Your oncologist has just told you that you have triple-negative breast cancer. You have many questions, and that's normal. Keeping yourself informed will help you understand the proposed treatment and overcome this ordeal.
What is triple-negative breast cancer? How common is it?
Triple-negative" means that tumor cells express neither hormone receptors (estrogen and progesterone) nor the HER2 receptor. This means that certain drug treatments (hormone therapy and targeted anti-HER2 therapy) will not be effective.
Of all breast cancers diagnosed each year, triple-negative breast cancer accounts for an estimated 10-15%. When diagnosed early, recovery is frequent, although this cancer is more serious than other forms of breast cancer.
How is the diagnosis made?
Most often, breast cancer is discovered by chance during a mammogram. Occasionally, you may have discovered it yourself after observing a nipple or breast abnormality:
- Redness of the skin,
- Ball in the breast,
- Breast deformity,
- Retracted nipple,
- Ganglion in the armpit,
- Abnormal nipple discharge.
Do not hesitate to consult your doctor, who will prescribe tests.
When a mammogram shows an "ACR 4" or "ACR 5" abnormality in the breast, there is a strong suspicion of breast cancer. The radiologist will suggest a biopsy, i.e. a sample taken under local anaesthetic.
The biopsied tumour fragment is sent to the anatomopathology laboratory, also known as the Pathology Department. This stage is essential for confirming the diagnosis and type of cancer. It is also used to characterize the breast cancer, such as testing for estrogen or progesterone receptors and HER2. When all these tests are negative, the diagnosis is triple-negative.
Are there any risk factors for this type of cancer?
Some families have a higher risk of developing triple-negative breast cancer, especially when several members of the family have had cancer. If your doctor considers that your family is "at risk", he or she will suggest appropriate follow-up and referral to an Oncogenetics department.
Is recovery possible?
Broadly speaking, there are 2 evolutionary stages:
- the localized stage for which a cure is possible. This means that breast cancer extension is limited to the breast and adjacent lymph nodes in the armpit and supra-clavicular area.
- the metastatic stage, in which there is no cure, but effective treatments are available to help you live longer with the disease. Metastatic stage occurs when organs other than the breast and axillary and supra-clavicular lymph nodes are affected (bones, lungs, liver, brain, other lymph nodes, for example).
What treatments will be available in 2023?
In the absence of metastases, most treatments are identical to those used for other types of breast cancer.
SURGERY
Depending on the size of the tumour and the size of your breast, the surgeon will decide on the type of surgery to be performed. Breast-conserving surgery (called lumpectomy or partial mastectomy) is favored as far as possible, to preserve as much healthy tissue as possible. When the tumor is larger and cannot preserve a sufficient area of healthy tissue, the surgeon performs total removal of the breast (called total or radical mastectomy). The surgeon must also remove part (sentinel lymph node technique) or all (curage) of the lymph node chain in the armpit, on the side of the "diseased" breast.
CHEMOTHERAPY
Depending on the size and aggressiveness of the tumor, chemotherapy is often recommended. Neoadjuvant" chemotherapy, when performed before surgery, can help avoid total removal of the breast. When performed after surgery, it is known as "adjuvant" chemotherapy.
The drugs available are usually administered by intravenous infusion:
- EC or AC protocol
- Docetaxel
- Paclitaxel
- Carboplatin
One is available orally (tablets):
- Capecitabine
NEW DRUGS
- Immunotherapy: Pembrolizumab is now available in early access, in combination with chemotherapy when the latter is performed prior to surgery (known as neoadjuvant chemotherapy), then continued for 9 cycles after surgery.
- Targeted therapy: in patients with a germline BRCA1/2 mutation previously treated with chemotherapy, AND when the breast cancer is considered to be at "high risk of recurrence", oral olaparib is now used for 1 year.
RADIOTHERAPY
This treatment is usually carried out after surgery and chemotherapy. It is systematic when breast-conserving surgery has been performed (lumpectomy or partial mastectomy), and is discussed on a case-by-case basis after total mastectomy. Radiotherapy involves delivering small doses of radiation to the operated area and sometimes to lymph nodes, in several sessions spread over 3 to 6 weeks. The precise number of sessions and weeks is defined by the radiotherapist after analysis of your medical file and treatment simulation, on the dedicated radiotherapy machine.
In the presence of metastases
SURGERY
Surgery of the breast and adjacent lymph nodes is of no interest in this situation, as it cannot treat all lesions. It may be discussed on a case-by-case basis, in certain exceptional situations.
CHEMOTHERAPY
This is the main treatment, used alone or in combination with intravenous or oral targeted therapies. A wide range of drugs are available:
- Paclitaxel
- Docetaxel
- Capecitabine
- Eribulin
- Gemcitabine
- Vinorelbine
NEW DRUGS
In 2023, only a few molecules are used on a standard basis and under certain conditions - depending on the treatments you have received in the past, and the molecular abnormalities of your tumor. There are several drug families:
IMMUNOTHERAPY :
Pembrolizumab is the only drug in this family to be used to treat breast cancer. It is indicated after analysis of the PD-1 anomaly on cancer cells.
TARGETED THERAPIES :
- Either Bevacizumab, an intravenous "anti-angiogenic" targeted therapy (acts by reducing the development of blood vessels feeding the tumor),
- Either Talazoparib, or Olaparib, oral targeted therapies of the "PARP inhibitor" type (act by preventing cancer cells from repairing themselves, thus leading to their destruction) in case of BRCA1/2 abnormality.
BRCA1 and BRCA2 designate genes normally present in the body; if they become abnormal (mutated), they no longer function, which has an impact on the development of breast cancer.
ANTIBODY-DRUG CONJUGATE (ADC) :
- This includes Sacituzumab-Govitecan, better known as Trodelvy. It may be available through an early access device, for patients who have already received at least one prior chemotherapy regimen.
RADIOTHERAPY
It can be used to relieve certain symptoms associated with the location of metastases.
Therapeutic trials
Advances in knowledge of the disease and its treatment have considerably improved prognosis. Your doctor may suggest that you take part in a therapeutic trial, when an innovative drug or technique seems suitable for your situation, and even before they are routinely available.
The choice of these treatments is discussed and validated at a multidisciplinary consultation meeting (Réunion de Concertation Pluridisciplinaire - RCP), depending on the specific nature of each patient's disease.
This is personalized medicine.
Supportive oncology care
In curative or metastatic situations, supportive oncology care can improve your quality of life and relieve the side effects of treatment. In curative situations, it can improve your chances of recovery.