Adam M. Brufsky, MD, PhD, and Lynn Acierno, BSN, RN, OCN, RN-BC, highlight breast cancer subtypes and the diagnostic tests used to confirm a diagnosis and discuss how they educate patients on their prognosis.
PUBLISHED January 11, 2018
Adam M. Brufsky, MD, PhD: There are 3 types of breast cancer. Actually, there are more than that that we know about. There’s ER-positive breast cancer, which is driven by estrogen and the estrogen receptor. There is HER2-positive breast cancer, which is driven by the HER2 gene. And then there’s triple-negative breast cancer. They all have completely different treatment approaches. One of the problems we have is truly knowing which cancer you have. It’s always a problem in the clinic, and you know that. I always ask for more staining on a tissue block, and things like that, to really tell whether you’re HER2-positive or not. ER positivity, we consider that if someone has a tissue block, that we send off, that is greater than 1%. We consider that 1% staining, which is ER-positive. As you know, in our clinic, we don’t do that. We consider 10%. When I look at people and I say they’re 5% ER-positive, I say, “No way. We’re not treating them with hormone therapy.” And, so, that’s one thing.
The other thing is HER2 positivity. When we have people who come in with HER2-positive disease, how do you define it? In our clinic, what tends to happen is that people come in and they have HER2 staining. You do an immunohistochemistry test, which is basically tissue staining of the block. If it comes back 3+, then we consider it positive. If it comes back 2+, it’s equivocal. That, potentially, means they may not respond to Herceptin [trastuzumab] or drugs like it.
We always get into this quandary about what to do with the 2+ patients. They’ll come in and they’ll have a tissue block that, maybe, has a staining of 2+. Then, we do a FISH [fluorescence in situ hybridization] test on it. This looks at copies of the HER2 gene. And oftentimes, we’ll have people who come in with 4 copies, which is equivocal. Less than 4 copies is negative. Four copies is equivocal, and 6 copies is positive. And, as you know (knowing me very well), I take a very skeptical view of other pathologists. And so, what’ll happen is that we will go to the patient and we’ll say, “Listen, bring us the block. Let’s redo it for FISH, in our institution. If it comes back greater than 4, I’ll generally treat you.”
Do patients ever ask you about that? Do they ever say, “Why is Dr Brufsky doing this? I thought it was HER2-negative?” “Why is he redoing a block?” Do they ever ask you that question?
Lynn Acierno, BSN, RN, OCN, RN-BC: Actually, they usually don’t question that. They understand that you want to give them the best treatment possible, so they want to make sure that you’re absolutely sure of what you’re treating.
Adam M. Brufsky, MD, PhD: Does the same thing happen with the estrogen receptor business? Do they ever ask questions about that?
Lynn Acierno, BSN, RN, OCN, RN-BC: One thing that I, as the nurse, do discuss with them is that each breast cancer is different. The pathology is different. We determine how to treat them based on the characteristics of their breast cancer.
Adam M. Brufsky, MD, PhD: Correct.
Lynn Acierno, BSN, RN, OCN, RN-BC: So, they may be in the treatment room and the patient across from them has breast cancer and has a completely different regimen. This happens because their cancer expresses different characteristics.
Adam M. Brufsky, MD, PhD: Right, but they always go, “Well, my sister had X. My friend down the road had Y. Why am I getting Z?”
Lynn Acierno, BSN, RN, OCN, RN-BC: Many people consider breast cancer a blanket statement.
Adam M. Brufsky, MD, PhD: Right. Exactly.
Lynn Acierno, BSN, RN, OCN, RN-BC: And they think that it’s all going to be treated the same.
Adam M. Brufsky, MD, PhD: I agree. And the other thing that we always run into is people who come in and, for example, have metastatic disease. They go, “It’s in my bone, but it’s still breast cancer?” Remember that one? You’ve probably had that conversation with people before?
Lynn Acierno, BSN, RN, OCN, RN-BC: Yes.
Adam M. Brufsky, MD, PhD: They say, “Oh, my goodness, how do we? It’s bone cancer.” Or, “It’s liver cancer.”
Lynn Acierno, BSN, RN, OCN, RN-BC: Correct.
Adam M. Brufsky, MD, PhD: “Uncle Fred had liver cancer and he died in 2 months. I have liver cancer.” I think one of the big things that we’ve got to do, all the time, is explain to people that it’s breast cancer that has spread to your liver. And, in general, especially if it’s ER-positive or HER2-positive disease, it’s something that you can live with for a long, long time. That’s a big thing that we try to tell people.
Lynn Acierno, BSN, RN, OCN, RN-BC: Right. As the nurse, that’s what we try to do. First, we make the patient feel comfortable and confident in the care that we give them. We let them know that we are in it with them for the long haul.
Adam M. Brufsky, MD, PhD: Right. That’s important.
Lynn Acierno, BSN, RN, OCN, RN-BC: And if things do change, if the cancer stops responding to a treatment, we always have another treatment.