HER2+ Early-Stage Breast Cancer

Treatment Options

Significant improvements in treating HER2+ early-stage breast cancer have occurred in the past 10 years. Recent advances have changed this cancer from having a poor prognosis to having one of the best among breast cancers. A noteworthy change came in 2012 with the introduction of targeted therapies designed for HER2+. Today, they offer hope to many women.

Many studies, such as imaging, bloodwork, genetic tests and biopsy results, can contribute to determining the best therapy. To personalize your treatment, your doctor will take into account your age, general health and menopausal status, as well as the size of the tumor, its biomarker status (ER, PR and HER2), the stage of the cancer and, for some patients, genetic markers such as BRCA1 (breast cancer 1) and/or BRCA2 (breast cancer 2) mutations.

HER2+ early-stage breast cancer is typically treated with a combination of therapies that may include surgery, targeted therapy, chemotherapy, radiation therapy and/or hormone therapy (if you have hormone receptor-positive disease). You may also be a candidate for a clinical trial, which may give you access to therapies, such as immunotherapy, that are still being researched. Following are descriptions of common treatment options for HER2+ early-stage breast cancer.

Surgery

Surgery is typically the first treatment option used for most early-stage breast cancers, including HER2+ breast cancer. However, your doctor may choose to treat your breast cancer with targeted therapy, chemotherapy or radiation therapy before you have surgery. This is called neoadjuvant (preoperative) treatment and may be used to shrink a tumor so it can be more easily or safely removed with surgery. Often, neoadjuvant/preoperative therapy is offered in order to shrink a large breast tumor so that you might have more surgical options, including breast-sparing treatment (lumpectomy and breast irradiation therapy).

Treatment given after surgery is known as adjuvant therapy. Whether delivered before or after surgery, an important goal of systemic therapy (drug therapy that travels throughout the body, such as hormone/endocrine therapy, chemotherapy and/or targeted anti-HER2 therapy) is to destroy breast cancer cells that may be hiding in other organs of the body, such as the liver, lungs, bones or brain. These hidden cancer cells are called micrometastatic disease, which is usually too small to detect with laboratory testing or imaging studies. Delivering carefully selected systemic therapy to appropriate patients can often completely eradicate micrometastatic disease and is, therefore, extremely important as a partner with surgery for breast cancer in rendering a patient disease-free.

For surgery, lumpectomy/breast conservation and mastectomy are the two main options. Axillary surgery, such as a sentinel node biopsy or axillary dissection, is often done along with the breast surgery.

A lumpectomy removes only the tumor along with a small margin of normal-appearing tissue around it. It is considered breast-conserving or breast-sparing. It is used for early-stage breast cancers detected as small tumors, which include Stages 0, I and II (see Figure 1).

Lumpectomy is usually followed by breast radiation treatments, which are designed to kill microscopic cancer cells hiding in other parts of the breast. If your tumor is relatively small and you wish to spare as much of your breast as possible, this surgical plan may be an option. Some patients are considered to be poor candidates for a breast-conserving lumpectomy because of abnormalities seen on their breast imaging (mammogram, ultrasound) or because of the inability to receive radiation treatment. It is also important that you discuss the likely cosmetic outcome of breast-conserving surgery with your doctor because radiation can cause some shrinkage of the breast.

Figure 1

A mastectomy involves removal of the entire breast and may be the preferred surgery for larger tumors, especially when they occur in a smaller breast (see Figure 2). Several types of mastectomy exist, including total mastectomy and modified radical mastectomy. Total mastectomy is the surgical removal of the entire breast without removing muscle. A modified radical mastectomy means that the total mastectomy is being performed along with removal of a block of underarm/axillary lymph node tissue (axillary dissection). You may need drains following this surgery, and your health care team will give you information for drainage care, if applicable.

Most mastectomy patients will be candidates for breast reconstructive surgery performed by plastic surgeons, which often is performed immediately after the mastectomy, during a single operation. Mastectomy patients undergoing immediate reconstruction may be eligible for enhanced cosmetic approaches, such as skin-sparing or nipple-sparing mastectomy. After the incisions have healed, outpatient radiation treatment to the breast may be necessary for cases of high-risk breast cancer.

Chronic nerve pain, known as post-mastectomy pain syndrome (PMPS), is a possible side effect from a mastectomy. The most common areas to feel this pain are in the chest, armpit and/or arm. Symptoms of PMPS include tightness, burning, tingling or itching in these areas. In addition, the surgical site may also have numbness or may be extra sensitive. Tell your doctor about your pain or disability to ensure your PMPS is managed as effectively as possible. PMPS will not go away without treatment.

Another possible side effect from a mastectomy is phantom limb pain. Your brain may treat your mastectomy site as if the breast were still present. You may feel nipple or breast pain. This can be temporary and can linger for a long time. Over time, the brain adjusts to understanding the absence of the breast.

