Breast Cancer - It Is the Beginning of a Journey Rather than the End of the Road

Stage IV Breast Cancer - It’s the Beginning of a Journey rather than the End of the Road

Breast Cancer is the most common cancers in women in India. The numbers are increasing every year. While a part of that can be attributed to increasing life expectancy, a significant blame can be laid upon worsening lifestyle in our population.

When diagnosed in Stages I, II or III, most women with breast cancers can be cured with a combination of treatments that include surgery, radiation, and systemic therapy (chemotherapy, hormonal and in certain cases targeted therapy).

However, the biggest challenge is when a patient is diagnosed with stage IV breast cancer. Stage IV, in simpler terms means that the cancer has already spread from the breast to other organs including liver, lungs, bones, brain etc. There is a limited role for local treatment in this situation. The major back bone of treatment is systemic therapy. Which is chosen as per the breast cancer subtype or disease biology

What to expect when a patient is diagnosed with a Stage IV breast cancer?

The general perception among common people is that stage IV breast cancer is a death sentence with expected life span about a year. There are enough reasons for that to change. There have been tremendous advances in the understanding of the disease leading to emergence of new, more effective breast cancer treatment options. The average life expectance of these patients is now anywhere between 3 to 4 years. Infact there is a significant percentage of patients who live much longer and succumb to other diseases than cancer.

Are all Stage IV Breast Cancers the same?

All patients diagnosed with breast cancer are subjected to not only a biopsy but also further testing to look at expression of markers like Estrogen Receptor (ER), Progesterone Receptor (PR) and Her 2 receptor. In certain cases, other specialised tests including Next Generation Sequencing (NGS) are also undertaken. This then helps divide breast cancer patients into further subtypes like Hormone Receptor Positive breast Cancers, Her 2 positive Breast cancers and Triple Negative Breast cancers. This means that different treatment options can be offered to patients with Stage IV breast cancer.

How do we treat Hormone Receptor Positive breast Cancers?

These are traditionally the least aggressive subtype of breast cancers.  The thumb rule of treatment is ‘avoid chemotherapy unless absolutely needed”. 

The back bone of treatment is hormonal therapy. Most of the drugs are in the form of oral medications. In the past half a decade or so, at least 5 new medications have emerged showing greater effectiveness in controlling these cancers, with many more in the pipeline. These drugs are not only more effective than the older medications, in many instances they are safer and work for a longer period of time. Typically patients receive a combination of two hormonal drugs in most setting. Chemotherapy is reserved for those patients where there are no further options of hormonal therapy or a very fast response is needed. The average life span is upto 3 to 5 years with the treatment.

How do we treat Her 2 positive Breast Cancers?

The expression of Her 2 Receptors makes these cancers more aggressive. Two decades ago, these patients would generally be treated with chemotherapy alone and results were dismal. It’s the emergence of anti-Her 2 targeted therapy that has brought about a paradigm change in the treatment of these patients. 

What started with one drug called Trastuzumab which showed improvement in survival when combined with traditional chemotherapy, has now expanded into a large portfolio of anti Her 2 drugs that include Trastuzumab, Pertuzumab, Trastuzumab Emtansine, Lapatinib, Neratinib, Tucatinib, Trastuzumab Deruxtecan and others. These drugs, used either alone or in combination with chemotherapy (or now in some cases with oral hormonal therapies) are highly effective and safe. Similar to the Hormone Receptor positive breast cancers , these patient have an average life span of 3 to 4 years.

How do we treat Triple Negative Breast Cancers?

These are the most aggressive subtype of breast cancers being most difficult to control. Traditionally, the only treatment options for these patients have been chemotherapy.

However, that seems to be changing. There is recent data to suggest, that a new class of treatment, called Immunotherapy, has shown promising results for these cancers. These drugs reactivate our body's immune system, own immune cells then kill the cancer cells. Initial studies suggest better outcomes and improvement in survival for selected patients with Triple Negative Breast Cancers.

Another drug that seems to be making waves is the antibody drug conjugate called - Sacituzumab-Govitecan. This drug has shown impressive results in heavily pretreated Triple Negative Breast Cancers and is now being tested in the frontline settings.

There is an impressive array of clinical trials that is evaluating the effectiveness of newer chemotherapy and targeted therapy for these patients.

So what happens when one is diagnosed with stage IV breast Cancer?

The first step is usually a biopsy, with sub typing as discussed earlier, followed in most cases with Whole Body PET CT. On confirmation of diagnosis, subtype and stage, the treating oncologist will typically evaluate the disease pattern, patients’ general condition and fitness and appropriate treatment options are then considered. The case is discussed in a Multi-Disciplinary Tumour Board for optimising treatment choices. Once treatment is started, the first few weeks are spent optimising medications to ensure minimisation of side effects. Most patients undergo a PET CT for disease re evaluation typically 2 to 3 months after initiation of treatment.

Stage IV Breast Cancers are now typically treated like Diabetes or other chronic illnesses. Most patients can expect to be on some medication most of the times. Typically medications are changed when they stop working or give intolerable side effects. Patients can expect to sometimes have a repeat biopsy.

The goals of treatment for Stage IV Breast Cancers are not only longer survival but a good quality of life. That is being achieved not only through more effective medications, but also safer drugs and improvement in supportive care. Most patients will also be under the care of Palliative Care Physician along with a team that comprises of Clinical Psychologist, Dietician, Physiotherapist, Oncology nurse practioner etc.

Conclusions

There have been significant clinically meaningful treatment advances in Stage IV Breast Cancers. The story of these patients now revolves around long survivals, safe and more effective treatments and multi modal team based care. This ensures that the modern patient can go back to her normal life very soon after the diagnosis and treatment initiation. It is indeed, the beginning of a new journey for these patients.