COVID-19 and Breast Cancer
COVID-19 has had severe impacts on many aspects of everyday life. Because of the pandemic, healthcare facilities have had to delay elective care, resulting in the delay of screenings, surgeries, and other non-emergent treatments. Many people diagnosed with breast cancer wait weeks, even months if their diagnosis is not an aggressive type of breast cancer. Imaging is only available in critical cases, new treatments are restricted, and fertility procedures are inaccessible in some areas.
During the current pandemic, public health authorities suggested that non-urgent surgeries should be postponed, affecting a variety of patients including those who wanted breast reconstruction. Due to a shift in requirements, this surgery became considered elective surgery. Screenings became delayed and some breast cancer patients were left undiagnosed because they were considered “non-urgent” patients.
What is Neoadjuvant Therapy?
Neoadjuvant therapies are used to increase the chances of success for primary treatment and decrease recurrences of cancer. These therapies include chemotherapy, hormone therapy, radiation therapy, immunotherapy, and targeted therapy.
Neoadjuvant therapy can prevent the growth of cancer and shrink tumors by breaking down the cancer cells within the tumor. This allows for primary treatment such as surgery or radiation treatment to be done with fewer obstacles.
Healthcare researchers have found that neoadjuvant therapy is an efficient solution to the delays brought on by Covid-19 for screenings and surgeries.
Who qualifies for neoadjuvant therapy? What steps can you take to find out?
Neoadjuvant therapy is not for everyone. It is often recommended for those with early-stage cancer, whose doctors believe they could benefit from additional preoperative treatment. There are beneficial factors for neoadjuvant therapy in patients, such as: high tumor volume-to-breast ratio, younger age, and patients with HER2-positive, which gives them the highest probability of achieving pCR (pathological complete response) in response to neoadjuvant therapy. Doctors also recommend patients with locally advanced breast cancer, and absolute or relative contraindications to surgery. A contraindication is a factor that can cause a medical treatment to be stopped because of the harm it could cause the patient. Contraindications usually include greater age or medical issues. Patients with tumors smaller than 2cm can usually just undergo surgery, rather than having neoadjuvant therapy first. This is because the smallest tumor that can be felt by a surgeon’s hand is routinely 1.5 to 2 centimeters.
To determine if you qualify, you must go through a series of tests. In order to receive these tests, talk to your primary care physician. After discussing with your doctor, there will need to be consults with surgical oncology, medical oncology, radiation oncology, nursing, pathology, radiology, and clerical booking staff.
Here are the steps you can take to find out which type of neoadjuvant therapy will be best for you:
1. Medical history and physical examination
- Determines if you are at risk for hereditary breast cancer.
2. Diagnostic mammogram
- Can diagnose unusual breast changes.
3. Axillary lymph node dissection (ALND)
- Physical examination of the lymph nodes surrounding the breast.
- Axillary lymph node dissection (ALND) may not be needed for patients with sentinel lymph node positive (SLNP) breast cancer. This is because there is a small chance of local and systemic therapies being affected by finding more positive lymph nodes.
4. Determine tumor status
- Get accurate measurements of the tumor.
5. Genetic counseling – if at risk for hereditary breast cancer
- Guidance on whether or not you need genetic screening to look for the gene that puts you at higher risk for breast cancer.
6. Fertility counseling and pregnancy test – if premenopausal
- Guidance on the best options for your fertility, as anticancer treatments can harm fertility.
7. Screen for distress
8. Imaging of the chest and abdomen
- Scans for distant metastasis.
Optional tests, which depend on doctor recommendation, include:
1. Ultrasound of the breast
- Determines whether or not there are concerning growths in the breast.
2. Ultrasound of the axillary lymph nodes
- Determines whether or not there are concerning growths in the axillary lymph nodes.
3. Biopsy of lymph nodes suspected of cancer.
Steps taken before therapy:
Meet with a surgeon to determine a proper surgical plan for you.
Ensure that all of the tests have been completed.
Consult with a radiation oncologist to check on the size and volume of the tumor.
Neoadjuvant Chemotherapy
Neoadjuvant chemotherapy is given before surgery to treat breast cancer. Doctors recommend this type of neoadjuvant therapy based on the size of the tumor because the drugs can shrink the tumor. If the tumor is effectively targeted, the therapy can allow some breast cancer patients to be considered for breast-conserving surgeries rather than mastectomies. Breast cancer patients who have undergone neoadjuvant chemotherapy may also become candidates for a lumpectomy, which is surgery to remove a tumor.
Chemotherapy tends to be given to patients through a vein in the arm. There are also forms of chemotherapy that are taken orally. The cycle of treatment depends on the patient, but the most common cycle is every three weeks. Most breast cancer patients will undergo chemotherapy for three to six months. While going through chemotherapy, many patients are still able to work and live their daily routine fairly normally.
