Breast cancer
Breast Cancer? ER Positive Or Negative
A new study reports that recent decline in breast cancer mortality rates have been most noteworthy among women with estrogen receptor (ER)-positive tumors and women younger than 70.
The results of the study are being published online April 2 in the Journal of Clinical Oncology (JCO).Approximately 75% of breast cancers are ER-positive. The average age of breast cancer diagnosis is 62.
Between 1990 and 2003, breast cancer mortality rates declined by 24%. This is the first study to examine which patients have experienced the greatest declines in mortality. In 1989, the mortality rate for breast cancer peaked at 33 out of 100,000 women per year. By 2003, the mortality rate had dropped to 25 out of 100,000 women per year.
Although breast cancer mortality has declined for all groups of patients, declines were greatest for women under 70 and women whose tumors were ER-positive. The researchers found that among women under 70, mortality from breast cancer declined 38% for those with ER-positive tumors vs. 19% for those with ER-negative tumors. Among women 70 or older, mortality declined 14% for those with ER-positive tumors vs. No decline for those with ER-negative tumors.
'These trends in breast cancer mortality since 1990 are likely attributable to at least two important factors: the use of tamoxifen after surgery, which substantially reduces the risk of recurrence in ER-positive tumors only; and widespread use of screening mammography, which is more likely to detect the slow-growing tumors that tend to be ER-positive,' said Ismail Jatoi, MD, PhD, Director of the Breast Cancer Center in the Department of Surgery at the National Naval Medical Center, and the study's lead author.
This study did not explore the reasons why breast cancer mortality rates declined less for older women. However, previous studies have suggested that older women are less likely to receive adjuvant therapy for breast cancer. Because older women are under-represented in clinical trials, their optimal treatment has not been well established.
Advertisement
The researchers point to the importance of further reducing mortality rates among women over 70 and women with ER-negative tumors. The authors argue that recruiting more older women into clinical trials could lead to better treatments and outcomes for this age group. In addition, while a number of breast cancer drugs have recently been introduced that are likely to benefit women with ER-negative tumors, any impact they would have on mortality was not seen during this study period. For example, adjuvant use of Herceptin (trastuzumab) was approved in November 2006 for HER-2+ breast cancer (many ER-negative breast cancers are HER2+).Investigators at the National Cancer Institute (NCI) and the National Naval Medical Center looked at 234,828 cases of invasive female breast cancer diagnosed between 1990 and 2003. The study analyzed data from the Surveillance Epidemiology and End Results (SEER) cancer registry, an NCI-sponsored, population-based database that compiles detailed cancer statistics.
Advertisement
Source-EurekalertPRI'I Was Diagnosed With Two Different Types Of Breast Cancer At The Same Time (Yes, That Can Happen)'
At the start of the summer of 2020, just a few months after the COVID-19 pandemic began, Morgen Chesonis-Gonzalez, a Miami public school clinical art therapist, felt a persistent pain in her right armpit that set off some internal alarm bells. She knew something in her body wasn't quite right.
Chesonis-Gonzalez, 47, had always been diligent about getting her annual mammograms, even though she has no family history of breast cancer. She followed guidelines set by the American Cancer Society, which recommends all women with an average risk of breast cancer start getting mammograms by age 40. But in spring of 2020, fear of catching the virus kept her from going to her scheduled exam.
"It was still early in the pandemic when schools were online, everything was upside down, and there was a lot of uncertainty," Chesonis-Gonzalez tells Well+Good. "I decided to delay my mammogram since I had been fine, and at that stage of the pandemic, the message was to stay home if you were not an essential worker."
But after a month of unexplainable pain, her armpit swollen and inflamed, Chesonis-Gonzalez knew it was time for a mammogram. Her fear was, to some degree, confirmed when doctors asked she follow up her mammogram with an ultrasound and biopsy. By August 20, 2020, she was officially diagnosed with breast cancer. But her diagnosis had an interesting twist.
