I can’t tell my mother that like my mom I can’t die before my mom. I can’t leave my daughter I had to stop practicing and I really felt adrift like why am I using up oxygen on this planet? It was crazy because, number one, I felt stupid. I’m a physician. I should know about the 25 to 35% of people with an early stage especially hormone receptor positive diagnosis will eventually become metastatic.
I was like, what? Like I’m five years out. I should be cured. It really hit me hard. If you’re treated by a community oncologist who might be seeing a patient with lung cancer at 9 am and three breast cancer patients in a row at 10 am starting at ten, but two of them are early stage.
They might have one or two people with metastatic breast cancer in their whole practice, and they’re doing everything lung, colon, you know, blood cancers. They’re not going to be up to date on what is happening. For more than 20 years we thought that HER2 was either positive or negative, and positive was about 20% of the tumors that were very aggressive that needed to be treated with chemotherapy, with many agents against HER2.
The other 80% was treated very differently. But what happened is that in that 80%, we knew that even if we called it negative, there was some HER2 just not enough to call it positive.
So nowadays more than half of all patients with breast cancer are called HER2-low because they have an expression of one plus or two plus non amplified. And what was impressive to see at ASCO is that in this very large population of patients delivering chemotherapy with this new class of drugs that we call antibody drug conjugates and with the drug in particular is called with a very long complex name trastuzumab-deruxtecan, for friends T-DXd or Enhertu, the commercial name was very effective much more effective than traditional chemotherapy. And so this drug has been approved in August 5th and is now available and we use it to treat many patients with metastatic breast cancer.
And the impact has been very large, not only because this has improved the shrinkage of or the duration of the response but also the survival of patients with metastatic breast cancer. HER2 was originally the cancer that, oh my God, HER2 is so aggressive and people just don’t do as well.
Then Herceptin came along, then Perjeta came along and now these new things called antibody drug conjugates They have made a huge difference to the point where those of us that have ER positive disease are going, oh God, I wish I was HER2 positive because there’s so many more options and things that are working really, really well. But again, I think what we’re learning in some of the data from these trials, looking at HER2-low is if you have a really high level of HER2, your HER2 positive, HER2 three-plus the drug is going to work really for a lot of people can work really, really well. If it’s two plus it’s still going to work well, but maybe not quite as well.
And then one plus and zero. But there even might be some, some efficacy, it might work.
And even people who have no HER2 overexpression. The thing is that in this setting metastatic breast cancer we really need options because so many times patients run out of treatment options. We use all the most effective treatments that we have endocrine treatment, taxane, capecitabine, biologic agents anthracyclines. And in the end we really don’t have any more effective options. Sometimes we have to recycle chemotherapies and in this setting we really would like to use a drug that is proven to be efficacious and even to improve survival in our patients.
I think one of the things that’s important for patients to know is that you can look back on biopsies from maybe your original breast cancer diagnosis or if you were diagnosed with Mets from the get go, de novo metastatic disease, if you had a biopsy that can be looked at to see, okay, do I have a little bit of HER2? Do I have none at all? And then that opens up this whole avenue of these new antibody drug conjugates as a treatment option.
I think that’s really exciting because the more options we have the better. Talk that I’m giving today as part of a panel on patient-reported outcomes, which are opportunities for patients to describe how they’re feeling what symptoms they’re experiencing, what psychosocial challenges they might have that might prevent them from optimizing their breast cancer journey.
There’s diversity across different communities. Many of the Black women who aren’t participating in clinical trials, it’s not necessarily that they need more socioeconomic help. It’s that they need to have faith in the healthcare system that has let down Black people for generations.
Many of the women who choose not to participate in clinical trials, who are African American it’s not because they can’t afford to do so. It’s that they have a justified mistrust in the system, a system that has not earned the trustworthiness of people of color.
I think that descriptions of trial results matter. Words matter. I just had a conversation today that some of these trials cost a billion with a B dollars. And if you don’t have advocates involved early to make sure your design is going to be palatable to patients, that the questions you’re asking makes sense to provide treatments to make lives not only longer, but better. You’re wasting time.
You’re wasting money. You’re wasting lives. You’re an advocate You’re an advocate for yourself. If you were that PTA mom that raised the money through the bake sales to get a new playground for your kid’s school well, you’d be great at fundraising for support groups, for research, etc.
If you’re that person that goes to the city council meetings is going, Why are you putting a stop sign here?
Then maybe legislative advocacy, you know, trying to get bills passed locally or nationally to help benefit the metastatic community Is your place. But everybody has a place and everybody has a role..
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