Preventing Recurrence: HER2-positive Breast Cancer
Adam M. Brufsky, MD, PhD: One of the things people are always worried about, is, they say, “My cancer is going to come back.” And they always go, “It’s going to come back in my breast.” What we try to tell people—at least I try to do this, and I’m sure that you reinforce it—is that there are 2 things we worry about: cancer coming back in your breast and cancer coming back elsewhere in your body. We treat each differently. But what keeps cancer from coming back in your breast is surgery and/or radiation and, to a lesser extent, the chemotherapy and your hormonal therapy. What keeps it from coming back elsewhere in your body is the chemotherapy. The analogy I always use is chemotherapy and a dandelion. You blow on a dandelion. The weed is still there, you pull it out, and little things go all through your body. Chemotherapy, in a way, is like a weed killer. That is the weed killer analogy.
Lynn Acierno, BSN, RN, OCN, RN-BC: That’s a good way of saying that.
Adam M. Brufsky, MD, PhD: Yes.
Lynn Acierno, BSN, RN, OCN, RN-BC: Actually, I’ve had patients who have expressed concern. They’ve asked, “Why am I getting chemotherapy when my cancer’s gone?”
Adam M. Brufsky, MD, PhD: Right. Exactly.
Lynn Acierno, BSN, RN, OCN, RN-BC: We try to explain that we are doing our best to prevent a recurrence.
Adam M. Brufsky, MD, PhD: Right. We have a lot of tests, right now, that we didn’t have before. With these molecular tests, such as Oncotype DX and MammaPrint and Prosigna, we can actually look at the cancer itself, determine someone’s rate of recurrence and then, from that data, decide whether they should get chemotherapy or not. I think that’s been a major change in the last 10, 12 years.
Women actually come in now and we say, “We’re going to do a MammaPrint on you. If it’s low risk, great. Then, you don’t need chemotherapy.” That’s a real change. Before all of these tests came around, we’d have to kind of guess. “All right, you’ve got a 1-cm, 1.5-cm ER-positive node-negative breast cancer. You’re 45 years old, so you probably need chemotherapy.” But now what we do is use one of these tests. If they’re low risk, they don’t need chemotherapy. I think it’s cool. Do you think people understand those tests? Do they ever talk to you about them at all?
Lynn Acierno, BSN, RN, OCN, RN-BC: They are overjoyed when you tell them that the results indicate that there’s a very low chance of recurrence. I think that you do a good job of preparing them ahead of time to understand that it can go either way. But many times you’ll say, “I believe this is going to come back.”
Adam M. Brufsky, MD, PhD: I do. You try to take a guess.
Lynn Acierno, BSN, RN, OCN, RN-BC: Again, the tests are amazing. I think that it’s just amazing that there are tests developed that can predict this with that level of accuracy.
Adam M. Brufsky, MD, PhD: About half of the people that used to get chemotherapy don’t need it any more. So, it’s really good. Most people with HER2-positive early stage breast cancer will survive and do really well. It’s really neat to be a part of this. We did some of the first clinical trials with TCH [docetaxel, carboplatin, trastuzumab] in Pittsburgh in the clinic. It’s really cool to kind of see, 15 years later, that this is a part of the standard of care and to see it do so well.
The issue, though, is some people will relapse despite that. There are a lot of new drugs that we’re trying to use to prevent relapse. One of them is a drug called neratinib. The trade name is Nerlynx. Neratinib is a pill that you take, a certain amount of pills a day. Basically, it means that you’ll get the standard therapies. So, you get TCHP [docetaxel, carboplatin, trastuzumab, pertuzumab]. Then, maybe you’ll get Herceptin for a year. And then, if you have a high enough risk of recurrence or you are someone who has a lot of disease left over or you are someone who has a lot of lymph nodes or a big tumor, from when it started, and it really has not gone away, especially if it’s ER-positive, we’ll think about putting you on this extended adjuvant therapy. You take this drug, neratinib, for a year. This is something that’s just come to play. I think that the trials went on for a long time. The drug was owned by several companies. Finally, Puma Biotechnology bought it and finished the development on it. The trial literally was finished about a half-a-year ago, and it was approved by the FDA over this past summer.
Lynn Acierno, BSN, RN, OCN, RN-BC: My experience with neratinib has been through the research.
Adam M. Brufsky, MD, PhD: Right, through all of the clinical trials. We do a lot of clinical trials in metastatic breast cancer, HER2-positive breast cancer. We have had a lot of experience with patients, in our clinic, with neratinib. That’s kind of how we have started to use it. But right now, the way people are going to be using it, at least for the time being, is by the label—which is going to be for a year after Herceptin. In fact, we’re just starting to put some patients on it. We’ve had a patient actually come in to request it from us, and her insurance is giving her a hard time. So, she keeps on requesting it.
Lynn Acierno, BSN, RN, OCN, RN-BC: I’ve begun to see it advertised.
Adam M. Brufsky, MD, PhD: Again, the insurers are a little bit behind. It has been somewhat tough, at least for now, to use. But in the future, it shouldn’t be that bad to get approved. Clearly, if you have a high enough risk of recurrence, I think it’s a reasonable drug to consider.
Lynn Acierno, BSN, RN, OCN, RN-BC: As the nurse, when looking at side effects, I am aware that diarrhea is almost a given.
Adam M. Brufsky, MD, PhD: Right. One issue, that’s important, that I think I’d love to hear your opinion on is, you’re done with your breast cancer journey, right? You had your neoadjuvant therapy and you had a great response. Do you really want to do another year? What do you think patients will think? Is the patient really going to ask, “Do I have to do this for another year?” Do you think they want to do that?
Lynn Acierno, BSN, RN, OCN, RN-BC: I have to be honest. Probably, what I see most is, people feel more comfortable on something then off something.
Adam M. Brufsky, MD, PhD: Yes, I kind of agree with you on that.
Lynn Acierno, BSN, RN, OCN, RN-BC: Patients don’t want to break up with us.
Adam M. Brufsky, MD, PhD: They don’t. They want to stay.
Lynn Acierno, BSN, RN, OCN, RN-BC: They want to be managed.
Adam M. Brufsky, MD, PhD: Especially if they have high-risk disease, I would agree with you. It’s a real balance. Part of me goes, “They don’t want to do the break-up thing.” But part of me goes, “You’re kind of tired. You want to be over it.” You want to say, “My cancer’s done and I want to get back to my life.” Right? There’s always that tension. I’m really curious to hear your opinion on this?
Lynn Acierno, BSN, RN, OCN, RN-BC: In my experience, most patients feel more comfortable knowing that they’re being managed, every ache and every pain. Every “Could it be my cancer?”
Adam M. Brufsky, MD, PhD: Right.
Lynn Acierno, BSN, RN, OCN, RN-BC: And “If I’m not taking anything, then it must be.”
Adam M. Brufsky, MD, PhD: My rule on that is, if you want to go see a chiropractor, see me first. Everybody gets aches and pains, especially as we get older. But if it’s the kind of pain where it’s in your bone, it gets worse and worse, it’s nagging, and it gets worse when you lay down, it could be something serious. I’ve picked up a number of metastatic diseases that way, from people who say, “Oh, yes, I just went to the chiropractor and it didn’t get better.” I say, “We should do a bone scan and see if something happens.”
I think that it’s really important to make the point that patients don’t want to break up. I think they do like that safety net, especially if they are ER-negative and don’t have tamoxifen or Arimidex or something else to go on for another 2 or 3 years when they’re done with their Herceptin.
Lynn Acierno, BSN, RN, OCN, RN-BC: That’s my experience. They don’t want to end the relationship.