Figure 2

Reconstruction is an option for many breast cancer patients (see Reconstruction ). Having your body look as it did (or as close as possible) before cancer may be part of your healing process. If you prefer, a breast prosthesis is another option. Talk with your surgeons, nurse navigator and other members of your health care team. Ask questions about the procedures, recovery times and potential side effects, as well as the pros and cons of surgical vs. non-surgical options. It’s your body, and you should make the decision that makes you most comfortable.

Lymph node surgery is usually necessary to either stage the cancer or to control cancer that is known to have spread to the nodes. The underarm (axilla) is the most important location for management of lymph nodes in breast cancer patients as it is the most common site of spread of breast cancer.

Most women with early-stage breast cancer undergo an initial staging procedure of their lymph nodes at the same time as their breast surgery. This staging procedure is called a sentinel lymph node biopsy. If the sentinel nodes contain a tumor, sometimes a more extensive operation to remove additional tissue from the underarm may be necessary, and this is called an axillary lymph node dissection (see Figure 1, above). In some circumstances after a lumpectomy, if the patient is receiving radiation therapy and systemic therapy after surgery, no further axillary surgery is recommended even when there are metastases in the sentinel node. Some patients will have cancerous axillary lymph nodes detected by a needle biopsy performed prior to their breast surgical procedure. If a needle biopsy reveals a metastatic lymph node, then neoadjuvant (preoperative) chemotherapy may be recommended, and if the neoadjuvant chemotherapy is successful in clearing/killing the axillary lymph node disease, then the axillary lymph node dissection may be avoided.

After surgery to remove breast cancer and breast reconstruction surgery, exercising is an important part of your healing process to increase mobility, promote circulation and reduce stiffness and scar tissue. Your doctor will likely give you recommended exercises. You can typically begin with gentle stretches, such as shoulder rolls or arm circles two or three days after surgery. You may follow up with additional exercises to strengthen your muscles as you feel able. If you had an exercise routine before surgery, don’t simply pick up where you left off. Before resuming any pre-surgery workouts, talk with your doctor.

Targeted Therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells. Targeted therapy drugs that specifically treat HER2+ breast cancer are known as anti-HER2 agents, or HER2 inhibitors. These target and attach to specific parts of this type of cancer cell to interfere with or stop its growth.

This type of treatment may be used before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). Some patients will be candidates for extended adjuvant therapy, which is designed to further reduce the risk of tumors recurring.

Your doctor may prescribe more than one type of HER2 inhibitor based on your diagnosis. Research shows that HER2+ treatment is more effective when combined with chemotherapy. It is important to be aware that during your treatment, your doctor may feel the need to periodically change your regimen to keep it working most effectively for you.

Chemotherapy

Chemotherapy is the use of drugs to stop the growth of cancer cells either by killing them or preventing them from dividing and growing. For early-stage HER2+ breast cancer, chemotherapy may be given as a combination of two or three drugs together or one after the other.

It may be given before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). When given before surgery, it may be used to shrink a tumor so it can be surgically removed or to reduce the tumor’s size to allow for a lumpectomy rather than a mastectomy. It may also permit you to avoid having an axillary dissection if nodal disease is eradicated. Neoadjuvant chemotherapy also has an advantage of helping your doctor determine how well the chemotherapy drugs work against the tumor. Adjuvant chemotherapy is given to destroy cancer cells that may remain after surgery, some of which may be too small to be detected with laboratory testing or imaging studies.

Chemotherapy can be given orally or intravenously (IV) through a vein in your arm. Or many people have a port placed so they can receive the medicine without repeatedly being stuck with a needle or damaging their veins. A port is surgically inserted under the skin in the upper chest area or arm to gain easy access to veins. Once chemotherapy ends and you no longer have the need for easy access to your veins, the port is removed. Your medical team will show you how to care for your port if you receive one.

Radiation Therapy

Radiation therapy is another treatment used to treat breast cancer and may be necessary along with surgery regardless of whether your tumor is HER2+. Radiation therapy is usually recommended after a lumpectomy to destroy any cancer cells that may remain hidden in normal-appearing breast tissue. Research shows that women with a small tumor who have radiation therapy after a lumpectomy live as long as those who have a mastectomy. Radiation therapy is sometimes necessary after a mastectomy and is typically recommended for individuals at high risk for cancer recurrence on the chest wall, such as women with cancer in multiple axillary lymph nodes or a large cancer.

 

The most common type of radiation therapy is external-beam radiation therapy (EBRT). EBRT is delivered from an external machine.

Internal radiation, or brachytherapy, may also be used either alone or in combination with EBRT for lumpectomy patients. Brachytherapy involves placing radioactive seeds through a catheter into the breast to deliver radiation directly to the area where the tumor was removed.

Hormone Therapy

Hormone therapy, also known as endocrine therapy, may be included in your treatment for HER2+ breast cancer if your disease is also estrogen receptor positive (ER+) or progesterone receptor positive (PR+). Hormone therapy treats these types of breast cancer by either lowering the amount of estrogen in your body or by blocking the hormone receptors on the cancer cells. Many types of hormone therapy drugs are available.