Related Stories
{{ truncate(post.Title, 12) }}
Chesonis-Gonzalez was diagnosed with not one, but two different types of breast cancer at the same time. Her armpit pain was from two malignant tumors in her breast. One was stage 2 triple-negative breast cancer, which Chesonis-Gonzalez calls "a particularly aggressive type of breast cancer that can metastasize rapidly." The other was a type called ER+/PR+/HER2-, a cancer that grows in response to estrogen, per the Mayo Clinic.
The shock of the news was compounded by the fact that Chesonis-Gonzalez had to take it all in by herself. Because of COVID-19 restrictions, her husband had to wait in the parking lot, listening to the diagnosis on the phone and taking notes. Chesonis-Gonzalez's first reaction was shock—her prior mammogram had had no abnormalities. "I kept thinking how this would affect my children," she says.
The odds of having two types of cancer at the same time is rare, especially two types of breast cancer. The dual diagnosis meant Chesonis-Gonzalez had to undergo multiple types of treatment back-to-back. And because of the pandemic, she had to go through them alone, and always with the fear she'd catch the virus.
Photo: Morgen Chesonis Gonzalez
Chesonis-Gonzalez's diagnosis is particularly rare. Starr Koslow Mautner, MD, a breast cancer surgeon at the Miami Cancer Institute, part of Baptist Health South Florida, says cases with two different types of cancer (one of which being triple-negative) is rare, occurring in roughly five percent of patients. While multiple tumors of the same type of breast cancer are not rare, multiple with different amounts of ER (estrogen), PR (progesterone), and HER2 (human epidermal growth factor) receptors are, Dr. Mautner adds.
"The patient's prognosis is usually dictated by the cancer that is larger or has more aggressive features," Dr. Mautner says. According to Dr. Mautner, if tumors are located in different quadrants of the breast, it often means you'll need to get a mastectomy (i.E., surgery to remove the entire breast) rather than a breast-preserving lumpectomy (i.E., surgery to remove the tumor). It also means the treatment plan might include a variety of medications meant to target the different individual receptors of each tumor.
In Chesonis-Gonzalez's case, this led to two different treatments: chemotherapy for the triple-negative mass, and endocrine therapy for the estrogen-receptor positive mass.
Difference between triple-negative breast cancer and other typesTriple-negative breast cancer, written as ER-/PR-/HER2-, is considered an "invasive ductal cancer that lacks receptors," according to Dr. Mautner. Meaning, the cancer cells don't have estrogen or progesterone receptors, and they don't make too much of the growth-promoting protein HER2, per the American Cancer Society.
This type of cancer can spread quickly and is often more difficult to treat. It makes up only 10 to 15 percent of all breast cancers, and is more commonly diagnosed in people who are under 40, Black, or have the BRCA1 genetic mutation, which can increase your overall breast cancer risk, per the American Cancer Society. (For context, Chesonis-Gonzalez does not have the BRCA1 mutation.)
In these cases, patients will almost always need chemotherapy, before or after surgery, because it cannot be treated with targeted medication, says Dr. Mautner.
Hormone-positive breast cancer is more commonChesonis-Gonzalez's second tumor bore different characteristics—it was a smaller, stage 1 tumor (meaning it was contained to one area) called a Luminal A tumor. Luminal A tumors (medically known as ER+/PR+/HER2-) are a "very common" type of hormone-positive breast cancer, says Dr. Mautner. This type of cancer is slow-growing and is highly responsive to endocrine therapy—a treatment that involves taking an oral medication to block the estrogen receptor for at least five years.
Hormone-positive breast cancer is more common, making up roughly 70 to 80 percent of newly diagnosed breast cancers, per Susan G. Komen.
In sum, hormone receptor-negative breast cancers (like triple-negative) respond to chemotherapy, while hormone receptor-positive breast cancers respond to endocrine (i.E., hormone) therapies. While endocrine therapy limits the cancer's ability to access the hormones it needs to grow, chemotherapy kills cancer cells or slows their growth, per the National Cancer Institute. Because Chesonis-Gonzalez had both, she had to undergo both types of treatment.
