Treatment

Surgery

The principles that govern breast surgery in triple negative breast cancer are similar to the ones that govern surgery for other types of breast cancers. Surgery is still the cornerstone of treatment for all of these tumors and an integral part in all treatment strategies.

The principles that govern breast surgery in triple negative breast cancer are similar to the ones that govern surgery for other types of breast cancers. Surgery is still the cornerstone of treatment for all of these tumors and an integral part in all treatment strategies. In order to appropriately treat any breast cancer and in particular triple negative breast cancers, it is important to surgically remove all signs of cancer within the breast and the lymph nodes in the axilla or armpit.  If the cancer is limited in scope then it can be cured by preserving the breast and performing what has come to be known as a lumpectomy ( complete removal of the cancer without removing the breast).  However, if the scope of the cancer is very extensive to the point where removal would cause a cosmetic deformity then it is best to treat the cancer with a mastectomy or removal of the entire breast. The lymph glands or lymph nodes are evaluated at the time of either operation through a procedure known as a sentinel lymph node biopsy. This procedure involves the injection of a blue, radioactive, or both types of dyes into the breast prior to the operation. The dye travels to the lymph node in the axilla most likely to have the cancer in the event the cancer has spread to the lymph nodes. At the time of lumpectomy or mastectomy, the lymph node is identified and removed and sent for pathologic evaluation. What happens if the lymph node has cancer is a complex topic. In very general terms if a lumpectomy is being performed and there are one or two nodes with cancer, then the sentinel lymph node is the only one removed. If there are three or more lymph glands involved, if the cancer has grown beyond the limits of the node or if the cancer was felt within the axilla prior to the surgery, then a more formal resection of axillary lymph nodes is performed (axillary lymphadenectomy). In the case of a mastectomy, if the sentinel node has cancer then the rest of the nodes are removed as well.

 With triple negative cancers the surgical decision is sometimes more complex. In a substantial number of patients, chemotherapy is administered prior to surgery and the decision of which operation to perform needs to be made after we know how the patient responded to the chemotherapy. For instance, if a cancer was initially not deemed suitable for breast preservation but after chemotherapy the tumor is reduced to a small or non-detectable size then a breast preserving option can be offered to the patient. By the same token, if lymph glands were initially involved but then are sterilized by chemotherapy, the removal of the sentinel node and the node that was initially biopsied maybe all that is necessary without having to remove all of the lymph glands. This complex decision algorithm is one that can only be made with your surgeon and the knowledge your surgeon can gain from evaluating the response of the cancer to the chemotherapy. However, I will again repeat in very general terms that in order to preserve the breast safely it is necessary to entirely remove the cancer surgically, evaluate the lymph glands and preserve a cosmetically acceptable breast. If these three goals cannot be reached, then mastectomy will usually be the best course of treatment.

From time to time it's impossible to preserve the breast and a mastectomy is required. There are times when breast preservation is possible, but the patient chooses to undergo a mastectomy. Sometimes this can be bilateral. There are multiple ways to do this including skin a sparing mastectomy when the nipple and areola are removed but the skin is preserved. More recently nipple sparing mastectomies have become feasible for a large number of patients. As the name implies, the nipple and the skin are preserved with allows for greater cosmetic satisfaction. Even more recent advances include the possibility of a robotic nipple sparing mastectomy that limits the size of the scar and preserves nipple sensitivity in a large number of patients.

Finally, I'd like to mention an exciting clinical trial that is evaluating whether some patients may not need an operation at all! Those patients who achieve a, "Pathologic Complete Response (PCR)", are being treated without surgery altogether. To read more about this, read our Experts Forum post by Dr. Henry Kuerer who is the Robinson Endowed Distinguished Professor of Surgery at the MD Anderson Cancer Center.

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Radiation

As with surgery, the guidelines for the administration of radiation in triple negative cancers are similar to the guidelines of any other breast cancer. If breast preservation is possible and chosen, then radiation therapy is almost universally administered following surgery and chemotherapy.