 

Clinical Trials

Clinical trials may also be an option to consider. Many advances in cancer treatment that are saving lives today are due to therapies that were tested in clinical trials. Trials for many types of treatments, including immunotherapy, which uses the body’s own immune system to fight cancer cells, are underway.

Resistance to Treatment

Resistance to treatment occurs when breast cancers stop responding to treatment and begin to grow again. Resistance may be caused by several factors. The promising news is that if disease progresses during treatment, a different drug may be an option. Scientists are experimenting with different drug combinations, developing new drugs and evaluating the order in which drugs are given (sequential treatment) as ways to address drug resistance. Tests are being developed to target certain mutations in an individual’s tumor.

 

Medication Adherence

Taking the right dose of the right drug at the right time on the right schedule is referred to as medication adherence. This is very important while on adjuvant and extended adjuvant therapy for HER2+ breast cancer.

If you don’t follow your scheduled regimen exactly as prescribed, it’s called non-adherence. Often, non-adherence is unintentional. If you miss one or more doses of your medication because you forgot to take it, let your health care provider know.

You may be tempted to stop taking the medications to avoid uncomfortable side effects, but it’s in your best interest to continue them to prevent a recurrence. If the side effects are so severe that they disrupt your daily life, talk with your doctor, who may be able to adjust your dosage or prescribe other treatments to lessen the symptoms so you can stay on your medication schedule as planned. Don’t stop taking the medication without consulting your doctor first. Options for reducing the symptoms may be available.

 

Understanding and Preventing a Recurrence

During and after treatment, you may worry that the cancer may return at some point. Understanding what recurrence is and how to minimize your potential risk may help you manage that fear.

Although many women will be treated successfully for their breast cancer, some women will experience disease relapse or recurrence. Breast cancer can recur in different ways, and sometimes in multiple ways. Local recurrence refers to regrowth of the cancer at the site where the prior surgical removal was performed, such as the lumpectomy bed or the mastectomy scar. Regional recurrence refers to cancer growing back in the lymph nodes of the axilla or just above the clavicle (collarbone). Distant recurrence refers to metastatic spread of the breast cancer to other organs that becomes clinically apparent (either by causing symptoms or being visible on body imaging such as a CT or PET). A cancer in the opposite breast is usually a new, unrelated cancer.

After treatment ends, your doctor will monitor you for any recurrence with a follow-up plan that includes regularly scheduled exams, along with blood tests. It’s important to tell your doctor at the exams or between appointments if you notice any health changes or new symptoms. After being monitored continuously during treatment, you may be concerned that only having blood tests at intervals to monitor for recurrence is not enough. This is the norm. Of course, if you have additional symptoms or are at higher risk for recurrence, scans or other tests may be ordered. Mammography will be done to monitor both breasts after lumpectomy to detect a recurrence or new cancer.

In the meantime, medications for HER2+ breast cancer are available to help avoid recurrence. Keep in mind that these medications are designed to be taken for many months, which can be difficult if the side effects are challenging. Your doctor has prescribed these medications to limit the risk of recurrence, and it’s crucial to continue your treatment uninterrupted. Your health care team will work with you to manage side effects, so be sure to let the team members know if any new symptom begins.

 
Commonly Used Medications
Targeted Therapy
ado-trastuzumab emtansine (Kadcyla)
pertuzumab (Perjeta)
trastuzumab (Herceptin)
trastuzumab-dkst (Ogivri)
trastuzumab-dttb (Ontruzant)
trastuzumab-pkrb (Herzuma)
trastuzumab-qyyp (Trazimera)
trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)
Extended adjuvant therapy
  • neratinib (Nerlynx)
Chemotherapy
cisplatin
cyclophosphamide
docetaxel (Taxotere)
doxorubicin (Adriamycin, Doxil)
epirubicin (Ellence)
fluorouracil – also known as 5-FU
ixabepilone (Ixempra)
paclitaxel (Taxol)
Combination Therapies
ACTH (doxorubicin, cyclophosphamide, paclitaxel, trastuzumab)
TCH (docetaxel, carboplatin, trastuzumab)
TCHP (docetaxel, carboplatin, trastuzumab, pertuzumab)
TH (paclitaxel, trastuzumab)
THP (paclitaxel or docetaxel, trastuzumab, pertuzumab)
Hormone Therapy
Premenopausal
  • goserelin (Zoladex)
  • leuprolide (Lupron)
  • tamoxifen
Postmenopausal
  • anastrozole (Arimidex)
  • ethinyl estradiol
  • exemestane (Aromasin)
  • letrozole (Femara)
  • tamoxifen

As of 5/7/19

 

Additional Resources

 

Previous Next

 



Register Now! Sign Up For Our Free E-Newletter!

Read Inspiring Cancer Survivor Stories

Order Your Guides Here