The combination treatment of Herceptin (trastuzumab) and chemotherapy for early-stage, HER2-positive breast cancer may reduce the recur- rence of — and mortality from — the disease by a third, according to study results.

“It’s really important because when a patient gets a diagnosis of HER2-positive breast cancer, immediately the first thought is, ‘This is so bad.’ This is one of the more aggressive cancers. I believe this is why it’s so important to understand that trastuzumab has changed the way we think about HER2-positive breast cancer. This study showed the significant positive impact trastuzumab has had on outcomes in HER2-positive breast cancer,” said Dr. Zahi Mitri, an assistant professor of medicine in the Division of Hematology and Medical Oncology at OHSU Knight Cancer Institute in Portland, Oregon, in an interview with 

. “Patients can actually be confident that their treatment can help them really beat this cancer because this study follows patients for not one or two years, but up to a 10-year follow-up for most patients.”

Of note, HER2-positive breast cancer accounts for 10% to 20% of early-stage breast cancer diagnoses annually.

“One of the biggest takeaways is ... the treatment historically had been chemotherapy alone. And with chemotherapy, alone, we had seen a lot of risk of breast cancer coming back. But ... this study shows that the addition of one drug, trastuzumab, has reduced the risk of breast cancer coming back, and that actually translated into (fewer) people dying of HER2-positive breast cancer,” Mitri said.

Seven trials that assessed chemotherapy plus Herceptin versus chemotherapy alone were included in the study, which had 13,864 participants. The mean scheduled treatment duration was 14.4 months with a median follow-up of 10.7 years. Researchers reported that the risks of breast cancer recurrence, as well as death from breast cancer, were lower with the group treated with Herceptin plus chemotherapy. At 10 years, recurrence risk was reduced by 9%, and mortality rate was reduced by 6.4%.

“It is as clear as it can be that adding the anti-HER2 treatment trastuzumab to chemotherapy and other strategies definitely improved survival for patients with early-stage breast cancer,” said Dr. Edith Perez, a professor of medicine at Mayo Clinic in Jacksonville, Florida, and chief medical officer at Bolt Biotherapeutics, a biotechnology company that focuses on cancer immunotherapy.

Perez, whose trial was one of the seven in the study, said that prior to these results patients didn’t have options for a targeted therapy against HER2 in the early-stage setting. “And I think it exemplifies what can be accomplished with good science and good research and good patient participation in trials,” she said.

In comparison with chemotherapy, Herceptin also had very manageable side effects. “The biggest side effect that we could see — that we monitor for — is an impact on the heart muscle, (which) is rare, meaning single digit. (Fewer) than 10% of (patients) will have an impact on the heart muscle function. And more importantly, it is reversible. ... With interrupting the treatment, it can recover,” Mitri explained, noting that the treatment also doesn’t lead to high risks of infection, nor does it require what he calls “premedication” such as steroids or nausea medication. “I think patients have tolerated this beautifully.”

Mitri added, however, that many of the studies included in the trial used anthracycline-based chemo- therapy — also known as the red devil for side effects such as increased risk for heart damage — which generally has been removed from treatment for this patient subset due to novel effective non-anthracycline regimens.

Herceptin can be given with other chemotherapy agents, or even after chemotherapy as a single agent. “Since we demonstrated the trastuzumab added to the benefit of chemotherapy, further advances have continued in terms of adding a second type of anti- HER2 therapy,” Perez said. “I think the message is that finding cures for cancer ... it’s really a journey. But as we go through the journey, significant progress is being made. And many patients today are cured of HER2-positive breast cancer who would not otherwise have been cured if trastuzumab had not become available.”

For more news on cancer updates, research and education, don’t forget to 

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Rapid Reporter

More than 10 years of follow-up data have shown that combining Herceptin with chemotherapy is safer and more effective than chemotherapy alone in this patient population.

Long-Term Data Show The Impact of Herceptin On Treating HER2-Positive Breast Cancer

"During treatment for breast cancer, I kept two journals: one to write in at night to chronicle the day, and one I wrote in as I sat in the infusion chair or waited for radiation. The journal I carried to the cancer center helped not only with memory and perspective but also with processing feelings right there in the moment." – Felicia Mitchell

"Living with metastatic breast cancer for more than seven years, I have found keeping to a schedule or routine keeps me focused and more in control of my life. There are so many aspects of this disease that are out of my hands. A daily routine helps me to keep going and have purpose and direction in my life. I thrive on consistency, not surprises." – Marissa Holzer

"To stay mentally strong during breast cancer treatment, pretend your body is on a cancer conveyor belt; you will most likely move from therapy to therapy. I started with chemotherapy, then moved to a double mastectomy, then radiation and finally,
10 years of medication (Tamoxifen). I advise that while you’re on this cancer conveyor belt, keep your mind out of it, i.e., don’t obsess. Don’t think about cancer. Before you know it, you will have survived." – Laura Yeager

"My mental health was almost as big a danger for me during cancer treatment as the cancer itself. After learning I had inflammatory breast cancer, within a couple of days I realized I had raging, uncontrolled medical post-traumatic stress disorder due to medical treatments I had received when I was very young. I quickly knew that I had to do two things: First, honor and respect how I really felt without forcing myself to put on a fake happy face so that I could play the socially expected role of the brave cancer patient. In other words, I had to be true to myself. Second, I had to get into regular therapy to try to deal with the twin traumas of having cancer and having to engage with the world of medicine again." – Brenda Denzler

"During treatment, I kept thinking, 'This too shall pass, it is just a bump in the road of my life.' Fourteen years later, I continue to work hard to not let cancer define me. I am a person who had cancer, cancer is not who I am. My self-care includes exercises to help release stress from my body, practicing my faith, counseling, coffee with friends and some hard-to-find alone time. All these things help me focus on not being defined by the fact that I am a cancer survivor. Being mentally strong takes work, and I think we don’t talk about how to do that enough." – Doris Cardwell

"Part of mental strength and resilience is understanding that sometimes life doesn’t go as planned. I let myself feel the fear and disappointment, but I know that there’s only one way to stay alive, and that is to keep moving forward for as long as I can. I have learned to focus on where I find happiness, to stay connected with the people who love me and to keep my dreams alive. It’s easy to get caught up in cancer, but I am a complete person first, and remembering that helps me find balance and strength." – Martha Carlson

Connections

Several breast cancer survivors share how they stay mentally strong while living with breast cancer.

