Myself I have a secondary liver cancer, which is in my cse not curable, yet I keep myself awake by blogging about it to everybody (since the amount of visitors I get at home is soooo little)
A very big hug!
SK
How the pain was getting too much at:
http://www.metastaticlivercancer.org
Posted by See Kim at December 7, 2006, 1:00 pm

I thought of one more risk factor for primary liver cancer to share with your readers.
Hemochromatosis, or “iron overload syndrome”, is an additional cause of liver cancer, and affects one in 200 individuals in the United States. In reviewing your family history, ask if anyone has developed liver disease that was not related to hepatitis or alcohol abuse. Also ask if anyone has ever been told they have an elevated iron level.
Usually hemochromatosis is asymptomatic until serious heart or liver disease is present. Treatment is available that includes phebotomy (periodically “donating” blood to lower iron levels).
Thanks for your review and helping raise awareness!
Lynne Eldridge M.D.
Author, “Avoiding Cancer One Day At A Time”
http://ww.avoidcancernow.com
Posted by Lynne Eldridge M.D. at March 6, 2007, 9:40 am

A Few Basics on Cancer Trials

Maybe doctors and patients can help each other out.  We do have some locally available cancer trials in phases II-IV in the Philippines. 

Is someone that you know considering participation?  From my own knowledge of what's available hereabouts, current studies are mostly large, pharmaceutical company-sponsored, & international in scope (with a local arm).  Any doctor can refer you to these trials, if they are aware of them.  I hope that the Philippine Society of Medical Oncologists would list them all and post each center coordinator's contact details because there are eligibility issues for enrollment, with study-specific inclusion & exclusion criteria.  (For example, one project requires evidence of chemotherapy-induced anemia.)  Patient care will be coordinated by the study investigators while on the trial, in tandem with the participant's own doctors.  This is a plus– local investigators for the trials are board-certified & respected oncologists based in academic and/or major cancer centers.

Phase II & III trials usually provide both accepted & investigational cancer treatment, as well as all related medical services, laboratory & imaging.  Some phase IV trials give steep discounts (~50%) for the privilege of collecting your data while on standard treatment with their drugs.

As an oncologist, I prioritize these trials but have learned to expect resistance from patients AND doctors.  Misconceptions abound.  The trialists will not supplant the role of the primary physician.  Participants in these studies are not legally compelled to finish the process.  Patient well-being is secured by protocol checkpoints & side effects are minimized by constant protocol reviews.  Both active therapy & follow-up are under the direct supervision of respected oncologists, and their protocols may serve as treatment options where standard therapies don't exist or have run out.  But yes, not all side effects can be foreseen, nor can treatment benefit be guaranteed.  In fact, those issues may be part of the clinical questions to be answered, especially by the earlier phase trials. 

So– don't dismiss these trials upfront, but know what to ask the doctors in charge.  One of the requirements for a patient's enrollment is informed consent after all.