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Treating Triple-Negative Breast Cancer

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Published on February 28, 2020

Key Takeaways

  • Adding immunotherapy to chemotherapy for TNBC is showing a good response in clinical trials.
  • This combination before surgery offers new hope for treating TNBC.
  • Clinical trials are a viable option for treatment. Ask your doctor about what trials may be suitable for you. 

Can using immunotherapy be the answer for treating the notoriously difficult-to-treat triple-negative breast cancer (TNBC)? Recent clinical trial data shows that adding immunotherapy to chemotherapy can be effective in treating TNBC in the neoadjuvant setting - before surgery. Watch as breast cancer expert Dr. Peter Schmid, from the Royal College of Physicians, shares results from the KEYNOTE-522 trial.

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Transcript | Treating Triple-Negative Breast Cancer

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrea Hutton:              

Hello. I'm Andrea Hutton from Patient Power. I'm here today at the San Antonio Breast Cancer Symposium, the largest breast cancer conference in the world, and I'm very pleased today to welcome Dr. Peter Schmid.

Dr. Schmid:              

Thank you. 

Andrea Hutton:       

Dr. Schmid, you are an expert in the field of immunotherapy. Can you explain to our patients who are coming here—we hear this terminology all the time—what does it even mean?

Dr. Schmid:              

That's a good question. So, we have thought for decades that there's a clear link between the immune system and cancer, because we know cancer cells can occur in our bodies every day. But usually, the immune system deals with them and Hoovers them up. Our immune system is trained to deal with anything that's considered foreign—bacteria, germs that are coming from the outside—and usually tolerates what's the own body, what happens in cancer is cancer occurs from the own body system but can be very foreign. Cancers often use a form of camouflage to hide from the immune system.

And what we're trying to achieve with immunotherapy is we take away this immune protective cloak, we open up the cancer to the eye of the immune system, and the immune system can then come in and tackle the cancer. Now, this is a treatment that is standard of care in many cancers, in skin cancers and lung cancers. And in breast cancer, for once, we were slightly behind. But a year ago, we showed for the first time that in advanced triple-negative breast cancer, if we add immunotherapy to chemotherapy, we can improve outcomes of patients substantially.

Now this year, we were fortunate enough to do a similar trial, but this time in early triple-negative breast cancer, early meaning the cancer is still in the breast and may also be in the lymph nodes under the armpit. And in this situation, we normally give chemotherapy before surgery. And with chemotherapy, we try to make the cancer shrink and hopefully melt away as much as we can.

What we've learned over years is if the cancer is completely gone at the time of surgery, those patients have a fantastic outlook, and it's very rare that they get disease recurrences. On the other hand, if the cancer doesn't completely shrink and doesn't completely go away with chemotherapy, those patients unfortunately have a higher risk of recurrence. What we try to achieve now is by adding in the immunotherapy to chemotherapy before surgery, we wanted to see can we make the cancer disappear more effectively.

We were able to show in this trial that patients have a substantially higher clearance of the cancer from the breast and from the lymph node if you add in immunotherapy, which is fantastic. We saw this especially in patients who had a higher risk with higher stage cancer, larger cancers, or when a cancer had already spread to the lymph nodes. So, those groups of patients where we normally know they are slightly more difficult to treat. 

 What we have to wait for is obviously—does the disappearance of the cancer from the breast translate into a higher cure rate? And we only have about 15 months follow-up in this trial, but we already see the patients who received the immunotherapy seem to be doing quite a bit better. And the early data suggests although this is technically not statistically significant, it looks like we have about a third reduction in the recurrence risk at this time point.

What we'll have to do is we have to follow up those patients and probably in a year's time, we have even more, hopefully more positive, but certainly more robust data on the long-term effects. But the short-term effects are incredibly encouraging, showing that patients who get immunotherapy in addition to chemotherapy have a much better clearance of the cancer from their breasts.