Here's What Breast Cancer Survivors Had to Say About Staying Positive

Claudia Nicholls received a diagnosis of stage 1 breast cancer in 2017. It was what she and her daughter, Kate Nicholls, called "the Cadillac of cancers." It did, indeed, take her for a ride, as she then received a diagnosis of stage 3 and eventually stage 4 breast cancer when she went to Mercy Medical Center in Baltimore for a second opinion.

"That was when we went through kind of the grieving, the sadness and gathering family, but I don't feel like we were stuck in that (phase) for too long," Claudia Nicholls said.

Instead of dwelling on the sadness, Claudia decided to use this time to do something she always wanted to do with the help of her daughter, a professional comedian who moved from Los Angeles to Maryland to care for her. Claudia originally wanted to write a blog about a topic she’s been passionate about for nearly a decade.

“I’ve been salty since 2012 when the movie ‘Argo’ beat out the movie ‘Lincoln’ for best picture, so I wanted to talk about that,” she said.

Kate Nicholls added, “She wanted to make a blog as her bucket list thing. She comes out of her bedroom with a notebook that she had written — handwritten — five pages ... and said, ‘Put this on the internet. Let’s start a blog.’ ‘So basically what you’re asking me to do is type up your ramblings from your notebook and put it on the internet for you?’ I was, like, no.”

Although that’s what Claudia wanted, Kate expanded on this idea to make a podcast to allow her mother to conduct “bucket-list-worthy interviews” using her daughter’s contacts from her comedy and podcast connections. This is when their podcast, “Stage 4 Clinger,” was born.

“The name ‘Stage 4 Clinger’ kind of just came to me,” Kate said. “I was like, ‘What do you think?’ And (my mom) said, ‘Explain it to me.’ I (said), ‘Well, you’ve got stage 4 (cancer) and you’re really clingy.”

Claudia agreed, saying she clings to her kids so it’s only appropriate.

During each episode, which they host together, there are different segments such as “Let Me Get Something Off My Chest,” where Claudia vents about whatever is on her mind, allowing mother and daughter to work out some issues. There is also the segment “Dying to Talk to You.” For this, Kate sets up an interview for each episode and Claudia prepares questions for the celebrity. “(Kate) lets me talk during that segment,” she jokes.

Some of Claudia’s favorite guests include Yassir Lester (“Black Monday”), Neal Reddy (season 1 of “Queer Eye for the Straight Guy”), Rob Huebel (“The Office”), Poppy Liu (“Hacks”), Jon Glaser (“Parks and Recreation” and “Girls”) and Jenn Lyon (“Claws”).

The connection to the guests that they interview doesn’t end when the podcast goes live. Claudia mentioned that they have met some “amazing people” along the way, some of whom have become lifelong friends of Kate and even text her to see how her mother is doing.

Actress Joan Cusack and singer Dolly Parton are at the very top of their bucket list for interviews they’d love to conduct.

They don’t seek out guests who have a connection to cancer, but somehow many guests do.

“It’s amazing to me how many of these people have a parent, best friend or someone who has dealt with cancer,” Claudia said.

“I haven’t reached out to anybody because of their connection to cancer, or at least the ones that I have didn’t respond,” Kate added. “It’s just been people that I think that my mom would enjoy talking to, and then it does turn out that ... everyone has a personal connection to cancer in some way or another.”

Throughout the fun and laughs on their podcast, they use humor as a way to control the situation.

“Instead of whispering about cancer, or acting like ... everything’s so awful, we’d rather laugh and we’d rather bully cancer because cancer sucks,” Kate said. “We’re like, ‘You’re such a nerd, cancer. Get out of our face.’ We’re not fans of cancer, so that’s why we like to be lighthearted about it and make jokes because cancer doesn’t deserve our respect. People with cancer, we respect.”

Claudia added, “And we don’t want to hurt anyone’s feelings. That’s always been a little bit of a concern of mine, but this is how we deal with it. And it has made my life much better.”

Throughout her cancer journey, Claudia credits humor for helping her along the way.

She said, “Now, this is not earth-shattering what I’m going to say, and everybody knows this, but laughter, I swear — we always kid on the podcast, I probably got an extra month (of life) out of this podcast because I’ve been laughing so much.”

Listen to Claudia and Kate's full interview on CURE®'s "Cancer Horizons" podcast 

Features

Combine a mother’s breast cancer diagnosis with her daughter’s comedy background — what do you get? A podcast that laughs in cancer’s face.

The Mother-Daughter Duo That Bullies Cancer With Humor

Tamera Anderson-Hanna credits one thing for helping her to regain strength and quiet her mind during treatment for breast cancer: yoga.

According to breastcancer.org, yoga may improve physical functioning, reduce fatigue, reduce stress, improve sleep and improve quality of life for patients with breast cancer.

For Anderson-Hanna, it all started in 2004 — 10 years before she received her diagnosis — when she stepped onto a yoga mat not long after giving birth to her daughter. She was hooked. For years, she practiced Ashtanga (an energetic yoga with synchronized breath and movements popularized by K. Pattabhi Jois), Vinyasa (a yoga with smoother transitions between poses) and other styles of yoga, but “for some reason, I got back into yoga very strongly ... about the time that I had to go in and get a breast exam,” she said.

She also had signed up for yoga teacher training. Two weeks later, Anderson-Hanna received a diagnosis of breast cancer.

“Everything I knew about yoga, every way I had practiced was kind of turned upside down,” she said. Advanced poses were modified due to her reduced physical strength.
But even then she pushed through, continuing her teacher training and learning a new way to practice that was best for her. “I was training in Vinyasa yoga, but I was able to modify everything. So while they were doing different poses, I found a pose that would work (for) my body, modifying it for surgeries, for post cancer and things like that,” she explained.

Anderson-Hanna was told that she needed chemotherapy, radiation and a lumpectomy but she ended up opting for a double nipple-and areola-sparing mastectomy. “I would say I practiced throughout treatment, but there was a part of treatment where I couldn’t be as physically active. So through pain or just the restrictions of the doctor, the recommendations and when you’ve got drains or other things, I couldn’t have a physical practice,” she explained. During these times, she opted for meditation.

