Triple-negative breast cancer (TNBC) is usually treated with some combination of surgery, radiation therapy, and chemotherapy. Unlike other subtypes of cancer, triple-negative tumors do not have targeted agents that can be used in the early setting. With ongoing research trials and new treatments, TNBC is becoming a treatable breast cancer with increased survival rates, giving hope to patients with this diagnosis.
Patient Situation
A 55-year-old patient with no family history of breast cancer presented to her physician for an annual physical and expressed a concern about a palpable mass. She had a history of a previous biopsy in the same area and thought it might be scar tissue. A mammogram and an ultrasound were performed, and a solid mass was identified after the ultrasound. She subsequently underwent a core biopsy, which revealed an invasive triple-negative ductal carcinoma. After consultation with a surgeon and a medical oncologist, both suggested that she receive chemotherapy first followed by surgery.
She began 4 cycles of chemotherapy with a platinum-based regimen. Following a period of recovery, she underwent surgery revealing a 22-mm mass with no involved lymph nodes. No other significant findings were noted.
What Is TNBC, and Who Is at Higher Risk?
Estrogen receptors and progesterone receptors are important proteins that help determine the treatment that may be useful in breast cancer. These proteins are expressed on the surface of cells and are very important for medical oncologists not only for risk stratification but also to determine appropriate therapy. These proteins are absent in TNBC, making chemotherapy the most effective treatment of this subtype of breast cancer. Researchers have noted that younger, premenopausal, or African American women are at increased risk of developing TNBC, but the mechanism that causes this to occur is not yet understood.1 According to Breastcancer.org, TNBC accounts for 10% to 20% of all breast cancers. Risk factors for TNBC include being African American or Hispanic, being younger than 50 years, or harboring the BRCA1 mutation.2
Patient Situation
A 39-year-old female is busy with life, busy in her career, and is receiving infertility treatments to try to have a family with her loving husband. She knew she had a family history of breast cancer, pancreatic cancer, and prostate cancer; however, it was on her father’s side of the family. One morning in the shower, she found a lump in a breast and scheduled a visit with her ob-gyn. A mammogram and ultrasound were ordered, and both were negative. The patient continued to feel the lump and now had breast redness and swelling with pain. Her ob-gyn referred her to a breast surgeon who started her on antibiotics for a possible breast infection. After 2 courses of antibiotics, there was no improvement. The patient was then referred for a repeat mammogram and ultrasound, which showed a large mass with abnormally enlarged lymph nodes. A biopsy of the mass was performed, and the pathology showed a triple-negative invasive ductal carcinoma. She was diagnosed with inflammatory breast cancer based on the clinical presentation with inflamed skin. Unfortunately, she was unaware that members of her family had the BRCA1 gene mutation. She received genetic counseling and underwent blood-based testing that confirmed the presence of the BRCA1 gene mutation that confers an increased breast cancer risk.
Advances in Treatment of TNBC
TNBC has a high probability of recurrence within the first 3 years after diagnosis, and when it spreads it often involves visceral organs, such as the lung, liver, and brain. With this aggressive behavior and short survival once it becomes metastatic, developing optimal therapeutic strategies for the treatment of early TNBC is crucial to prevent recurrence. In the past decade, extensive efforts have been made to find new therapeutic targets of TNBC based on its molecular structure. At this time, no targeted agents are approved in the curative or early setting.
However, exhaustive research efforts are underway to identify novel therapeutics for both early and advanced disease. Just last year, atezolizumab, an immunotherapy drug, was approved in conjunction with a standard chemotherapy for the initial treatment of metastatic TNBC. This therapy showed a longer survival for women who received the immunotherapy combined with nab-paclitaxel compared with nab-paclitaxel alone. Clinical trials are integral not only for the treatment of patients today but also to improve the available therapies for patients to come.
