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

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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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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
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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