A pivotal moment came after the mastectomy. “You can’t really move, so I had what my daughter and I called ‘little T-rex arms,’” Anderson- Hanna said. Even small things such as feeding herself were impossible. Once she was given the OK by her health care team, however, “yoga really kind of helped me build back up to get range of motion,” she said.

Soon after recovering from surgery, she continued her yoga education with Tari Prinster, who founded the Yoga4Cancer Foundation, and became certified to teach yoga for patients with cancer two years later in 2017.

Today, Anderson-Hanna teaches free yoga classes for patients with cancer through Zoom to help them rebuild strength after treatment or surgery.


When it comes to trying yoga, Anderson-Hanna said, “Don’t judge yourself. You should walk into a class and there should never be judgment.”

A patient turned to yoga during treatment for breast cancer and is now helping others do the same.

How a Patient With Cancer Turned to Yoga During Breast Cancer Treatment

Patients with cancer often face another challenge: financial toxicity. And while demographics like tumor stage and treatment can influence this, one expert says there are ways to mitigate or plan for the costly effects of cancer treatment.

“We need to better characterize (patients with cancer who) are at risk of financial toxicity and identify interventions to mitigate it,” said Dr. Rachel A. Greenup, an associate professor of surgical oncology and chief of breast surgical oncology at Yale School of Medicine in New Haven, Connecticut, in an interview with 

In this study, researchers assessed 571 patients with breast cancer who underwent lumpectomy or mastectomy. The findings demonstrated that elements such as work reduction or cessation, increased out-of-pocket spending and advanced tumor stage were all associated with increased financial distress. Patients with lower financial distress were more likely to have supplemental insurance, increasing annual household income and a credit score above 740.

Those facing financial toxicity often cope by borrowing money from friends or family, pulling money out of retirement or savings, fundraising and cutting down on daily spending. Greenup highlights that women from all socioeconomical backgrounds can be at risk for this toxicity.

“It is important to recognize that all women are at risk of cancer-related financial hardship, regardless of socioeconomic status or wealth — yet this can look different across varied patients,” Greenup, who was an author on the study, said. “More affluent women are less likely to go into bankruptcy, yet they may still employ cost-reducing strategies such as using savings, taking out second mortgages on homes or cutting out vacations. Certainly, this is a very different presentation of financial toxicity when compared to our most vulnerable patients who are at risk of food insecurity and losing housing. Ultimately cancer treatment costs can be unaffordable for everyone.”

The different treatment options for breast cancer may play a role in financial toxicity. Patients may not know what the financial implications of preference-sensitive decisions are, according to Greenup. She uses the example of deciding between
a lumpectomy or mastectomy. “If I could say to a patient, ‘You have a 2% lower risk of your breast cancer coming back if you undergo mastectomy compared to lumpectomy, but it may cost you $40,000 out of pocket if there are complications.’ This cost transparency and communication may impact patient choice,’” she explained. In short, she said, there seems to be a lack of cost consideration when discussing cancer treatment choices with patients and their families.

“Arguably the health care system is not as clear as we probably should be with patients about the real burden of cancer treatment,” she said.

“Another important finding from our work is that unexpectedness or a lack of preparedness puts patients at higher risk of financial hardship,” Greenup explained.

Ways to prepare for the financial impacts of cancer treatment include knowing the total duration of treatment, how much time patients will need off work, how many appointments they might have, what the out-of-pocket payments are based on their insurance plan and what their plan deductibles may be.

Greenup noted data from previous studies that have demonstrated that cost discussions between patients and their physicians allow for health care teams to identify opportunities to reduce financial toxicity by coordinating appointments, writing prescriptions for generic drugs and even having expensive imaging done at offsite locations where costs are generally lower. According to Greenup, patients also have access to social workers and financial navigators, who can help to find resources to cope with financial burdens. “Preparedness is protective,” she said.

Making the idea of financial hardship more approachable as a reality of cancer care is important for next action steps, according to Greenup. “One of the more important aspects of our work is to socialize financial hardship as a common side effect of treatment in order to improve awareness among patients and society, and that will drive some of the patient questions, the behavior, kind of what normal discussions look like,” she said.

Some ways for patients to start bringing more awareness include knowing the details of their insurance plans and communicating with health care teams early if they are worried about finances.

“Historically — especially among marginalized populations — there has been concern that an inability to pay for care may result in care being withheld,” she concluded. “Contemporary health care systems have resources in place to support our patients. If patients have concerns about afford- ability, they should feel safe telling their doctors.”

Talking with a doctor about costly cancer treatments and being frank with health care teams can ease financial distress for patients with cancer.

Facing Financial Toxicity in Cancer Care

In July 2019, 35-year-old Stephanie Judge was a married mom of three young children who had just delivered a surrogate baby. One day, after finishing pumping breast milk for the baby, she found a lump in her left breast. After visiting her doctor, Judge received a diagnosis of stage 2 breast cancer in December and scheduled a lumpectomy for one month later. On March 6, 2020, Judge received a diagnosis of metastatic breast cancer.

“Being diagnosed right at the beginning of (the COVID-19) pandemic was definitely interesting. You’re kind of hit twice,” she explained. “I’ve done almost everything alone. I’ve had two surgeries because I had a very quick recurrence. ... Well, I’ve had three surgeries because I had a port put in. I’ve done all my scans alone. I’ve done (the) majority of my appointments alone. I’ve done every single (chemotherapy) alone. ... I don’t know any different, but it’s also been kind of sh-tty.”

Judge now is 18 months into her first line of treatment of intravenous chemotherapy. She noted fatigue is one of her biggest side effects, along with nausea, headaches, bone pain, joint pain, weight gain, hair loss and allergy-like symptoms.

“I decided very quickly that it wasn’t worth my time to be angry or focus on what could have been or what could be. I needed to focus on the time that I do have, because no one can tell me when my time will come up,” she said.

“For me ... my tolerance for saline is very low because I associate the taste with chemo and it makes me nauseous when I get it. So for me, (I bring) hard candy or Tic Tacs or something that will mask the taste (of) any flushes that I have, which happens a few times every time I go in. I would say that’s pretty high on my list because otherwise I don’t feel well.”

