February 9, 2023

Filipino Guardian

Sentinels of Filipino Free Press

New treatments for metastatic breast cancer

Medically reviewed by Jailan Elayoubi, MD

In 2008, Barbara Daley was diagnosed with stage 1 breast cancer after finding a lump in her breast. It was recognized early and her treatment consisted mainly of chemotherapy. Despite this, the chemo was tough on her and often made her sick. But it worked: Daley was soon in remission.

Fast forward to 2020 and she began noticing changes in her body: she felt a lump under her arm, had chest pains, and had trouble breathing when she had to run to catch the bus.

Daley, 61, soon found her cancer had returned, this time spreading to her bones, lungs and chest wall. She was diagnosed with stage 4 breast cancer, or metastatic breast cancer — a term applied once the disease has moved beyond the breast and nearby lymph nodes.

Currently, Daley, who is seeing Jailan Elayoubi, MD, an oncologist and breast cancer researcher at the Karmanos Cancer Institute in Detroit, is dependent on two drugs: palbociclib, part of a breakthrough class of drugs that disrupt the growth of cancer cells known as CDK4/6 -Inhibitors. The second is letrozole, which helps lower female hormone levels.

And this treatment helps her maintain her quality of life. Her side effects are minimal – she sometimes feels tired and nauseous – and she can continue to do housework full-time.

What is metastatic breast cancer?

Before we delve further into the treatment, let’s explain a little more about the disease itself. “Metastatic breast cancer is cancer that has spread outside of the breast and chest wall area, meaning some of the cells have slipped into the bloodstream,” Elayoubi said. “They circulate and then lodge in an organ outside of the chest.” This could be in the bone, the liver, or the brain—anywhere outside of that original region, really.

More than 168,000 women in the United States have metastatic breast cancer, with the majority — like Daley — diagnosed with earlier-stage breast cancer, according to the nonprofit breast cancer organization Susan G. Komen. In fact, only about 6% of people are initially diagnosed with stage 4, according to Komen.

Although there is no cure for stage 4 breast cancer and survival rates vary by subtype, overall five-year survival rates have improved over time. For example, a 2022 report by the American Cancer Society (ACS) found that the five-year survival rate for all subtypes was 29%. For comparison, 10 years ago, in 2012, that figure was 23%.

Racial differences exist in almost every stage of breast cancer. In this 2022 report, the ACS found that black women have lower survival rates compared to white women at every stage of diagnosis except stage 1. The largest black-and-white disparities were among those diagnosed with stage 3 and stage 4 breast cancer. The five-year survival rate for white women with stage 4 breast cancer is 31%—and only 20% for black women.

Overall, the goal with metastatic breast cancer is to treat and sustain the disease for as long as possible while helping women maintain a good quality of life – and new treatment options are helping make this an option for many women.

Treatment of metastatic breast cancer

There are different subtypes of breast cancer – and treatment depends on which type you have. (Because every case is different, your doctor will know best which treatment is best for you.)

What are the three main breast cancer subtypes?

Hormone receptor positive breast cancer: This type of breast cancer can be fueled by abnormal estrogen or progesterone signaling in the cells. So treatment typically involves blocking these hormones. “We used to start with pretty harsh cytotoxic chemotherapy regimens,” said Azadeh Nasrazadani, MD, Ph.D., an assistant professor in the Division of Medical Oncology of the Breast, Division of Cancer Medicine, at the University of Texas MD Anderson Cancer Center at Houston. “Now we are able to start this special class of breast cancer patients with an oral option that is less harsh and does not impact their quality of life as severely.”

This class of oral drugs are CDK4/6 inhibitors and includes three types of oral drugs: palbociclib, ribociclib, and abemaciclib. Although side effects do occur, they are minimal, and the pills can be taken in combination with others – like Daley taking palbociclib and letrozole. And the research is showing its effect: A 2021 study found that women who took a combination of ribociclib and letrozole lived about a year longer than those who took just the hormone blocker.

HER2-positive breast cancer: People with this type of breast cancer have elevated levels of a protein called HER2, which can make cancer cells grow faster. Treatment typically targets the HER2 protein. Elayoubi said that 20 years ago there was only one HER2-targeted therapy (trastuzumab). “Now we have more than eight new-generation HER2-targeted treatments that we can use in patients with metastatic breast cancer,” she said. One thing to know: Enhertu (that’s the brand name for something called trastuzumab-deruxtecan), which is given via IV. Earlier this year, the FDA approved its earlier use in a Stage 4 regimen and for patients with lower levels of HER2.

Triple negative breast cancer: This very aggressive type of breast cancer has no specific receptors or proteins to target, making it difficult to treat. Treatment typically includes chemotherapy, and immunotherapy has been helpful in some patients in addition to chemotherapy. Immunotherapy boosts your immune system so it can find and kill cancer cells more efficiently. In 2021, the FDA approved use of the treatment sacituzumab govitecan — known by the brand name Trodelvy — which is given intravenously. The drug has been shown to help patients live longer, Elayoubi said. In the study cited in the drug’s FDA approval, the median overall survival for patients taking sacituzumab govitecan was about five months longer than for patients undergoing chemotherapy.

The treatment of metastatic breast cancer is evolving

Also helping change the treatment game for patients with metastatic breast cancer: next-generation sequencing, aka molecular testing. In this method, either a tumor biopsy or a blood sample is taken and then tested for a range of markers or mutations to create a treatment that specifically targets any markers found.

“If we don’t look for these markers, we’re missing out on the few but fortunate patients who have this marker.” [and] may benefit from an additional line of treatment,” said Elayoubi. And sometimes, she said, that extra treatment is tailored to that particular patient’s cancer, which can help them stay healthy even longer.

Next-generation sequencing — along with many FDA-approved drugs — is often covered by insurance, but check with your doctor and insurance company before starting any new drugs or treatments.

“The therapies that have been developed in recent years are the culmination of our great advances [in] Understanding the underlying biology that drives the different types of breast cancer,” said Nasrazadani. “This has enabled the development of more targeted therapies that are more effective and less toxic, which translates into improvements in survival rates and a better quality of life.”

Advances are likely to continue, but these new drugs, treatment regimens, and testing options have already made a big impact, turning what was once an incurable disease into a chronic condition for many.

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