Triple-Negative Early Breast Cancer

Joan Miró. Portrait of Mrs Mills in 1750
Modern technology has greatly improved the diagnosis & treatment of the malignant diseases.  Here's one of many instances for Breast Cancer.

When a patient has a biopsy or definitive surgery for non-metastatic breast cancer, the tumor specimen itself is screened for receptors for estrogen, progesterone, and the growth factor effector called “Her2″ (aka cErbB2).  The results are predictive of response to a specific therapy type, thereby limiting guesswork among medical oncologists in the choice of appropriate drugs.  The tests are also prognostic, i.e, they hint at the natural course and outcome of the disease.  When assays for estrogen & progesterone receptors as well as for Her2 yield insignificant levels, the breast tumor is designated “triple-negative”. 

This is one area where an all-negative result is bad news.  That morbid bunch, ie., the oncology folks– they wear big smiles when tumors have lots of hormone receptors (estrogen & progesterone).  Although one can’t really say the same for her2-positive disease, at least effective targeted therapy is now widely available for affected patients.  No such luck for triple-negative breast cancer for which the rate of distant failure is known to be significantly higher and where the prognosis remains immutably dicey for high-risk patients.  In non-metastatic disease, good chemotherapy is still the only meaningful systemic cancer treatment option at this time.

Many trials now focus on this subset of patients.  Hopefully, science will be able to offer more in the near future.

Previous Comments

I have the triple negative diagnosis. Diagnosed by core needle biopsy. I am not African American nor Hispanic. My tumor was just less than 2cm. (stage I). I had a lumpectomy. I had Mammosite radiation therapy. The tumor was recognized as grade 2 infiltrating ductal carcinoma. I would have liked for my doctors to have shared all of this research with me and allowed me to be a partner in determining what is my best chemo treatment option. My doctor chose for me, T4 X CA4. Based on what I have read this is probably standard treatment for patients in my situation. But I would like for someone to have acknowledged that the onocologists just don’t know what is really appropriate for this triple negative population until more research is completed.
Also, I wanted the receptor pathology redone on the actual tumor as opposed to relying only on the core biopsy specimen. I was told that this was not standard medical practice, and I shouldn’t pursue that route since rarely are mistakes of this type made. It seemed to me that a test that determined so much in terms of treatment options should be tested twice on all triple negative patients.
I would appreciate a reply
Posted by Janet Littlejohn at June 2, 2007, 3:25 am

Hi. Yes, those so-called “dose-dense” AC-T adjuvant protocols are backed by solid evidence.
Receptor pathology testing on core biopsy specimens, when done at a validated laboratory, should be alright. Results are more dependent upon technique than the anatomic source of the tumor specimen. As you know, even in newly diagnosed stage IV disease (where radical surgery is not an option), cores can be relied upon to do a good job for a competent lab.

Posted by oncodoc at June 9, 2007, 6:31 am

I am triple negative - diagnosed in April. At time of diagnosis - the tumor was 3.5 cm, lymph node pos, grade 3. Course of treatment: dense dose chemo (4 a/c 4 t), radiation & surgery. During the 2 weeks between dx and chemo, the tumor doubled in size, and spread to more lymph nodes. My chemo therapy will end this month, the tumor is almost non-exisitant so I will probably have a lumpectomy.
I would like to know what the odds are of reoccurance? What can I do to improve my chances of avoiding reoccurance?
Posted by Lydia Thomann at July 15, 2007, 10:20 pm

The persons who can best help you with these questions are the members of your medical team. There’s a lot I don’t know. For example, the number of nodes you’d started out with are a key element in prognosis. Likewise, the outcome of the surgery will have an impact on the risks of recurrence & subsequent management. For example, patients with pathologically negative nodes and breast after neoadjuvant chemotherapy have a better risk profile than those with persistent disease.
Good luck.