The type of breast cancer can affect recurrence rateWhether someone's breast cancer is hormone receptor-positive or -negative can also affect recurrence. "If you are going to have a recurrence of triple-negative breast cancer, then it will most likely happen in the first two to three years after initial treatment," says Dr. Mautner. But "recurrences after five years are rare for triple-negative breast cancer as opposed to estrogen receptor-positive breast cancer."
Hormone receptor-positive cancers, on the other hand, are more likely to recur more than 10 years after diagnosis, according to Susan G. Komen. Case in point: A January 2023 in Annals of Surgical Treatment and Research1, which followed 2,730 people with breast cancer, found 47.8 percent of hormone-positive participants had a recurrence within five years of diagnosis, while 78.7 percent had a late recurrence (i.E., after five years).
"While the risk of recurrence is influenced by tumor subtype, prognosis and survival are more dependent on tumor stage," Dr. Mautner adds. Thankfully, Chesonis-Gonzalez responded well to chemo, which reduces her risk of recurrence. She has an "excellent prognosis despite having two cancers in one breast, and despite one of those cancers being an aggressive triple-negative breast cancer," says Dr. Mautner.
Treatment was a multi-faceted approachChesonis-Gonzalez's treatment was particularly challenging, not just because of the pandemic, but also because of the rarity of having two cancers in the same breast. "Everything changed after being diagnosed," she said. "Since I was only 47, it felt like I was being cut down in the prime of my life and would not be able to see my children grow up."
Her treatment, which totaled about ten months, started with four months of chemotherapy to shrink the tumors. Dr. Mautner says in many cases like these, chemotherapy actually reduces the cancer to the point that no tumor is found at the time of surgery. This often givens people "an excellent prognosis," she says.
After Chesonis-Gonzalez finished chemotherapy, she had a bilateral mastectomy—a surgery where both of your breasts are removed. Chesonis-Gonzalez says she made the choice to have both breasts removed for "ease of mind." According to Dr. Mautner, this decision is a highly personalized one: "Without having a genetic mutation, removing the other health breast is not something that is medically necessary, but many women choose to pursue this option for 'peace of mind' or symmetry."
But treatment was far from over. After surgery, she began physical therapy to help extend the range of motion in her chest and shoulders to prepare for what was next: 28 rounds of daily radiation therapy. In each radiation treatment, Chesonis-Gonzalez had to raise her arms above her head for long periods of time—no small feat after breast surgery. The goal was to ensure no cancer remained.
It also took an emotional tollAside from being physically taxing, treatment took a psychological toll. It was a situation she'd never expected: Her diagnosis was rare, she had no family history of breast cancer, and she had no pre-existing factors (like BRCA1 mutation) that would potentially increase her risk. And up until the pandemic, she'd made sure to get her mammograms once a year. On top of that, Chesonis-Gonzalez had to go to her appointments alone because of the pandemic—distanced six feet apart from everyone and wearing double masks.
"Although I felt everyone's love and prayers, we were physically isolated from all social support for those months of active cancer treatment when I was the most vulnerable, fighting for my life," Chesonis-Gonzalez says. "It took a toll on my mental health and was difficult for my family as well."
Life after two types of cancer is possibleAfter all the chemo, surgery, therapy, and radiation (and even after no signs of cancer remained in her body), it still took Chesonis-Gonzalez six months to heal. After her mastectomy, she opted to get breast reconstruction surgery, and now, more than four years since her diagnosis, she is almost done with her maintenance therapy.
Despite the rarity of a double diagnosis and intense treatment, Chesonis-Gonzalez was able to continue working as a clinical art therapist by doing virtual appointments for Miami public schools. She also enjoys hobbies, like paddling for a dragon boat team called Team SOS Miami, a team specifically for people who've gone through breast cancer (they even compete with other teams around the world). Had she not chosen to get a mammogram in 2020, her story might've been very different.
Skipped mammograms are common, and were especially so during the pandemic. Dr. Mautner says skipped mammograms went up 44 percent between 2019 and 2020, with some places not returning to pre-pandemic levels until after 2022. At the Miami Cancer Institute, Dr. Mautner personally continues to see the ramifications of people skipping mammograms to this day.
