Your oncologist has just informed you that you have triple-negative breast cancer. You have a lot of questions and that’s perfectly normal. The information we can provide will help you to understand proposed care and to cope with this difficult situation.
What is triple-negative breast cancer? Is it frequently observed?
The term ‘triple-negative’ means that the tumour cells express neither hormone receptors (oestrogen and progesterone) nor the HER 2 receptor. This means that certain medicinal treatments (hormonotherapy and anti-HER2 targeted therapies) will not be effective.
Of all breast cancers diagnosed per year, it is estimated that around 10 to 15% are triple-negative. When diagnosed early, patients are often cured of their cancer, even if this type of breast cancer is more serious than other forms.
How is it diagnosed?
Most often, breast cancer is discovered fortuitously on a mammography. Sometimes patients discover it themselves after noticing something abnormal on a breast or nipple:
- Skin redness,
- A lump in the breast,
- Deformed breast,
- Inverted nipple,
- Ganglion under the armpit,
- Abnormal nipple discharge.
Don’t hesitate to consult your GP who will prescribe further exams.
When a mamography reveals and abnormality in the breast identified as ‘ACR4’ or ‘ACR5’, this means that there is a strong suspicion of cancer. The radiologist will then refer you for a biopsy, i.e. a sample of breast tissue under local anaesthesia.
The biopsied tumour sample is sent to the anatomopathology laboratory, also called the pathology department. This step is essential for confirming diagnosis and for determining the cancer type. It also enables breast cancer to be characterised, and to test for oestrogen and progesterone receptors, and for HER2. When these tests are negative, the cancer is referred to as triple-negative.
Are there risk factors that promote this type of cancer?
Certain families are at a higher risk of developing triple-negative breast cancer, in particular when several members of the same family have had cancer. If your doctor deems your family to be ‘at risk’, he/she will recommend adapted monitoring and advice from an oncogenetic department.
Can it be cured?
There are 2 distinctive progressive stages:
- the localised stage that can be cured. This means that the cancer is limited to the breast itself and to adjacent lymph nodes in the armpit and supraclavicular area (between the neck and shoulder).
- the metastatic stage for which cure is no longer possible; we nevertheless can propose efficient treatment to treat this cancer and to help you to survive the disease as long as possible. Cancer is referred to as metastatic when other organs, beyond the breast and the axillary and supraclavicular lymph nodes, are affected (bone, lungs, brain, other lymph nodes, for example).
What treatment is available in 2023?
In the absence of metastases, most treatments are the same as for other types of breast cancer.
SURGERY
Depending on the size of the tumour and of your breast, the surgeon will decide which surgical procedure is possible. He/she will always place priority on conservative breast surgery (referred to as tumorectomy or partial mastectomy), which enables as much healthy tissue as possible to be left untouched. When the tumour is larger and does not permit the conservation of a sufficient zone of healthy tissue, the surgeon removes the entire breast (this is referred to as total or radical mastectomy). The surgeon must also remove all (curettage) or part (sentinel lymph node technique) of the lymph node chain under the armpit on the side of the diseased breast.
CHEMOTHERAPY
Based on how large and agressive the tumour is, it is often recommended that surgery be associated with chemotherapy. When administered before surgery, it is referred to as ‘neoadjuvant’ chemotherapy and can help avoid breast removal, and when it comes after surgery, we call it ‘adjuvant’ chemotherapy.
Most often, available medicinal treatment is administered intravenously:
- EC or AC protocol
- Docetaxel
- Paclitaxel
- Carboplatin
One is available in oral form (tablets):
- Capecitabine
NEW DRUGS
- Immunotherapy: Pembrolizumab is now available at an early stage, in association with chemotherapy when administered before surgery (neoadjuvant chemotherapy), then continued for 9 cycles after surgery.
- Targetted therapy: for patients presenting with a germline mutation of the BRCA1/2 genes and previously treated by chemotherapy, AND when breast cancer is considered at a ‘high risk of recurrence’, we now use oral olaparib for one year.
RADIOTHERAPY
This treatment is generally organised after surgery and chemotherapy. It is systematic when conservative breast surgery is performed (tumorectomy or partial mastectomy), and is discussed on a case-by-case basis after total mastectomy. Radiotherapy consists in delivering small doses of radiation to the operated zone and, sometimes, to lymph nodes, during several sessions over a period of 3 to 6 weeks. The exact number of sessions and weeks is determined by the radiation oncologist after analysis of your medical file and treatment simulation on the radiotherapy machine.
In the presence of metastases
SURGERY
Surgery of the breast and adjacent lymph nodes is not relevant in this situation, for it would not enable all lesions to be treated. It can be discussed on a case-by-case basis, in certain exceptional circumstances.
CHEMOTHERAPY
Chemotherapy, in these cases, is the principle treatment. It is used alone or in association with intravenous targeted therapies. A vast range of chemotherapy drugs is available:
- Paclitaxel
- Docetaxel
- Capecitabine
- Eribulin
- Gemcitabine
- Vinorelbine
NEW DRUGS
In 2023, only a few molecules are used as standard treatment and under certain conditions – depending on previous treatment you have received and on the molecular abnormalities of your tumour. Their are several drug families:
IMMUNOTHERAPY/
Pembrolizumab is the only drug in this category to be used to treat breast cancer. It is indicated after analysis of PD-1 expression in cancer cells.
TARGETTED THERAPIES:
- Either Bevacizumab, an intravenous targetted ‘anti-angiogenic’ therapy which reduces the development of the blood vessels that feed the tumour.
- Or Talazoparib, or Olaparib, oral targetted therapies from the ‘PARP inhibitor’ family (prevent tumour cell repair, leading to cell destruction) in the case of BRCA1/2 abnormalities. BRCA1 and BRCA2 are genes that are normally present in the body; if they become abnormal (through mutation), this disturbs their function and impacts breast cancer development.
ANTIBODY DRUG CONJUGATES (ADC):
- They include Sacituzumab-Govitecan, better known as Trodelvy. It can be available at an early phase for patients who have already recevied chemotherapy at least once.
RADIOTHERAPY
It can be used to relieve certain symptoms associated with metastasis location.
Clinical trials
Advances in our knowledge of disease and its treatment have considerably improved cancer prognosis. Your doctor can propose that you join a clinical trial, whenever an innovative medicinal drug or technique seems appropriate to your specific situation, and before they are available for routine use.
Choice of treatment is discussed and validated during meetings of the Multidisciplinary Team (MDT), based on disease specifities for each patient. This is personalised medicine.
Oncology supportive care
Whether you are in a curative or metastatic situation, oncology supportive care can help improve your quality of life and relieve treatment side effects. In curative settings, it can also improve your chances of recovery.