Management of Triple-negative Breast Cancer



Adam M. Brufsky, MD, PhD: The next thing we’re going to talk about is triple-negative breast cancer. It’s a tough subject because of the way we have defined it. Doctors define triple-negative breast cancer as all cancers that are not ER-positive or HER2-positive. The problem is, the tests may not have worked. So, 5% of the time, I have found patients who were probably HER2-positive and we didn’t know it. In my practice, for anyone who comes in with triple-negative breast cancer, if there’s even a hint that they’re HER2-positive, I make you re-do testing. It’s a pain because you’ve got to go get the block, and the patient’s waiting to figure out what happens.

So, that’s one thing: defining it. And the problem is, once you define it, there are multiple subtypes of it. There’s patients who are BRCA-positive, when we see them. That’s 1 subtype of triple-negative breast cancer. There’s triple-negative breast cancer that appears to respond to immunotherapy. There’s a triple-negative breast cancer in which we may give people antiandrogens. It’s like ER-positive breast cancer, but it’s for the AR [androgen receptor]. There’s all of these subtypes, and it’s hard to lump everything together. But, right now, the only thing we do is chemotherapy.

Those people come in. Most of them get neoadjuvant chemotherapy. The bigger thing with triple-negative breast cancer is, it’s got such a bad reputation. People must talk to you, and they must go, “Oh my, I’ve got triple-negative breast cancer. I read this thing on the internet. I’m done. I’m going to die in a year.” How do we handle that?

Lynn Acierno, BSN, RN, OCN, RN-BC: When we do our teaching and we tell them about the drugs and how they work, we tell them that we’re going to continue along this path with these drugs. We’re going to restage them. We’re going to follow them and make changes, as necessary. I’ve had patients who’ve been very concerned because they have felt like they have no options because they were triple-negative.

Adam M. Brufsky, MD, PhD: That’s a big one. “I can’t get tamoxifen. I can’t get Herceptin. I’m done.”

Lynn Acierno, BSN, RN, OCN, RN-BC: Yes. I always try to stop that, right there, because there’s so many things we can do. Just knowing how much research we’re involved in, I believe that there’s so many things on the horizon. If we’re treating you and we’re following you, perhaps something that may not be available today might be available in a couple of weeks, or a couple of months from now.

We’re there to encourage them and let them know that we’re doing the best we can with what we have available. And there’s always more that’s being worked on.

Adam M. Brufsky, MD, PhD: That’s an important thing. I think that’s really important. No matter whether you have early-stage triple-negative breast cancer, or late-stage triple-negative breast cancer that’s relapsed, there’s always something to do. That’s really important for us to convey. It’s very easy, as a doctor, to talk to providers, and to throw up your hands and say, “All right, go in hospice. There’s nothing else we can do.” There’s always something you can try.

Lynn Acierno, BSN, RN, OCN, RN-BC: I’ve told patients that I’ve never, ever, ever, ever heard you say that, “I’m done, I’ve got nothing left.” You always have something. There’s always something.

Adam M. Brufsky, MD, PhD: Sometimes, however, you don’t want to torture people. I tell that to them, my patients. As you know, we get to a point where no matter what we do, unfortunately, it’s just not working. At some point, people usually tell me, and I let them give me the lead, “I’m done. I just want to live whatever time I have left and be comfortable.” We don’t want that to happen but, unfortunately, in triple-negative disease, it happens more than we’d like. But, on the other hand, there’s always something to do. Even when you’re in hospice, there’s something you can do. You can always help someone have less pain, less nausea, less side effects. You can help them to be comfortable. That’s key. For people, when you give up all hope of anything and just feel abandoned, that’s what I don’t like. As you’ve worked with me for a long time, you know that’s what I don’t like more than anything.

Lynn Acierno, BSN, RN, OCN, RN-BC: I’ve had patients tell me that one of the best things that you’ve said to them is, “If you still want to fight, I’ll fight with you.”

Adam M. Brufsky, MD, PhD: Correct.

Lynn Acierno, BSN, RN, OCN, RN-BC: I’ve also had patients come right to me, rather than you. Part of the job, of the nurse, is to let them know the resources that are available. We need to let them know about palliative care. It’s important to figure out how we can make them as comfortable as possible, so they can enjoy the time that they have.

Adam M. Brufsky, MD, PhD: Right, and we’re not going to let them down. They just want to know that someone is there. We may not have a ton of things to do, but we’re there. I think that’s key.

Lynn Acierno, BSN, RN, OCN, RN-BC: Yes.

Transcript Edited for Clarity

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