Columbus Monthly Special Section: Health Matters – Surviving Breast Cancer

PERSONAL CARE When it comes to breast cancer treatments, a one-size-fits-all approach no longer suffices.

By Rebecca Walters

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ore than 276,000 women will be diagnosed with invasive breast cancer in 2020, according to the American Cancer Society.

The good news is that survival rates for breast cancer patients continue to improve, especially in women over age 50, due in part to early detection, increased awareness and improved treatments.

In the past, a breast cancer diagnosis often meant a radical mastectomy coupled with grueling rounds of chemotherapy and/ or radiation. While these treatments are still sometimes the best option, there have been tremendous advances in alternative breast cancer treatments. Personalized plans are gaining ground as physicians and scientists make strides in identifying markers, conducting genetic testing and employing targeted therapies that can slow the growth of, shrink or even eradicate cancer, as well as drastically improve quality of life.

Columbus is home to several leadingedge cancer research and medical facilities that are winning the fight against cancer, one patient at a time, by tailoring treatments to the individual to achieve the best possible outcome and carrying out clinical trials focused on bringing the next generation of cancer treatments to patients everywhere.

Personalized plans mean more than just looking for targeted treatments for the tumor; medical experts look at the patient as a whole when determining the most effective treatment plan by considering several factors, including overall health and family history, possible side effects of treatments and the genetic makeup of a tumor.

“Breast cancer treatments are tailored based on the specific cancer type and the stage of the cancer,” says Dr. Kavya Krishna, a medical oncologist with Columbus Oncology and Hematology Associates.

“There have been pretty amazing advances in survival and quality of life of breast cancer patients, and it’s changing the landscape of breast cancer detection and treatment.”

Individualized treatments, which can be used alone or in combination with traditional treatments, include hormone therapy, targeted therapy, surgery and reconstruction, chemotherapy, immunotherapy, and radiation. Targeted therapies in particular have shown favorable results because— unlike chemo and radiation—they specifically attack cancer cells, thus causing less damage to healthy cells and helping to avoid a compromised immune system.

Targeted therapies are drugs that attack

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a particular protein that is critical to the growth of the cancer.

Well-known side effects of chemotherapy and radiation include hair loss, immune system issues, changes in nails and neuropathy. Side effects of immunotherapy and targeted drugs vary and can include nausea, skin reactions, gastrointestinal problems and weakness. But, in general, the side effects of targeted therapies are milder than those of chemotherapy. The extent of some side effects depends on comorbidities and pre-existing conditions such as heart and liver disease, among others. This is why doctors highlight the need to treat the whole patient.

Although breast cancer itself has not changed, scientific understanding of the disease has greatly improved, says Dr. Robert Wesolowski, a medical oncologist with the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.

Over the years, scientists have discovered various subtypes of cancer that respond uniquely to different types of treatment. These subtypes of cancer are identified using molecular testing. The most common drivers of breast cancer are hormones (estrogen and progesterone) and the HER2 gene, Krishna says.

“In addition, we are understanding that even in a subtype of breast cancer, there are specific mutations that can drive a cancer growth and spread,” she adds. “Targeted therapy and immunotherapy are also emerging as treatment options for subsets of patients.”

When a cancer is driven by hormones, the cancer is called hormone receptor positive (HR+), and a breast cancer driven by HER2 is said to be HER2/neu receptor positive subtype (HER2+). When none of these are present, the cancer is described as triplenegative, Krishna explains.

Treatments targeting HR+ breast cancer have been widely used since the 1980s. Tamoxifen, which was approved in the late 1970s, was one of the first therapies targeting HR+ cancers, and it functions by blocking the effect of estrogen on the cancer cells. HER2+ cancers were first treated using the drug Trastuzumab, which is a monoclonal antibody and was approved in the late 1990s.

Krishna describes the HER2 receptor as an “on switch” that signals a cancer

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cell to grow. The HER2 targeted therapy, which is usually used in combination with chemotherapy, can inhibit or slow the tumor growth and, in some cases, can kill the tumor entirely.

Unlike HR+ and HER2+ cancers, triplenegative breast cancer (TNBC), which has a higher risk of recurrence, historically had fewer effective treatment options available, experts say. This is because the drivers of triple-negative cancers are not yet completely clear and targeting tumors is more challenging. Because of these challenges, TNBC is one of the most studied areas of breast cancer and currently has a large number of clinical trials, both in the U.S. and worldwide.