Survivorship/Outcomes
Treatment is completed. What is next? Survivorship is part of the breast cancer journey, and it is different for everyone. Since TNBC does not have posttreatment drug options like hormone-positive breast cancers, patients worry about what they can do to protect themselves from a recurrence. Some patients have difficulty moving forward after TNBC because of fear of recurrence or the cancer becoming metastatic. With TNBC, the risk of recurrence, or the breast cancer coming back outside the breast, is strongest in the first 3 years after a diagnosis. After 3 to 5 years, the risk of recurrence decreases. In fact, eventually the recurrence risk for TNBC becomes lower than the recurrence risk for hormone-driven breast cancers that more frequently come back years and years after an initial diagnosis.3
Surveillance Is Key
After treatment, the patient will have follow-up appointments with the medical oncologist for a history and physical examination every 3 to 6 months for the first 3 years, then every 6 to 12 months for the next 2 years, and every year thereafter. If the patient had a lumpectomy, breast surveillance imaging should continue.3 During medical oncology appointments, patients should bring their questions and report any new complaints, such as headaches, bone pain, weight loss, or any pains or problems that are out of the ordinary and are more severe or last longer than before. It is recommended that patients pay attention to their body and report any symptoms to their doctor. If the physician deems it necessary, additional scans will be ordered based on the patient’s complaints.4
Many patients who need additional scans, such as an x-ray, CT scan, or MRI, after treatment can have what other cancer survivors call “scanxiety” or PSS (pre-scan syndrome).5 Scans can often bring feelings of uneasiness and nervousness as patients cope with physical constraints during the scan and emotional uncertainty about their results. However, scans can be an important part of keeping healthy following treatment. Once the scan is clear, the patients are often feeling they are living on borrowed time until their next follow-up appointment or scan, repeating the uncertainty feeling. Many survivors of TNBC have voiced a decrease of scan anxiety and fear of recurrence as time has passed from their diagnosis; however, it is always in the back of their mind. Tips for coping with scan anxiety include distracting yourself and staying busy, sharing your story, meditating, exercising, treating yourself, knowing when and how you will receive your results, and acknowledging your anxiety, because feeling anxious is perfectly normal.5
The concept of living in survivorship can also bring emotional issues similar to posttraumatic stress disorder (PTSD). Cancer-related PTSD can negatively affect a patient’s psychosocial and physical well-being during treatment and into survivorship.6 Symptoms of PTSD can include:
- Nightmares or flashbacks about the cancer experience
- Continuously focusing on the cancer experience
- Avoiding people, places, and events that remind you of the experience
- Trouble sleeping
- Extreme irritability
- Intense feelings of fear
- Feeling helpless or hopeless
Support groups for patients with TNBC can be an important resource and a powerful source for healing. Support groups can be specific to type of diagnosis, treatment, age, and language. However, support groups are not for everyone; the patients have to be comfortable sharing their feelings in a group setting. Other patients may be more comfortable sharing one-on-one with a counselor or attend an online or telephone support group.7 PTSD symptomatology may require more intensive therapy and may require more time to reach a level of normalcy in a patient’s life.
Receiving a diagnosis of TNBC can sometimes make a patient feel overwhelmed with treatments and side effects. Even though doctors consider TNBC to be an aggressive cancer, it does not mean it is untreatable. With ongoing research trials and new treatments, TNBC is becoming a treatable breast cancer with increased survival rates giving hope to patients with this diagnosis.
References
- Centers for Disease Control and Prevention. Breast Cancer Rates Among Black Women and White Women. www.cdc.gov/cancer/dcpc/research/articles/breast_cancer_rates_women.htm. 2019.
- Breastcancer.org. Triple-Negative Breast Cancer. www.breastcancer.org/symptoms/diagnosis/trip_neg. 2020.
- Living Beyond Breast Cancer. Guide to Understanding Triple Negative Breast Cancer. www.lbbc.org/get-support/print/guides-to-understanding/guide-understanding-triple-negative-breast-cancer. 2017.
- Triple Negative Breast Cancer Foundation. Survivorship. https://tnbcfoundation.org/living-with-tnbc/survivorship. 2020.
- Sarah Cannon. 7 Tips for Coping with Scan Anxiety. https://sarahcan non.com/blog/entry/7-tips-for-coping-with-scan-anxiety. 2016.
- Leano A, Korman MB, Goldberg L, Ellis J. Are we missing PTSD in our patients with cancer? Part I. Can Oncol Nurs J. 2019;29:141-146.
- Susan G. Komen. Getting the Support You Need. https://ww5.komen.org/BreastCancer/SupportGroups.html. 2017.