But getting annual mammograms is crucial to catching breast cancer early and successfully treating the disease. Left untreated, it can spread to your lymph nodes, prompting more aggressive treatment and side effects. Ask your OB/GYN about the best age for you to start getting mammograms (the age for women of average risk is 40, but it could be younger if you're at increased risk).
And of course, reach out to your OB/GYN if you notice any pain, bruising, redness, or lumps in your armpits or breasts.
Well+Good articles reference scientific, reliable, recent, robust studies to back up the information we share. You can trust us along your wellness journey.
The Wellness Intel You Need—Without the BS You Don't
Sign up today to have the latest (and greatest) well-being news and expert-approved tips delivered straight to your inbox.
Use Of New Cancer Drugs Needs A 'Tincture Of Time And Information'
With newer breast cancer treatments, it's essential that nurses and APPs educate themselves and advocate for their patients.
While effective new cancer therapies have been approved in recent years, clinician education and patient advocacy is key to putting these drugs into practice, explained Jamie L. Carroll, APRN, CNP, MSN, of the Mayo Clinic.
In a recent Community Case Forum, Carroll and colleagues discussed the evolving second-line treatment landscape of patients with HR-positive, HER2-negative metastatic breast cancer. She mentioned that many community cancer centers treat with palbociclib (Ibrance) because that was the first CDK4/6 inhibitor to be approved for HR-positive, HER2-negative metastatic breast cancer that progressed on endocrine therapy.1
"Many of the community settings are using palbociclib because that was the first drug to market. In the academic center, we tend to use the other CDK4/6 inhibitors, but they came after [Palbociclib], so I think it's just going to be the tincture of time in getting that information to them and then having them start using and becoming familiar with new drugs and new therapies," Carroll said in an interview with Oncology Nursing News after the event.
Among patients whose disease becomes recurrent to endocrine therapies, ESR1 mutations are common, occurring in 10-50% of metastatic endocrine therapy-resistant cancers.2 For this population with ER-positive, HER2-negative breast cancer, the FDA approved elacestrant (Orserdu) — an oral selective estrogen receptor degrader (SERD).3
This approval put an importance on testing patients for ESR1 mutations after they experience disease progression on a CDK4/6 inhibitor.
"You don't need to test your patients every 3 months or every 6 months looking for an ESR1 mutation. You would test them when they progress on their CDK4/6 [inhibitor] to see, are they eligible for elacestrant," Carroll explained during the forum. "It's also important that you don't use archived tissue."
A poll at the forum asked nurses and advanced practice providers (APPs) in attendance what molecular testing method they would use for a patient with HR-positive, HER2-negative breast cancer who experienced disease progression on a CDK4/6 inhibitor. Answers were as follows:
"For my clinic, we're looking for actionable mutations. So we're looking for biomarkers that we can do something with. We're looking for an ESR1 mutation," Carroll said.
Since nurses and APPs tend to spend more time with patients, they can be advocates to physicians for the best treatment option for each individual patients.
"It might be [a matter of saying] I just know my patient better. I know this little old lady that lives in Denison, Minnesota is not going to be able to get back for these labs. Or, you know, I know that transportation is an issue for her, or the financial toxicity piece, or she's not going to remember to take a pill three days on two days off," Carroll said. "I feel like I know my patients really well."
References
1. FDA. Palbociclib (Ibrance) Published February 22, 2016. Accessed October 30, 2024. Https://www.Fda.Gov/drugs/resources-information-approved-drugs/palbociclib-ibrance-capsules
2. Zundelevich A, Dadiani M, Kahana-Edwin S, et al. ESR1 mutations are frequent in newly diagnosed metastatic and loco-regional recurrence of endocrine-treated breast cancer and carry worse prognosis. Breast Cancer Res. 2020 Feb 3;22:16. Doi: 10.1186/s13058-020-1246-5
Comments
Post a Comment