Posted by oncodoc at July 16, 2007, 7:51 am

Question, I was diagnosed with triple negative, stage 3, grade 3 (2 tumours both positive for cancer) and had 5 out 8 lymph nodes test positive. I underwent 4 rounds of AC and 4 rounds of Taxol (dose dense) followed by 16 radiation treatments. My follow up was a mastectomy with TRAM reconstruction. I had a mammogram in March on other side and all was clear. I subsequently found a lump a few months later, underwent another mammo and ultrasound both showing nothing but doc is concerned and wanted another opinion. Onc had a feel and said ‘it didn’t feel like cancer’. My left side didn’t ‘feel like cancer or show like cancer either’ but 2 years later I was dx’d stage 3. Am I being paranoid?
Posted by Jode at August 5, 2007, 10:41 am

No, you’re not being paranoid. Besides, it seems that your doc has similar doubts– hence, his search for a second opinion.
Mammography with ultrasound does not pickup 100% of breast cancers. I guess you’d fallen into the minority subset that first time around with your left breast lesions. When the index of suspicion is high in the face of a negative mammo, there are other tests.
As to “feel” of a breast mass– well, imaging won’t be necessary if that were a reliable indicator. Oncologists are trained to be suspicious, especially in cases with a prior history of breast cancer. They’ll not go with “feel” alone.

Posted by oncodoc at August 5, 2007, 11:14 am

I am a triple negative - diagnosed Feb/04 tumor size 1.75 cm, State 1, Grade 3, 1 out of 3 lymph node involement. Lumpendectomy and Lymph Node Dissection. Took 2 out 6 cycles of CFE. Unable to receive chemo ever again. Had 5 wk radiation with 1 wk boost
How high is my risk for reocurrence or metasticies. Doctor told me 92%. Everything that I have read says 77%. I’m confused
Posted by Paula at September 19, 2007, 3:16 am

You’ll need a bit more info to make a good assessment of recurrence risk. You can input the necessary data yourself at ADJUVANT! (www.adjuvantonline.com)
Posted by oncodoc at October 4, 2007, 5:34 pm

Hello! I had minor surgery on January 11, 2008. The biopsy tested positive for mucinous carcinoma. On January 25, upon the advise of my surgeon, i had mrm on my left breast. Thereafter, er pr results are positive 50% and 85% respectively. Her2 is negative. I was diagnosed Stage 2, nodes negative. My oncologist advised 6 cycles of chemotheraphy using Evista, to be followed by hormonal treatment after i graduated chemothrapy.
I have a strong family background of cancer. My mother had mrm on her left breast though she was clear of cancer before she died. My uncle died of throat cancer, and the first cancer patient i knew in the (same) family was the brother of my grandfather whom i remembered succumbed to bone cancer. Lately, a distant cousin of mine in my father’s side was diagnosed with breast cancer stage 3.
My question is, is it safe for me to try alternative medicine? I was hoping that good diet, mainly vegeterian diet, cleansing of the body and stress reduction can help me combat this battle. Thanks for your reply!

Posted by maria rona arnan at February 17, 2008, 10:29 pm

Hi. Although all approved drugs are meant to be treatments, Evista (raloxifene) isn’t “chemotherapy” in the traditonal sense. What’s more- at this time, it isn’t a standard “adjuvant” for breast cancer after surgery. It is NOT one of the drugs currently recommended to decrease your risk of cancer recurrence.
Good diet & exercise are complementary to conventional anti-cancer treatment, not “alternative”.
A certain amount of anxiety is normal after a diagnosis of cancer. I find that when the patient understands her risks and the benefits of further treatment, stress is greatly reduced. Control is given back to the patient.
So what is your estimated risk for recurrence and what benefit will adjuvant treatment give you? What is the best type of treatment & what data supports the choice? To ease your mind, talk with your medical oncologist. Ask as many questions as necessary. Make careful but informed decisions in this matter.