“I ice my feet with my treatment (to reduce) neuropathy. ... If you wear the ice booties, they are very, very, very cold. So having socks with me is always super important.”

“Any appointment I have, I will write down all of my questions before I go in because half the time you get there and you forget what you want to ask. ... And then I usually write my answers to those questions in my book so that I can discuss them with family later.”

“They prefer in the chemo suite that you wear headphones so that you’re not disturbing other people. ... I usually charge them in the car on the way there.”

“I’m starting to do some legacy work for my kids because of my diagnosis. I know it’s not the same for everyone. But I did just pick up these little memory journals that I bring with me now. ... They’re basically a ‘their story’ kind of thing. So it’s not necessarily a baby book, but it’s stuff from when they were infants all the way up to when they’re grown. It’s just questions that you can fill out for them, which I thought would be cool if I do during chemo, and then, eventually, they can read them when they’re older.”

“I always have Advil with me or Tylenol, and then I also carry my ... nausea medication because sometimes I am nauseous during chemo. ... So I just like to have it on hand.”

“My chemo center ... is notoriously freezing. I think they keep the chemo suites cool because it’s supposed to help with nausea, which makes sense, because if you’re warm and you don’t feel well, it just makes it worse.”

“It keeps all my books and stuff separated. A friend of mine gave it to me, and it just kind of keeps things a little more organized.”

“I always have a cell phone and a charger. Always, always. Because half the time I spend on TikTok doing mindless stuff. There’s a lot of waiting. There’s always waiting.”

“I did buy the icing booties and the icing mitts. In the beginning I didn’t need them, but someone had recommended having them, and it turns out that I didn’t need them until about halfway through before neuropathy. And my cancer center has them. So I didn’t have to waste the money on that, and I didn’t realize that they would have them and be able to provide them to me. ... The ones that I purchased weren’t as heavy duty as the ones that the hospital already has. I would definitely check that before you waste your money on something off of Amazon.”

Side Note

A mother of three who received a diagnosis of stage 4 breast cancer right before the pandemic shares what her must-have comfort and entertainment items are in her treatment bag.

What to Bring in Your Cancer Treatment Bag

Sarah Hosea was terrified. In February 2019, the 27-year-old had just received a diagnosis of breast cancer, and she didn’t like the information that a Google search turned up.

“I didn’t really know anything about triple-negative breast cancer (TNBC),” says Hosea, now 30, who lives in Missouri City, Texas. “No one in my family had ever had breast cancer. I didn’t even know there were different types. But when you Google it, it’s not a pretty picture. It’s pretty scary.”

Doctors at her local hospital were frank. The diagnosis was a difficult one, with a significant chance that she would not survive. They wanted her to begin a rigorous course of chemotherapy later that week. But Hosea hesitated. She knew time was of the essence, but she decided to seek a second opinion at The University of Texas MD Anderson Cancer Center in Houston.

TNBC is defined more by what it isn’t than what it is. TNBC cells lack receptors for the hormones estrogen and progesterone and do not overproduce the HER2 protein. That means that targeted drugs against hormone or HER2 receptors are not effective for this cancer type, so chemotherapy is generally required. But that’s not to say that all TNBCs are the same.

“Triple-negative breast cancer refers to a very heterogeneous group of breast cancers,” says Dr. Rita Nanda, an associate professor of medicine and director of the breast oncology program at UChicago Medicine in Illinois. “All these triple-negative cancers get lumped together because of lack of expression. But there are differences.”

There is some nuance among TNBCs, but generally there are variations that make the cancer more likely to respond to one treatment over another. A prime example is a mutation in the BRCA1 or BRCA2 genes, which is what Hosea had. It responds to poly (ADP ribose) poly- merase inhibitors, commonly known as PARP inhibitors, which work by blocking an enzyme that cancer cells produce to repair their DNA, ultimately killing the cells since BRCA mutations also affect DNA repair, giving the cells a “double whammy.”

TNBCs are widely thought of as aggressive because they tend to be diagnosed at higher grades, often appear in younger people and grow faster than some other breast cancers. Furthermore, when these cancers do not respond to chemotherapy at early stages, they have a high tendency to spread to other parts of the body. The American Cancer Society reports that the five-year relative survival rate for people with TNBC is 77% for all stages, 65% with regional metastases and 12% with distant metastases. Even when the disease is caught early, by some estimates, approximately one-third of patients will experience a relapse of TNBC after standard therapy with chemotherapy and surgery.

“For patients with pretreated metastatic TNBC, standard chemotherapy is associated with low response rate and poor progression-free survival,” explains Dr. Aditya Bardia, director of the breast cancer research program and an associate professor of medicine at Harvard Medical School in Boston. “TNBC traditionally has been tough to treat because it lacks actionable receptors and is associated with significant genomic heterogeneity and aggressive tumor biology.”

He estimates that with standard-of-care chemotherapy for patients with pre-treated metastatic TNBC, the response rate is as low as 5% to 10%. Further, patients with metastatic TNBC who receive standard chemotherapy often see their disease progress within two or three months.

However, as researchers learn more about the variations in TNBC and develop more targeted therapies, a diagnosis that used to seem hopeless now comes with new rays of hope, largely thanks to major advances in treatment that have taken place over the past two or three years. “I would say we’ve made a ton of advancement recently,” Nanda says. “Within the past couple of years we’ve had a lot of drugs approved for triple-negative disease.” 

Bardia adds that the difficulty of treating TNBC is precisely what has spurred these recent developments. “Triple-negative breast cancer represents a major unmet need in the field of breast oncology and consequently there has been considerable interest in developing novel therapies for patients,” he explains.

Recent advances in TNBC can be sorted into three categories: immunotherapy drugs, antibody-drug conjugates and PARP inhibitors.

Immunotherapy options for patients dealing with cancer are not new. But on July 26, the Food and Drug Administration (FDA) announced it had approved the immunotherapy drug Keytruda (pembrolizumab) for the treatment of high-risk, early-stage TNBC. Immunotherapy drugs work by activating the body’s immune system to attack cancer cells. Keytruda is approved both in combination with typical chemotherapy as a neoadjuvant, or pre-surgery, treatment and for use alone and as an adjuvant therapy.

