When Nancy Hassen, 61, of Port Townsend, Washington, began having a dull, aching pain in her upper chest in December 2020, she thought it might be acid reflux or a hiatal hernia (when part of the stomach pushes into the chest cavity).
After waking up one morning feeling like she couldn’t breathe, Hassen went to urgent care. The doctor also thought she had reflux but told her if she didn’t get better in a week she would need scans.
“I felt better for a few days, but then the pain came back,” she says.
This time the doctor took a chest X-ray, which revealed that Hassen had a large tumor mass in the midline of her chest that was encroaching on her lungs and esophagus. “I knew something bad was coming,” says Hassen.
Nearly a decade earlier, in August 2012, she had been diagnosed with stage 2B lobular breast cancer. Now it was January 2021, and the cancer was back and had spread.
But Hassen was optimistic. When she had her first bout with breast cancer, she “powered through it,” she says — but this time, she had the support of her new husband (she had recently remarried) and her friends, who had “gone through the exact same thing and are doing really well.”
Making Progress in Targeted Treatments
While there is no cure for metastatic breast cancer, in recent years newer targeted therapies that slow tumor growth without damaging normal cells, such as trastuzumab deruxtecan, or Enhertu, have been making a difference in treatment outcomes.
In a recent trial involving patients with HER2-low metastatic breast cancer, the medication was shown to slow tumor growth for about 10 months, compared with five months in those who received standard chemotherapy. Patients who received trastuzumab deruxtecan survived for 23.4 months, compared with 16.8 months for women with the same mutation who received standard chemotherapy.
New drugs, known as cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors — which include palbociclib, ribociclib, and abemaciclib — have transformed the standard of cancer treatment by interrupting cancer cell growth, according to an analysis published in 2021 in JCO Oncology Practice.
When combined with endocrine therapy, which blocks hormone receptors on cancer cells so that they don’t grow and multiply uncontrollably, CDK4/6 inhibitors significantly increase progression-free survival, or the time it takes before the cancer spreads further, in women with advanced metastatic breast cancer who are hormone-receptor positive, like Hassen.
In a study published in 2021 in Nature Medicine, dalpiciclib, when combined with the estrogen blocker fulvestrant, doubled progression-free survival and reduced the risk of disease progression or death by 58 percent, compared with using fulvestrant alone.
After receiving palbociclib and fulvestrant for six months, Hassen’s tumor has shrunk from about 9 centimeters (the size of a drink coaster) to 3 millimeters (the size of a pencil-top eraser).
She had a scan in May and says that they couldn’t even measure the mass because it was so small. “It was like a haze on the screen,” she says. “I had a good response.”
More Women Are Living Longer
In 2021, the estimated number of women in the United States living with metastatic breast cancer rose to about 168,000 from 155,000 the year before, according to the Breast Cancer Research Foundation. The good news is that survival rates are also climbing.
According to an analysis published in 2020 in the Journal of Cancer Research and Clinical Oncology, which included more than 1,030 women with metastatic breast cancer, survival rates rose from 24.42 months to 37.8 months over the course of the last two decades.
And according to Hannah Linden, MD, clinical director of the breast cancer program at Seattle Cancer Care Alliance and a joint member of the clinical research division of the Fred Hutchinson Cancer Research Center, advances over the last few years have also led to a decrease in the risk of the breast cancer coming back and a lengthening of the time before a relapse.
Dr. Linden says that staying on endocrine (hormone) therapy is key to preventing hormone-positive cancers from growing — despite the side effects, which can be easily managed.
“What’s interesting, and truly amazing, is that five years of endocrine therapy is kind of a way to help ensure that the cancer does not come back — and that effect is not just durable, it increases over time, despite the fact that after five years most people are off all therapy,” says Linden.
New research is focusing on whether hormone therapy can even be extended past five years in women with a high risk of the cancer returning.
“There are some patients who live a long time with metastatic breast cancer and can die from a different disease. It is unusual, but we see it,” says Linden.
Hassen, who is being treated by Linden, hopes to be one of those patients.
“I believe in science and that my cancer will be manageable,” says Hassen. “I have now one job — to survive and live,” she adds.
It was during the pandemic, in June 2020, that Erica D. Porter, 47, a professional wrestler with Women of Wrestling and owner of Endorphasm, a physical fitness center in Richmond, Virginia, was diagnosed with stage 4 metastatic breast cancer that had spread to her bones and lungs. She had a lingering cough and was short of breath, which she originally thought was due to COVID-19. But despite the diagnosis of metastatic breast cancer, she believes she has a long road ahead of her.
“Maybe this will take me out, but I don’t feel like it is going to be in the next 10, 20, or 30 years,” says Porter. She is being treated with palbociclib and an aromatase inhibitor, which lowers the estrogen levels that fuel the growth of breast cancer cells.
Since receiving this treatment, and after eight rounds of chemotherapy and radiation, there has been no sign of the cancer in Porter’s lungs, and her bone metastases have not progressed and are stable.
Porter also relies on daily exercise to help her deal with the illness both physically and mentally.
“Fitness is leading me through the battlefield every day,” she says. “Every rep, every deep breath I take is another body blow to this opponent, and I intend to keep its ass against the ropes.”
Detecting Cancer Types with Better Screening
New screening scans and biopsies are contributing to more favorable outcomes, says Erica Mayer, MD, director of breast cancer clinical research at Dana-Farber Cancer Institute and associate professor of medicine at Harvard Medical School in Boston.
Since newer medications are only effective when targeting certain cancers, getting tumors checked by a biopsy to look for unique aspects of the tumor is critical.
“A good proportion of patients are found to have a tumor type for which appropriate medications can be available for them,” Dr. Mayer explains. In addition, she says that without this kind of testing, doctors may wind up treating a cancer with the wrong medication.
Unfortunately, “biopsies are not done in half the cases,” according to an abstract Linden and her coauthors presented at the 2022 American Society of Clinical Oncology meeting.
“It is pretty frustrating. Sometimes the biopsies are omitted and a big assumption is made that is not always correct,” says Linden. “It is wrong not to make a precise diagnosis of a patient. They might have cancer, no cancer, or a different type of cancer,” she says.
When biopsies can’t be obtained because of a tumor’s location, doctors can test a sample of blood, known as a liquid biopsy, to look for cancer cells from a tumor. This test can also find pieces of DNA from tumor cells, so that any “actionable” mutations can be treated.
New types of positron emission tomography scans, or PET scans, can now be used, according to Linden, that are “kind of like a whole-body tumor burden biopsy to assess estrogen-receptor status and help determine whether to use endocrine-based therapy versus chemotherapy.” In a study published in 2021 in The Journal of Nuclear Medicine, researchers studied 83 patients with breast cancer who had undergone one of these scans and found that in 87 percent of cases the scans helped physicians plan a more accurate treatment.
Pairing Targeted Treatments With Holistic Therapy
Success in treating and managing metastatic breast cancer doesn’t just come down to using new kinds of tests and drugs.
Alternative strategies, such as acupuncture, yoga and exercise, and nutrition, can help with therapy-related side effects or improve a person’s sense of well-being, notes Mayer.
While these strategies may help patients tolerate treatment better, Mayer says to check with your doctor to make sure what you choose is helpful and doesn’t interact with your overall treatment.
“Without fitness, I would most certainly be battling depression and physical ailments typically associated with the aggressive chemotherapy and radiation that have been a part of my treatment plan,” says Porter.
That’s why she created the Endorphasm Foundation — to empower cancer patients to move past obstacles in their life with “the healing power of movement.”