Patient Advocate Program Alamo Breast Cancer Foundation
2016 San Antonio Breast Cancer Symposium
Although extremely busy and exhausting, this was truly an inspiring and amazing learning experience. There were 36 breast cancer (including one other MBC survivor/advocate) patient advocates from around the world. They have no agenda in the scientific community other than looking for the best science; they have no conflict of interest. Their perspective cannot be duplicated by the doctors who care for them or the scientists who search for answers, even if these doctors and scientists too are patients. A lay advocate perspective is key to moving forward to help end breast cancer.
The SABCS and Patient Advocate Program take place in early December of each year at the Henry B. Gonzalez Convention Center in San Antonio, Texas. By attending this conference, patient advocates learn about the most recent breast cancer research so they can disseminate the information to their local organizations. ABCF is privileged to be associated with the SABCS, the largest single cancer conference in the world.
ALAMO BREAST CANCER FOUNDATION HOT TOPIC
Managing Metastatic Estrogen Receptor-Positive Breast Cancer
One major requirement for those accepted into the Alamo Breast Cancer Foundation Patient Advocacy Program at the San Antonio Breast Cancer Symposium (SABCS) is to sit in on one of the SABCS general or plenary sessions and write a review article, in lay terms, for the general public. The topic I was given was to review was the plenary session entitled “Management of metastatic ER+ Breast Cancer” that was presented by Dr. Steven Johnson from the Royal Marsden Hospital London, United Kingdom.
Estrogen receptors, which are activated by the estrogen hormone, are defined as a group of proteins which are found inside and on cells. It is estimated that approximately 80% of all breast cancers in women are estrogen receptor-positive (ER+), which means that the hormone estrogen promotes cell growth in these types of tumors, which are usually very successfully treated with hormone (endocrine) therapy.
Metastatic breast cancer can also be referred to as metastases, advanced or secondary breast cancer or stage 4 breast cancer. At this stage the disease has spread beyond the point of origin to other locations in the body. In most instances, metastatic breast cancer usually occurs several years after the primary cancer has been diagnosed. There is no cure for metastatic breast cancer.
Endocrine therapy or the use of tamoxifin and/or aromotase inhibitors play a major role in the first line treatment of estrogen receptor-positive metastatic breast cancer in post-menopausal women. However, their success can be limited because over time they may lose effectiveness as they may develop acquired endocrine resistance.
The goal of managing estrogen receptor-positive metastatic breast cancer is to provide progression-free survival for as long as possible before a more aggressive second line treatment, such as chemotherapy is required. Ideally it will be possible to find an endocrine monotherapy approach to delay acquired resistance.
Ultimately it would be advantageous to better know and understand the optimal sequence for endocrine therapy in the treatment of metastatic breast cancer. The key principles in the treatment of metastatic breast cancer include where the disease is located, the extent of disease, the patient symptoms, the status of the hormone receptor, how long the patient has been without treatment, and how well they are doing. It is then possible to decide if it is an unresponsive or life-threatening disease does it require chemotherapy as the first-line treatment or more likely, if the patient has hormone responsive and non-life threatening disease will an endocrine therapy approach be the best choice for first-line treatment. It is well established that sequential lines of endocrine therapy are an option and if the patient responds well to first-line therapy there is a good likelihood for a positive response for second and third line endocrine therapies.
The peripheral conversion of androgens to estrogen by the aromatase enzyme in postmenopausal women on endocrine therapies will activate the hormone receptor which will trigger growth of the tumor. The goal of all endocrine therapies is to prevent the proliferation of tumor growth. Recently some definitions have been accepted to better define endocrine resistance. Primary endocrine resistance can be defined as those patients who relapse early on into treatment. In comparison those patients who relapse after some benefit from therapy treatment are defined as having acquired or secondary resistance. These patients may be sensitive to other endocrine therapy approaches. Resistance to endocrine therapy is one of the most challenging clinical situations.
In recent years, clinical trials have shown that the CDK4/6 inhibitors are successful in significantly extending progression-free survival in all sub groups of ER+ metastatic breast cancer. This raises the question if this in combination with an aromatase inhibitor should become a new standard of care for all patients as a first-line treatment. It is important to understand how to use all this clinical trial data recently acquired in the treatment of metastatic breast cancer to develop a new standard of care, being careful to realize that the new CDK4/6 inhibitors may end up creating a more aggressive tumor.
Studies on second-line treatment of ER+ metastatic breast cancer using PI3K, TORC and AKT inhibitors are in their infancy and will be studied in depth in the years to come. Preliminary results indicate combination treatments can provide an increase in progression-free survival before the start of more cytotoxic treatments such as chemotherapy may be required.
In conclusion metastatic breast cancer patients are living longer with better quality of life. After recurrence, patients can:
- benefit from 14-16 months, progression-free survival using a single aromatase inhibitor
- incorporating a combination of CDK4/6 inhibitors can increase this to 24+ months
- second-line combination approach with PI3K, TORC and AKT inhibitors may provide an additional 7-9 months, progression-free survival.
Personal Comment
Breast cancer is a disease that can also affect men. Although very rare, slightly less than 1% of all breast cancer is diagnosed in men and approximately 90% of all male breast cancer (MBC) tumors are estrogen receptor positive. More often than not, MBC is diagnosed at a later, more advanced stage compared to women which increases the risk for the occurrence of metastatic breast cancer. This information should also become an integral part of the treatment of male breast cancer.
Submitted by:
Herb Wagner
A Man’s Pink
Brooksville, FL 34613
January 2017