Kristen Perello, who received a diagnosis of stage 2 TNBC in August 2017, participated in the phase 3 clinical trial, called KEYNOTE-522, examining the efficacy of Keytruda that led to the drug’s approval. “It was definitely a total shock,” she remembers. “I didn’t know people could survive from this type of diagnosis.”

One week after Perello’s initial appointment, her surgeon introduced her to Dr. Joyce O’Shaughnessy at Texas Oncology, Baylor Sammons Cancer Center, who was running the trial, and with a treatment plan in place, Perello felt a sense of relief.

Perello joined the trial, in which 1,174 patients with newly diagnosed, untreated, early-stage, high-risk TNBC were randomly assigned to receive placebo plus chemotherapy before surgery followed up by placebo after surgery or Keytruda plus chemotherapy before surgery followed by Keytruda monotherapy after surgery.

Because of the design of the study, Perello does not know for sure whether she received Keytruda or a placebo as part of her treatment plan, but she took her prescribed medications and went through 16 rounds of chemotherapy followed by a double mastectomy and completed 16 rounds of chemotherapy, with a complete response after just three rounds. Through it all, she dressed up for her treatments and maintained high spirits. Chemotherapy is often a difficult experience characterized by fatigue and side effects such as hair loss and nausea, but Perello’s course of treatment was fairly uneventful. “Honestly, I felt great the whole time,” she says.

Although she avoided many side effects, Perello did find herself fatigued during so-called red devil treatments, which consist of an infusion of a bright-red chemotherapy drug called doxorubicin and are notoriously grueling for patients. But she was able to keep going to the gym and working full-time throughout her chemotherapy. Through cold capping, a practice in which patients wear devices on their heads to cool the scalp during chemotherapy, she was able to minimize hair loss.

“I would say I was positive during treatments. I would also say that with the positives come dark moments, too, that only other survivors are going to understand,” she says.

In the trial, Keytruda combined with chemotherapy produced a complete pathological response in 63% of patients, meaning nearly two-thirds of patients had no evidence of cancer after treatment, compared with 56% among those who were assigned to receive chemotherapy alone. Overall, the drug reduced the risk for disease progression, recurrence or death by 37%.

Although Perello experienced differently, side effects in the study’s participants were common. The most frequently reported were fatigue (70%), nausea (67%), hair loss (61%), rash (52%), constipation (42%) and diarrhea and peripheral neuropathy (both 41%).

Another major breakthrough for TNBC treatment is with antibody-drug conjugates, which are medications that combine monoclonal antibodies — artificially made proteins that target proteins on cancer cells — with highly toxic, tumor-killing chemicals. The result is a drug that delivers extremely potent anticancer medications directly to the tumors without harming the rest of the body, sometimes referred to as a “Trojan horse” effect.

Bardia is particularly interested in the antibody-drug conjugate Trodelvy (sacituzumab govitecan-hziy) and led a large randomized phase 3 trial, called ASCENT, on the therapy. In April 2020, the drug received accelerated FDA approval for metastatic TNBC that did not respond to other treatments based on an earlier phase 2 trial showing remarkable activity in heavily pre-treated patients, and a year later it received the FDA’s regular approval for the same indications when the randomized trial showed a doubling of survival compared with standard chemotherapy options.

In the data recently published from the trial, Bardia and his team reported that patients with metastatic TNBC who received Trodelvy went a median of 5.6 months before their disease progressed, compared with less than two months in patients who received typical chemotherapy. Not only did patients live longer before their disease progressed, but they also lived longer overall: Median overall survival was 12.1 months in patients assigned to Trodelvy, compared with just 6.7 months in those who received standard chemotherapy. Trodelvy’s most common severe side effects were neutropenia (low white blood cell count), which occurred in 51% of the Trodelvy group compared with 33% of the chemotherapy group, diarrhea (11% versus less than 1%, respectively), anemia (8% versus 5%) and febrile neutropenia (5% versus 2%).

The patients in that trial all had advanced disease that did not respond to other treatments, and Bardia hopes to see this therapy turned into a first choice for patients with earlier-stage disease.

Dr. Tiffany Traina, who is section head of the TNBC research program at Memorial Sloan Kettering Cancer Center in New York, was a researcher on the ASCENT trial and is enthusiastic about the expanding range of options for patients with TNBC.

“Immunotherapy is curing more women of triple-negative breast cancer,” she says. “And some of the novel agents (such as Trodelvy) are really moving the needle in how long women are living with their breast cancer, even with advanced disease,” she says. “We’ve seen greater hope for women with triple-negative breast cancer in a meaningful way. ... This drug showed incredible activity.”

Generally speaking, new cancer treatments make their debut as alternative strategies in late-stage cases, then make their way to being used as a frontline, or first-choice, therapy.

“Moving forward, the drug needs to be evaluated in earlier lines, including first-line therapy for metastatic TNBC,” Bardia adds. “In the ASCENT trial, patients who had received prior immunotherapy also had benefit with (Trodelvy) suggesting there is no cross-resistance between (Trodelvy) and immunotherapy, and potentially combining (the drug) with immunotherapy would be an attractive therapeutic option for patients with PD-L1-positive metastatic TNBC.”

When Hosea went to MD Anderson for a second opinion, she was asked whether she wanted to participate in a clinical trial as part of her treatment for early stage TNBC. “Let’s do it!” she remembers telling her care team. “Give me a plan.”

She enrolled in an open-label phase 2 study, which means all of the 61 patients enrolled received Talzenna (talazoparib), a PARP inhibitor.

Hosea was one of a few dozen women with BRCA- mutated TNBC who took a PARP inhibitor as part of the study.

Dr. Jennifer Litton, vice president of clinical research and professor of breast medical oncology at MD Anderson, reported at the 2021 American Society of Clinical Oncology (ASCO) meeting that 49.2% of patients experienced a complete pathological response to Talzenna, meaning there was no evidence of cancer left in the affected breast after treatment and surgery.

“It was six months of a daily pill,” Hosea says. “It would eventually make the cancer die.” Depending on her progress with Talzenna, she could stay in the trial or drop out and proceed to the standard of care, which was chemotherapy. “I always had the choice to leave,” Hosea says, which helped her make the decision to participate.