As with surgery, the guidelines for the administration of radiation in triple negative cancers are similar to the guidelines of any other breast cancer. If breast preservation is possible and chosen, then radiation therapy is almost universally administered following surgery and chemotherapy. The purpose of the radiation is to eradicate any residual cells that may be present within the affected breast. Radiation is quite effective in decreasing the chance of a recurrence within the breast or lymph node regions, and is therefore an integral part of the treatment strategy.  

Radiation therapy may also be important to consider following a mastectomy, although it is not used quite as often.  There are multiple factors that are considered, such as how advanced the disease is within the breast or if there is lymph node involvement.  It is important to meet with a radiation oncologist so that radiation therapy can be appropriately integrated into your care if needed.

One of the most important considerations is to limit the dangers of radiation. Years ago, the heart and lungs received a high dose of radiation. They were innocent bystanders. However, today's techniques are very sophisticated and can easily spare the heart and the lungs. Read more about this in detail in our Experts Forum post, "How do we Protect the Heart?"

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Chemotherapy

The vast majority of patients with a triple negative breast cancer will benefit from chemotherapy. It is only those patients with severe additional medical conditions or extraordinarily small cancers or a very advanced age where chemotherapy may not be of benefit.

Most patients with triple negative breast cancer will benefit from chemotherapy. Only those patients with additional or severe medical conditions, very small cancers or advanced age might not derive benefit from chemotherapy. For practical purposes, chemotherapy will almost always be recommended if a triple negative cancer is identified,. This can be administered prior to surgery (neo-adjuvant chemotherapy)  or after surgery (adjuvant chemotherapy).  There is no survival advantage either way. In other words, our ability to cure the cancer is the same regardless of whether the chemotherapy is administered before or after surgery. However, there are important considerations in determining whether the chemotherapy should be administered before or after surgery. Doctors determine if a patient has local disease (only in the breast) or regional disease (the breast and lymph nodes in the armpit) If a patient presents with locally or regionally advanced breast cancer then neo-adjuvant chemotherapy is of great benefit. There are three main benefits to giving chemotherapy first:  It allows the doctor to evaluate the efficacy of the chemotherapy. It might shrink the tumor and turn a woman who would  need a mastectomy into one who can have a lumpectomy and preserve her breast. Finally, if there is still cancer in the breast after chemotherapy, additional treatments or enrollment in a clinical trial will enhance the chances of cure.

There is one other factor that is important to understand. Approximately 30 to 40% of patients who receive neoadjuvant chemotherapy obtain what is called a pathologic complete response. This means the complete erradication of any cancer within the breast or the lymph glands at the time of surgery. This group of patients is known to have a better prognosis and survival then those where cancer is present at the completion of chemotherapy. They can better be counseled regarding further treatment and follow up. Those that have residual cancer will will be counseled in a different manner since we know the chemotherapy did not have as good of a result as we would have liked.

The type of neo-adjuvant or adjuvant chemotherapy that patients might need might depend on whether the cancer has spread to the lymph glands.  Let me explain. The majority of patients with triple negative breast cancer will receive chemotherapy with a combination of Adriamycin and Cytoxan followed by weekly Taxol (and sometimes the addition of carboplatin).  The survival advantage of adding Adriamycin is especially important in those patients with cancer in the lymph glands. However, the survival advantage of adding Adriamycin to the treatment is very limited in those patients with normal lymph nodes. Young patients might still receive Adriamycin where you want to maximize treatment even if the lymph glands are normal. However, it may be desirable to avoid Adriamycin in an older patient or one with other medical conditions due to its potentially more severe side effects. In this second group of patients surgical treatment would be initially preferable in order to identify whether there has been spread to the lymph glands or not. If the lymph glands are clean then Adriamycin can be omitted but if there has been spread then the benefit of Adriamycin is quite evident. As mentioned previously, these complex treatment decisions must be made in conjunction with your surgeon and medical oncologist in order to personalize the best treatment for each individual patient.

Finally, I would like to talk about a new class of medications. They are called Antibody-Drug Conjugates. This new and exciting medication attaches a chemotherapy drug to an antibody that attaches itself to triple negative breast cancer cells. You can read about this in detail in one of our Experts Forum posts.