“Up until recently, a triple-negative diagnosis was associated with a poorer prognosis

than the other types of breast cancer and a high risk of early recurrence and death,” says Wesolowski, who specializes in treating patients diagnosed with all types of breast cancer. “For decades, chemotherapy was the only effective treatment.”

The numerous clinical trials for TNBC are starting to bear fruit; among the newest treatment regimens is a new immuno-oncology drug given in combination with traditional chemotherapy. The treatment combination was found to be effective in treating certain metastatic TNBCs, Wesolowski says. Called Atezolizumab, it was approved in March 2019 by the U.S. Food and Drug Administration. “The combined chemotherapy and immunotherapy did not have any side effects other than what would be expected from either agent alone,” Wesolowski notes.

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Disease Classification

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zoparib, which are promising in metastatic settings in patients with BRCA mutation after failing chemotherapy and hormonal therapy,” Sundaram says.

Targeted therapy is given based on the “actionable” mutation found in the tumor.

Molecular testing or gene sequencing

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mutation, recommendations are made on prophylactic surgeries and chemo. “About 5 percent of all breast cancer patients carry the breast cancer susceptibility gene, like the BRCA gene,” Sundaram says.

“We now have two drugs approved called PARP inhibitors, namely Olaparib and Tala-

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While the cancer subtype is a key aspect of the treatment and prognosis of cancer, understanding the stage of a cancer diagnosis is also critical for understanding both the treatment course and the expectations for the outcome.

Dr. Kothai Sundaram, medical oncologist with Zangmeister Cancer Center, says breast cancer treatment depends on the stage of the disease. Early-stage is treated aggressively with a curative intent.

“These patients are treated with surgery plus or minus local radiation treatment and systemic therapies with chemotherapy, hormonal therapy and HER2-based therapy,” Sundaram says.

Stage IV, or metastatic breast cancer, is when cancer spreads to organs outside of the breast. “The goal of treatment in the metastatic setting is to prolong life, improve the quality of life and symptom control,” she explains.

Genetic tests identify populations at high risk of developing hereditary cancers.

Patients with these mutations, as well as their families, are counseled and screened for multiple malignancies. Based on genetic

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Staging and Genetic Testing

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are standard procedure for many cancer types to identify targetable mutations.

“The responses are better and side effects are less with targeted treatment, because the drug mainly targets the cancer cells.

We have many new targeted therapies approved recently to treat metastatic breast cancers,” Sundaram explains.

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Clinical Trials

While survival rates and quality of life have improved for breast cancer patients, experts continue to make medical breakthroughs by conducting clinical trials.

The OSUCCC – James is conducting numerous clinical trials to investigate the potential of immunotherapy drugs that work together with the body’s immune system to fight cancer. Trials include a vaccine to prevent recurrence in patients with HER2+ breast cancer, an engineered immune cell therapy for treatment of HER2+ advanced tumors and targeted drug therapy trials for metastatic disease, Wesolowski says.

Another study at the James looked at the effectiveness of two targeted agents, Ibrutinib and Nivolumab, in treating participants with solid tumors that have become metastatic. The study also examined the therapy’s impact on the immunosuppressive function.

Sixteen patients with metastatic solid tumors enrolled, and the results are currently undergoing analysis, Wesolowski says.

Zangmeister is participating in a National Cancer Institute trial called MATCH, which stands for molecular analysis for therapy choice. Patients with advanced solid tumors, lymphomas and multiple myeloma who have progressed with standard treatments are assigned to receive treatment based on the genetic makeup of their tumor.

“This trial is to find out whether treating the cancer based on specific genetic changes is effective, regardless of the cancer type,” Sundaram says. “This is definitely an exciting time in the field of oncology, with so much ongoing research and new therapeutic options on the horizon.”

Columbus Oncology and Hematology is participating in several clinical trials in conjunction with OhioHealth and MD Anderson Cancer Center. The trials are looking at approach to care, various types of and dosing methods for radiation, and using standard care of systemic therapy regimens in addition to experimental treatments to improve outcomes in early-stage and advanced breast cancer.

“It’s not a one-size-fits-all approach anymore,” Krishna says.

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