Throughout the drug trial, her hemoglobin levels dropped to levels so low that it looked as though she might need to drop out of the trial. “We had to reduce
my dosage multiple times, but even with that I had a complete response,” she says. This would remain an issue throughout her chemotherapy, as well.

Although she had no significant side effects with Talzenna, during chemotherapy she dealt with neutropenia and contracted pneumonia.

After the trial, Hosea had surgery, and no cancer was found — demonstrating that she had a complete pathologic response to Talzenna. She completed 30 rounds
of radiation therapy after her double mastectomy, and received chemotherapy for six months.

“PARP inhibitors are really exciting as a proof of concept of using the DNA damage repair pathways,” Litton says. “An oral drug really improves quality of life for patients with metastatic cancer and a germline BRCA mutation, and I’m looking forward to the next generation of DNA damage repair agents that can potentially have similar or longer-lasting effects with less toxicity.”

Hosea initially hoped that her life would go back to normal after cancer, but like Perello, she found that some part of her had permanently changed.

In some ways, the change was bad, leaving a physical and emotional scar from a difficult diagnosis and intensive treatment. “The hardest part was that it happened at all,” Perello says.

But in one major way, the change was a good thing. “I’ve always been a worrier,” Hosea recounts. “And just worried a lot about every little thing. And I don’t anymore. I always tell people I’m so thankful for this perspective.”

Three therapeutic breakthroughs are revolutionizing care for triple-negative breast cancer and saving women’s lives.

Finding New Hope in Triple-Negative Breast Cancer Treatments

In October 2011, Kristen Wiley found a pea-sized lump in her breast. Having had a clear mammogram just seven months earlier, she thought it would go away.

When the lumps were still there in December, Wiley decided to go to her doctor at Mayo Clinic in Jacksonville, Florida. “She said, ‘I’m sure it’s nothing, but let’s be safe and do another mammogram,’” Wiley recalls her doctor telling her. The doctor also performed an ultrasound and biopsy. In January 2012, Wiley, then 41 years old, received a diagnosis of triple-positive breast cancer, which meant her tumors were human epidermal growth factor receptor 2 HER2-positive, estrogen receptor (ER)-positive and progesterone receptor (PR)-positive. This means the treatment like hormonal or HER2 antibody therapies would not be effective, and that the tumor was likely to be more dangerous.

“I was a picture of health,” she says. “No family history of breast cancer. I was very active and fit. It completely took us by surprise.” Wiley, who had a 3-year-old daughter, decided she would go “full throttle” with her treatment after learning how aggressive her disease was. Her cancer was stage 2, and three lymph nodes were affected by the disease. Wiley had a double mastectomy with reconstruction, and over a 14-month period she underwent 29 rounds of chemotherapy, 27 radiation treatments and five surgeries.

Immediately after her mastectomy, her menstrual cycles — which Wiley describes as regular until that point — stopped. She began to have hot flashes hourly, seven days a week. “I would go from fine to bright, cherry red and pouring sweat within five minutes,” Wiley, now 50, says. Throughout treatment, she continued to work full time as a senior managing director for a global financial technology company, but the menopause-induced hot flashes and mood swings were difficult to hide because they would spring up without warning.

For most women in the United States, the average age of menopause is 51. But, like Wiley, many women with breast cancer can be propelled into medical menopause following treatment for the disease. All women who have an oophorectomy, a surgery to remove both ovaries, will go into immediate and permanent menopause if they weren’t menopausal before the surgery because the ovaries are no longer there to produce estrogen. In addition, up to 40% of women under age 40 and anywhere from 70% to 90% of women over age 40 go into permanent menopause because of chemotherapy, according to breastcancer.org. For other women, the loss of ovarian function is temporary.

For patients who are premenopausal, “some of the chemo- therapies are toxic to the ovaries, and the older women are, the more likely these agents will cause ovarian failure,” says Dr. Stephanie Faubion, director of Mayo Clinic Women’s Health and medical director for The North American Menopause Society (NAMS). “Early menopause caused by surgery is rapid and results in a sudden and dramatic decline in estrogen levels. Women are often very symptomatic with hot flashes, night sweats, joint aches, mood disturbances and sleep disturbances.”

Other symptoms of menopause include anxiety, depression, fatigue, brain fog and weight gain. Women may also experience bone loss and vaginal dryness, which can lead to painful intercourse. Vaginal dryness usually occurs in the months after menopause onset, according to Faubion.

Rebecca Seago-Coyle says she felt isolated after experiencing a lack of desire and vaginal dryness, which she says took a toll on her relationship with her husband. “I was in my 30s and wanted an active sex life,” says Seago-Coyle, who received a stage 1 ER-positive/HER2-positive breast cancer diagnosis in 2010 when she was 35. At the same time, she learned she was BRCA2-positive — a gene mutation she inherited from her father. Women who have BRCA mutations are at an increased risk of certain cancers — most notably, breast and ovarian cancer — and for developing them at a younger age, while men with BRCA2 mutations are at increased risk for breast cancer.

Seago-Coyle’s cancer was labeled aggressive because of the grade and tumor size. She was treated with 12 weeks of Taxol (paclitaxel) and a year of Herceptin (trastuzumab). She also underwent bilateral mastectomy with reconstruction and had her ovaries removed to decrease changes of recurrence. “I don’t think anyone prepares you for menopause,” Seago-Coyle says. “Medically induced menopause in your 30s is different (from what) the average person goes through gradually. When it happens medically, it’s a jolt.”

All of these symptoms can be stressful, as they are constant reminders not only of what is happening to the body at that moment but also the cancer itself. They can reduce day-to-day quality of life, which can be difficult for someone to navigate.

“Hot flashes, mood changes, body image, self-esteem — all of these things that may naturally happen with menopause later in life are happening for some women much earlier, so this could be at a time when they’re thinking about having families, or have young children, or being in the workforce more, and the day-to-day can take a toll on people emotionally, mentally and physically,” says Lauren Chatalian, a licensed clinical social worker and women and children’s program manager for 

Hormonal therapies that suppress estrogen levels can also cause side effects of menopause. When Wiley began taking aromatase inhibitors (AIs), more of the symptoms kicked in. She was first put on Arimidex (anastrozole), but it caused weight gain, so she switched medications to Femara (letrozole). However, she then began to have severe bone pain.