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Reconstruction

Reconstructive surgery comes in two forms when it comes to triple negative or other types of breast cancers. A patient who has a mastectomy will almost invariably benefit from undergoing an immediate breast reconstruction and thus preserve body image and function.

Reconstructive surgery comes in two forms when it comes to triple negative or other types of breast cancers. A patient who has a mastectomy will almost invariably benefit from undergoing an immediate breast reconstruction and thus preserve body image and function. Some patients elect not to reconstruct the breast and use an external prosthesis which is certainly an option available for everybody, however with current day reconstructive procedures it is feasible to provide a patient within acceptable alternative immediately after the extirpation of the cancer. The other area where breast reconstruction comes into play is in women who choose to preserve the breast but either have a very large cancer that would leave a substantial deformity if it were excised by itself or in women who have large breasts who could benefit from a reduction on the side not affected by the breast cancer. For instance, in a patient with a large and pendulous breast, who has a large breast cancer, it is possible to perform a lumpectomy and a bilateral breast reduction which then achieves an optimal resection of the cancer plus asymmetrical and cosmetically acceptable breast shape and anatomy. This is what has come to be known as Oncoplastic Surgery, i.e.  the combination of oncologic and plastic surgical techniques for the extirpation of breast cancer and simultaneous reconstruction of the breast. Furthermore, with the advent of neoadjuvant chemotherapy, many patients who in previous years could not have undergone breast preservation are now candidates to achieve it with some of these advanced Oncoplastic and reconstructive techniques.

 

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Integrative Medicine

Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.

Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing. It is not a substitute for conventional treatments such as surgery, chemotherapy or radiation, but can be an excellent adjunct to those treatments. For instance, meditation and mindfulness have been shown to decrease stress and mood disorders in patients undergoing various-different types of treatments for cancer. Massage may also help with the control of pain and perhaps neuropathy in patients undergoing chemotherapy. It is important to discuss these treatments with your doctor to be sure they don’t interfere with the mainstay treatment. There are many claims regarding these types of treatments that are unsubstantiated by research, so it is always important to be sure that the effect that is desired is supported by good evidence. As mentioned above, it’s important to integrate these treatments as an adjunct to your care to improve the many physical, psychological, social and mental effects of the cancer itself and the treatment, but never as a substitute for conventional therapy.

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Immunotherapy

Finally, the era of immunotherapy has arrived in triple negative breast cancer. Some patients with metastatic disease will benefit from a group of immunotherapeutic agents called Check Point Inhibitors.

Finally, the era of immunotherapy has arrived in triple negative breast cancer. A group of drugs called PARP inhibitors have been shown to have efficacy against TNBC in women with BRCA mutations. In fact, there is a clinical trial using an oral drug called Talazoparib (Talzenna) prior to surgery and instead of conventional chemotherapy. The results are encouraging and the side effects are less than those from chemotherapy.

Some patients with metastatic disease will benefit from a group of immunotherapeutic agents called Check Point Inhibitors. These treatments are not used in the adjuvant or neoadjuvant setting. These inhibitors are antibodies that neutralize the receptor protein produced by a gene that exists within the cancers called PDL1 (Programmed Death Ligand1). This protein blocks the ability of the body’s own natural immune killer cells called lymphocytes to bind with the cancer and destroy it. The protein produced by the PDL1 gene essentially repels the lymphocyte killer cells and this allows the cancer to flourish.  The Check Point Inhibitors  are monoclonal antibodies that bind to the PDL1 protein and neutralize it and this allows the natural killer lymphocytes to identify cancer cells and destroy them. Furthermore, the side effects of this immunotherapy tends to be very mild. Not all patients with metastatic disease are candidates to receive this type of treatment and again this is a discussion that you must have with your treating oncologist.

Finally, I would like to talk about a new class of medications. They are called Antibody-Drug Conjugates. This new and exciting medication attaches a chemotherapy drug to an antibody that attaches itself to triple negative breast cancer cells. You can read about this in detail in one of our Experts Forum posts.

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