Andrea Hutton:       

So, that's amazing news, because triple-negative breast cancer has been incredibly difficult to treat, but every treatment has downsides. So, what are the side effects of immunotherapy, and how do you handle them?

Dr. Schmid:              

So, that's a good question. We know a lot about immunotherapy from many cancers. And what I often say to patients with chemotherapy, practically everyone gets side effects, but it's sort of a few typical side effects everyone does get. With immunotherapy, it's substantially fewer patients who get marked moderate or even sometimes severe side effects. It's a small group of patients, but it can affect many more parts of the body. And the way I always describe this to patients is sometimes the immune system gets activated a little bit too much and then starts tackling a part of your body.

Now, when we add immunotherapy to chemotherapy as we did in this trial, we see most of the side effects patients experience are chemotherapy side effects. And actually, the added side effects from immunotherapy were relatively modest, and then, if you look at it in terms of statistics, there are few differences. What we do see is more patients develop a change in the function of the thyroid gland, and they may need lifelong tablets to keep the thyroid gland going. We see, in some patients, rash. We see, in some patients, diarrhea. Some folks, we see an inflammation of the lung, which is about in 1 in 100 patients, which is a form of cough.

But these are side effects—for most of these side effects, we have a medication to make them go away in the form of steroids. I call it an antidote, which basically makes those side effects go away. And therefore, from what we have seen so far, yes, it does have some specific side effects, but actually, in the wider context, seems to be very manageable. We haven't learned anything new we didn't know already for immunotherapy, but we do feel also we need to follow-up with these patients for a year or two, three, five years to see are there possible late effects? At the moment, I would be surprised if you saw a substantial change over time, but we need to learn more.

Andrea Hutton:       

And so, this emphasizes the importance of patients enrolling in clinical trials, because this is how we find many of these things.

Dr. Schmid:              

Yes.

Andrea Hutton:       

And is it difficult to find patients? Why don't patients want to enroll? How do we make it easier?

Dr. Schmid:              

So, I think it's, obviously when patients are diagnosed with breast cancer, it's a hugely difficult time. And the majority of patients are in some form of shock and want to get on with treatment as quickly as possible, and just say, “Well, what do I need to do?” And so, patients are sometimes also a little bit vulnerable in that situation and may sometimes feel it's not the right time to talk about trials.

On the other hand, we especially in the triple-negative breast cancer community, the patients are now so well-linked through apps, through patient groups. A lot of patients come to our hospital in London from all over the country, sometimes from outside the country, because they've read about our immunotherapy trials and say, "I Googled breast cancer and I have triple-negative breast cancer. How can I best treat this? I need immunotherapy. I Googled it. We have to go there."

So, I think it is changing, and patients are now much more aware that trials are not there to use patient as a guinea pig. But trials are there first of all to, obviously, advance the treatment options for the future, but often enough, also to hopefully give patients a direct benefit from that treatment. Now, the patients who were on our trial, KEYNOTE-522, they had clearly a better outcome so far that patients who received the standard therapy there. That doesn't mean every single patient did benefit, but on average, patients seem to be doing better on this trial.

Andrea Hutton:       

And how long does it take for something like this to become standard practice at my hospital back home?

Dr. Schmid:              

Well, hopefully not too long. So, the first immunotherapy we established for patients with advanced triple-negative breast cancer, we presented the data in around October time 2018. The FDA, which is the regulatory authority in the USA, approved the drug in March. In Europe, we got the drug approved at the end of August. And from that moment on, it's standard of care. So, it took between 6 to 12 months to get those treatments then into the clinic. But this was based on what we call a definitive trial—a large enough trial to clearly establish there was a benefit for patients.

Andrea Hutton:       

Wow. So, we look forward to that as well.

Dr. Schmid:              

We hope to see this soon for our early breast cancer as well. 

Andrea Hutton:       

Well, these are all the kinds of things that this kind of knowledge and expanding our knowledge brings patients hope. So, we thank you for offering that as well.

Dr. Schmid:              

Thank you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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