“It was like someone took a hammer to my toes and fingers and crushed all my bones overnight,” Wiley remembers. “You would feel like you were (being hit with) a meat tenderizer. I can take a lot of pain, but not this much.”

Her oncologist switched her AI a third time to Aromasin (exemestane), but that also caused bone pain. Wiley went back on Arimidex, which she says caused her to gain 30 to 40 pounds. But the extra pounds were a trade-off for less pain.

“When we think of menopause, we think about middle adulthood. You’re diagnosed and experiencing mixed emotions, prepping for treatment, surgery — and it goes fast, it’s hard to slow down,” Chatalian says.

In facilitating support groups for CancerCare, Chatalian advises women with breast cancer who experience menopause related to cancer treatments to have a conversation with their medical team and their loved ones about the life-disrupting symptoms and let them help.

Seago-Coyle ended up needing additional support. “My medical team had the best intentions, but it’s also feeling comfortable enough to share,” she says. “It’s hard to explain to other people because they interpret it in different ways. When I was going through chemotherapy, I went to a support group and learned how to talk more openly. These women shared tips and tricks.”

In addition to support groups, Chatalian encourages self-care, such as focusing on stress relief, using relaxation techniques, reading or journaling.

To fight restless sleep, which Seago-Coyle attributes to menopause, she created a routine that involves reading and doing yoga every night before bed. She also takes a natural supplement with magnesium and an Advil PM, and she is in bed by 8 p.m.

Wiley turned to an informal support group — two friends who received breast cancer diagnoses after she received hers. In addition, she became active with The DONNA Foundation, which supports families who are trying to make ends meet financially following breast cancer, thanks to a friend who introduced her to the group. She runs in the foundation’s annual marathon to help raise money and awareness for the cause.

On the home front, Wiley switched to cooling pillows and mattresses, and she doesn’t leave the house without a handheld fan. “I carry two in my purse at all times,” she says.

Pharmacologic options can help reduce menopause symptoms. For instance, results of several studies have shown that medications such as Effexor (venlafaxine), Neurontin (gabapentin) and Oxytrol (oxybutynin) may reduce the frequency and intensity of hot flashes. The only drug approved by the Food and Drug Administration to treat hot flashes associated with menopause is Brisdelle (paroxetine), which is an antidepressant. “Many of the antidepressants have been studied for hot flash management, and none of them have much more than a 40% to 50% reduction in symptoms,” Faubion says. “These are not magic cures. They take the edge off hot flashes.”

Researchers in phase 3 clinical trials are investigating NK3 inhibitors, which are a promising new class of drugs that target neurons in the brain’s hypothalamus responsible for hot flashes. Specifically, they take aim at the neuron complex kisspeptin/neurokinin B/dynorphin, known as KNDy neurons. Study results have shown an approximate 90% reduction in hot flashes in a couple of days compared with placebo at 25% to 30%.

Alternative therapies such as hypnosis and cognitive behavioral therapy have evidence to support their use for hot flash management. And in some cases, acupuncture has been more effective than medication, according to Dr. Amy Tiersten, a professor and clinical director of breast medical oncology at Mount Sinai in New York City.

Nonhormonal lubricants and moisturizers are initially offered to women who have vaginal dryness. But if those don’t work, low-dose vaginal estrogen can sometimes be considered after breast cancer survivors consult with their oncologists. Vaginal dilator therapy, which gently stretches vaginal tissue, and pelvic floor exercises to stretch and relax pelvic muscles may boost pelvic blood circulation and help relieve discomfort with sexual activity.

In women who experience joint pain following treatment with AIs, Cymbalta (duloxetine) may be prescribed. Bone- strengthening medications, such as Zometa (zoledronic acid), are often suggested for women taking AIs. “Not only do these bone-strengthening agents protect your bones from the negative effect on bone density from the aroma- tase inhibitors, but some studies show they also reduce the risk of the breast cancer coming back,” Tiersten says.

Typically, most patients are on anti-estrogen therapy for at least five years, but it could be as long as 10 years. The decision is made by looking at risk of recurrence and how well the drug is tolerated, according to Tiersten.

Perhaps the most beneficial thing a patient can do is to find a physician who specializes in helping women through menopause. NAMS has an easy-to-navigate menopause practitioner finder on its website.

If patients want to address symptoms without medication, they can lean on resources available at their cancer center in addition to finding nonprofit organizations that offer support. For instance, CancerCare offers in-person and virtual support groups.

“This is going to be disruptive, and I don’t wish it on anyone. But your mental outlook is key to your success,” Wiley emphasizes.

And when those feelings of isolation creep in, Chatalian wants patients to remember they’re not alone.

“Take it one step at a time,” Chatalian says. “You are your best advocate. For any symptoms that arise, have a discussion with your medical team. Have questions prepared. And know there is support available for all the mixed emotions.”

Some breast cancer therapies and surgeries cause a reduction in estrogen levels, forcing many women immediately into menopause.

Breast Cancer Treatments Propel Many Women Into 'Rapid, Dramatic' Medical Menopause

Marie Valenzuela still recalls life around the time she received a diagnosis of stage 2B infiltrating ductal breast cancer. She was 40 years old, in a committed relationship with her girlfriend, employed at a job that she loved and diligent about her yearly health checkups. Yet she still feels the sting from a comment she believes was derived from her being a lesbian.

At the time, she had been in remission for a year after finishing treatment for breast cancer — which included a lumpectomy with axillary dissection followed by two rounds of aggressive chemotherapy, six weeks of radiation and two more rounds of chemo. After completing treatment, Valenzuela received Tamoxifen to help prevent a recurrence. Because the drug can cause abnormal growths, and rarely, cancer in the uterus, her oncologist ordered routine hysteroscopy — the insertion of a thin tube to view the lining of the uterus and take biopsies if needed — to make sure there weren’t any problems. The treatment is not often recommended in the absence of any symptoms like abnormal bleeding or changes noted on ultrasounds, which are also of low incidence in patients receiving Tamoxifen.