There are some side effects of chemotherapy that can be treated. The most common side effect is nausea, which your doctor can treat with anti nausea medicine. Hair loss is another common side effect of chemotherapy that you can prepare for in advance with hats or wigs, and there are many other options as well. Every drug has different side effects, so make sure to ask your doctor about your specific treatment and what you can do to minimize the side effects!
What to do after Neoadjuvant Chemotherapy:
Neoadjuvant chemotherapy is generally given over the course of 3-6 months. This therapy is followed up by the appropriate adjuvant therapy, anti-HER2 targeted therapy, and sometimes more chemotherapy.
It is recommended that patients participate in clinical trials as well.
Neoadjuvant Hormone Therapy
Neoadjuvant hormone therapy is another form of preoperative treatment that can help reduce tumor size in order to be able to undergo surgery. The treatment is very similar to neoadjuvant chemotherapy, but with particularly lower toxicity. Specifically, endocrine therapy is the most common treatment for estrogen receptor-positive (ER+) breast cancer. ER+ is the most common subtype of breast cancer, so this treatment is popular.
This treatment is administered with drugs taken orally or by an injection under the skin, or into the muscle. The side effects that come along with these drugs depend on which hormone is being blocked. Many of the side effects are similar to those that come along with menopause. For women, side effects include hot flashes, night sweats, weight gain, and headaches. For men, side effects include hot flashes, tiredness, nausea, and loss of sex drive. Make sure you talk to your doctor about which hormone treatment you are receiving, and how to prepare well for any side effects you may experience!
If you have tested positive for estrogen receptors, you may also be HER2-positive. Consult with your doctors for appropriate treatment options.
Neoadjuvant Therapy for HER2-Positive
In regards to neoadjuvant therapy for HER2-Positive and Triple Negative Patients, there are many potential treatments which are being offered. Ongoing testing is continuing to be used to establish a strong connection to their efficiency.
Trastuzumab:
Adding trastuzumab, an anti-HER2 monoclonal antibody (antibody that is created by cloning a unique white blood cell), to chemotherapy has shown increased pCR rates and decreased relapse rates. Along with this, Lapatinib a successful TKI (Tyrosine Kinase Inhibitor) that targets HER2 intracellularly has been added to trastuzumab neoadjuvant chemotherapy and has shown increased pCR rates. However, there has been no survival benefit to adding lapatinib to neoadjuvant trastuzumab chemotherapy so it is not considered standard care for early HER2-Positive breast cancer.
Pertuzumab:
Pertuzumab is also an anti-HER2 monoclonal antibody that has shown to be effective for metastatic HER2-Positive breast cancer patients. Adding pertuzumab to trastuzumab and docetaxel, a chemotherapy medication, improved pCR rates. The FDA has granted approval for the use of pertuzumab for neoadjuvant purposes. Along with this, the APHINITY trials studied the correlation of pCR rates with survival outcomes with the use of Pertuzumab. It confirmed that the use of Pertuzumab with added trastuzumab chemotherapy increased disease free survival rates for patients with HER2-Positive and operable breast cancer.
Pathological Complete Response
pCR rates are used to predict the likelihood of long-term outcomes in early-stage breast cancer patients who undergo neoadjuvant therapy.
The FDA identifies 2 definitions of pCR (in order to design trials for approval by the U.S. market):
1. “Pathological complete response (pCR) is defined as the absence of residual invasive cancer on hematoxylin and eosin evaluation of the complete resected breast specimen and all sampled regional lymph nodes following completion of neoadjuvant systemic therapy.”
Or
2. “Pathological complete response (pCR) is defined as the absence of residual invasive and in situ cancer on hematoxylin and eosin evaluation of the complete resected breast specimen and all sampled regional lymph nodes following completion of neoadjuvant systemic therapy.”
Patients with HER2- Positive and triple negative cancers obtain higher pCR rates after the use of neoadjuvant therapy.
General Benefits:
Studies have shown favorable results for neoadjuvant therapy given before surgery
Increases the rate of breast-conserving therapy
Lowers the rate of mastectomies needed
Offers a valuable opportunity to monitor individual tumor response
Offers potential opportunities for response prediction
Patients who achieve a pathological complete response (pCR) have shown to have lower recurrence rates compared to those with partial response
General Risks:
Not recommended routinely for patients with stage I breast cancer
pCR is achieved by about only 20%-30% of patients
Residual components may be left behind in the ducts after breast-conserving surgery
There have been some cases of overtreatment
There is no guarantee your tumor will become operable
Some patients have experienced distant metastasis - their cancer spread to other areas of their body
Above all else, please talk to your doctor and figure out what is best for you! We know COVID-19 is affecting you drastically in these unprecedented times, but stay strong! We at CARE believe in you.
**Disclaimer: The Team at CARE does its best to provide you with accurate information but have to emphasize that we are not experts. Please consult your doctor/specialist to see what is best for you!
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