Posted by oncodoc at February 18, 2008, 10:32 am

Hi, I was diagnosed 07/09. Stage 1 (1.2 cm, nodes neg 0/21, and M0). Biopsy took out entire tumor– followed by mastectomy where no other carcinoma was found in the specimen; no signs of metastes (the report reads). Triple negative, grade3. I am 41 yrs old. Scheduled to meet with onc in the next couple of weeks. Could you tell me what to expect to hear from onc given above details? I am dreading chemo, do I have alternative options? Thank you!
Posted by ConiT at August 11, 2009, 12:14 pm

You must be offered adjuvant chemotherapy. I assume that you’re premenopausal. You also made note of other risk factors– hormone receptor negative & high-grade. You won’t benefit from her2/neu antibodies or hormone treatments.
Posted by oncodoc at August 15, 2009, 2:36 pm

I was diagnosed Stage 1 triple neg in 08. I have chemotheraphy, no radition (suggestion from onc) and a double mastectomy. I found a lump in my pelvic area. Went to onc and she is worried (even though ob/gyn was not. Onc scheduled me for a zillion scans and I am not pleased with the reports I am reading. I am African American and under 40. (diagnosed at 33) 77% chance this crap is back? I don’t have boobies anymore (but the reconstruction is amazing) but does this mean it is somewhere else.
Posted by NBC's mom at March 19, 2010, 11:07 pm

I don’t know if there is a metastasis. How does the biopsy report of the new lump read? Some patients tell me I’m “paranoid”. Its an occupational hazard to worry, I suppose.
Your age bothers me. The double mastectomy– were you tested for genetic predisposition?

Posted by oncodoc at March 25, 2010, 10:27 pm

This is awesome!
Posted by Watch Pinoy Show at October 13, 2010, 12:48 pm

hi there my mom has a grade 2 ductal carcinoma. she went through MRM last Sept. and the result for Er-Pr, Her2 was triple negative which was really bad to hear from the doctor, i just coudn't stand the fact that my mom is dying, now, she's in Stage2B. the doctor recommends 6 cycles of chemotherapy of generic brand which is the cheaper one. but, then the doctor told us that it was not an asurrance of great healing, he give us another option, the very expensive one,… i just wanna is there another hope for us? any other possible way to treat my mom? pls reply as soon…
At this time, adjuvant therapy of triple-negative breast cancer still involves both taxane- and anthracycline- containing chemotherapy, usually AC–> weekly paclitaxel (although other protocols exist). There are several very promising studies that use other drugs in the pipeline, including BEATRICE (+ bexacizumab), Cetuximab, and Ixempra. At this time, your mother is best enrolled in such a clinical trial.
Best of luck– oncodoc

Posted by Nina at October 22, 2010, 1:20 pm

Im 57 years old. Below is my clinical diagnosis:
Breast cancer, St.II (T2N0M0)
MRM right breast, invasive ductal carcinoma nuclear grade 2, histologic grade 3, tumor size =2.8 cm. in widest dimension, ductal carcinoma-in-situ, comedo, cribriform and solid patterns (approximately 25%), with perineural invasion, no definite lymphovascular invasion, fifteen (15) axillary lymph nodes: negative for metastasis, all surgical margins free of tumor, nipple unremarkable, skin: seborrheic keratosis, non-tumoral breast parenchyma: fibrocystic change with florid ductal hyperplasia, apocrine metaplasia and microcalcifications.

ERA = positive
Staining intensity = +3
Percent tumor cells stained = +5
PRA = positive
Staining intensity = +3
percent tumor cells stained = +5

C-erb-2(her-2-Neu) = negative
After surgery I was placed in hormonal theraphy (aromasin), should I also get intraveneous chemo? Thank you.
Posted by Leixa at October 23, 2010, 11:06 am

Postmenopausal T2 N0, high grade, with perineural invasion. Strongly hormone receptor positive, but her2/neu negative.
Yes, hormone therapy is appropriate, and for postmenopausal women, aromatase inhibitors (like anastrozole/Arimidex) are best.
Will chemo add an additional benefit?
In the past, we made recommendations based on little more than gut-feeling . These days, they have the 21-gene assay, Oncotype DX, to help decide on this exact issue.

Posted by oncodoc at November 1, 2010, 4:03 am

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