What to Consider When Choosing Treatment

By Wade Smith, MD, as told to Kara Mayer Robinson

A diagnosis of HER2-positive breast cancer can be frightening at first, especially when you hear the words “aggressive cancer.” But there’s reason to be optimistic about today’s advances in treatment. There isn’t a one-size-fits-all approach, but with the help of your doctors, you can choose what’s best for you.

Your Treatment Is Unique

HER2-positive breast cancer is different from other breast cancer types, so your treatment won’t necessarily be the same as someone else who has a different form of breast cancer. It may also be different than another HER2-positive patient’s therapy.

Each cancer is unique, so doctors try to develop the treatment course that’s best for you. Things to consider include the size of your tumor, whether the cancer has metastasized (spread), or your overall risk of recurrence.

Treatments You May Consider

The most common treatment for HER2-positive breast cancer is chemotherapy plus HER2-directed therapy. This is followed by surgery, then continues with HER2-directed therapy. This is often best for patients with large tumors or cancer in regional lymph nodes.

For targeted therapy, your doctor may recommend a family of drugs commonly known as monoclonal antibodies. This includes trastuzumab (Herceptin), the first-in-its-class precision therapy drug approved by the FDA for HER2+ breast cancer.

It’s less common, but you may have surgery first, followed by chemotherapy and HER2-directed therapy. Your doctor may choose this sequence if you have a small tumor that isn’t in your lymph nodes.

Your doctor may also recommend endocrine therapy. This treatment involves taking a daily pill for at least 5 years after you complete chemotherapy and surgery.

Pros and Cons

Each treatment has pros and cons, and you may be a candidate for some types of treatments but not others.

Here are some things to consider:

• Chemotherapy is highly effective, but it’s known to cause side effects during and after treatment. These side effects vary in type and severity based on the prescribed drug. The most common side effects are hair loss, nausea, and vomiting.
• Chemotherapy and HER-2 directed agents are highly effective together.
• A benefit of trastuzumab (Herceptin) is that it’s given intravenously (through an IV) and can usually be given at the same time as chemotherapy.
• If you’re pregnant, you can’t take trastuzumab (Herceptin).
• If you’re breastfeeding or plan to breastfeed, you shouldn’t take trastuzumab (Herceptin).
• Trastuzumab (Herceptin) and related HER2-directed therapies may cause serious heart problems.

Cost of Treatment

If you’re concerned about the cost of your care, talk to your care team. Most approved cancer therapies are covered by insurance. But if you feel overwhelmed by coverage issues, ask for help.

One of the many benefits of receiving care from a top-ranked facility that specializes in cancer is that they can help you navigate the process.

Clinical Trials

Even with all the available therapies we now have, there’s always more to discover. Not only do clinical trials help us make scientific advances, they may also benefit patients.

Your doctor may recommend a clinical trial if they believe you’ll respond best to a new therapy or combination of therapies. If your specialist recommends a clinical trial, it may be a good option for you.

Make sure you understand what the trial involves. Talk to your care team.

Use Reliable Information

Always ask questions of your care team and focus the conversation on your particular case.

Remember that your diagnosis is unique. Use caution when you read advice from online discussion groups, bulletin boards, and social media. These resources can provide some support, but they may also have untrue or outdated information.

Talk to Your Doctor

It’s very important that you’re comfortable with your doctor and that you have a doctor who listens to you and addresses your concerns.

I recommend going to a research-based cancer center to get treatment, a second opinion, or both.

Find a care team that specializes in your type of cancer. Highly specialized physician-scientists stay up to date on new treatment options, which is important because cancer is complex.

Learn what you can about HER2-positive breast cancer and ask questions. You may want to write down questions before your appointment.

During your appointment, take notes or ask if you can record the conversation on your phone. Tell your doctor how much information you want and don’t be afraid to speak up if you don’t understand something that’s being explained.

I also recommend that patients involve their families in their decision-making. Technology gives us a lot of good options for including family or friends in the process. Telehealth and apps like FaceTime both make involving family members in a visit more convenient.