“I had to have a scoping procedure, and first thing (the doctor) did was complain about not being able to get the scope inside my uterus because I never had children. And it kind of went downhill from there,” she remembers.

While this comment could be made toward any woman who does not have children, regardless of sexual identity, those who identify within LGBTQIA+ often face harsher obstacles when it comes to starting a family, including the financial burden of fertility services, foster care or adoption.

Uncomfortable and possibly discriminatory situations such as what Valenzuela experienced are what keep many LGBTQIA+ community members from seeking health care on a regular basis.

Valenzuela reported the doctor’s remarks to her health care provider immediately and requested that she see only female doctors in the future. She was determined to not let one situation keep her from getting the health care she deserved. “Barriers exist, but putting off getting your diagnosis is the last thing you want to do,” she says.

Among other barriers, the LGBTQIA+ community has higher rates of smoking, drinking, depression and risk of obesity. These issues, along with the fear of facing discrimination, may prevent them from seeing the doctor on a regular basis, which, in turn, increases the risk of cancer or delays their receiving a cancer diagnosis and treatment.

“LGBTQIA+ individuals use tobacco products at rates 40% higher than the general population,” Michelle Veras, project director at the National LGBT Cancer Network, explains. “Why? Rejection and discrimination, the places we work and live, a legacy of targeting by the tobacco industry — these all become risk factors for diseases like cancer.”

The National LGBT Cancer Network reports that insurance claims sometimes are denied if a particular test is ordered that does not align with a person’s current gender identity, affecting the transgender and gender nonconforming communities. “This not only presents logistical issues in terms of getting tests and procedures covered but it can compound feelings of being discriminated against by the health care system,” she says.

Even for some members of the LGBTQIA+ community with health insurance, gaining access to the appropriate care is difficult, Veras says. For instance, someone who is trans- gender may not be covered for any procedure or cancer screenings that are inconsistent with the gender marked on the insurance card, such as a Pap smear for a transgender man who is assigned female at birth and still has an intact cervix. “Risk factors for our communities are the result of systemic inequalities; personal choice plays such a small role in our health outcomes,” Veras says.

In addition, a primary factor that contributes to these disparities is a lack of trust in the health care system due to homophobia and transphobia, according to Dr. Jennifer Aldrich, a professor of clinical medicine at Lewis Katz School of Medicine at Temple University in Philadelphia.

“Recent surveys indicate that LGBTQIA+ people are fearful of discrimination by medical providers, causing them to seek care less frequently and be diagnosed and treated later than their straight and cisgender counterparts,” she explains.

Health care professionals need training to become inclusive, Aldrich emphasizes.

Dr. Anosheh Afghahi, a medical oncologist at the University of Colorado Cancer Center in Aurora, adds that transexuals on estrogen supplementation also face an increased risk of breast cancer and other hormone-driven cancers. At greatest risk are individuals with a strong family history of breast cancer or who have inherited a genetic mutation such as BRCA1 or BRCA2.

Catherine Sumner, who is a lesbian, survived thyroid cancer in 2003. She had no known history of breast cancer, and she says she was good about getting medical checkups, especially after receiving her diagnosis of thyroid cancer.

In 2010, Sumner found herself in the doctor’s office for a cortisone shot after she believed she had pulled a muscle training for a triathlon. “I was feeling great, and I would run one to three miles a day,” she says. “I went in for a checkup when I found a lump above my breast while I was rubbing in Tiger Balm after pulling a muscle. ... So I went to my primary (care) doctor.”

The nurse practitioner was preparing the cortisone shot when she realized that it could be more than just a pulled muscle. After a same-day appointment to examine the lump with an oncology surgeon, she was diagnosed with breast cancer. “And it blew me out of the water at age 31,” Sumner says.

That was in March. By April 1, she had started a treatment of chemotherapy plus Herceptin (trastuzumab). By September 9, she had had a lumpectomy with clear margins. Her cancer diagnosis changed from stage 3 to a “smaller” stage 2, and she began two months of daily radiation, then continued the Herceptin. Sumner was lucky enough to have providers who were thoughtful with her treatment and care at Virginia Hospital Center in Arlington.

“Too often, doctors don’t work with patients in the gay community, and if that collaboration isn’t there, having someone talk at you and not with you — it doesn’t work,” Sumner explains. “My oncology team, even though I’m gay, (they) asked things like, ‘Don’t you want to freeze your eggs?’ I’m like, ‘With this? No way.’ But (my oncologist) told me that maybe I would want them someday.”

Sumner adds, “(My oncologist) was very aware of my fertility and treated me like a woman, not ‘Oh, she’s gay and she’s not going to get pregnant.’”

Sumner says she still struggled to find an inclusive support group where she could feel comfortable. The first group she attended consisted mainly of heterosexual women, and although Sumner says she was sure they were nice, she wasn’t able to relate as closely with their experiences. “I learned that it is very difficult to be the only lesbian in a breast cancer support group. I didn’t feel comfortable coming out to a group of older straight women. I had trouble relating to them and generally felt very out of place, so I didn’t go back after the first visit,” Sumner explains.

Instead, she relied on friends, family and her priest for support, and often she brought a friend with her to appointments, as well.

“It’s wise to bring someone with you and look for a doctor you feel comfortable with,” she adds. “The last thing you want to do is let fear take hold of you and you don’t go to your appointment, or you feel like you don’t have someone to talk to who understands you.”

When it comes to breaking down the barriers — such as those experienced by Valenzuela and Sumner — in health care for the LGBTQIA+ community, Afghahi believes medical professionals haven’t done enough to eliminate disparities.

“The medical community also has been slow to incorporate specific learning opportunities for providers and students so they can learn about specific issues surrounding the health of LGBTQIA+ individuals. That’s another reason why disparities persist,” she says.

Approximately 30% of LGBTQIA+ adults don’t seek health care services or have a primary health care provider, compared with 10% of heterosexuals, according to study results presented at the 2020 American Society of Clinical Oncology Quality Care Symposium. In the study, researchers partnered with the LGBT Community Center of Greater Cleveland, Plexus LGBT & Allied Chamber of Commerce and TransOhio to create programming, including a mammogram clinic for sexual/gender minority women, a “Cancer is a DRAG” show and a tobacco-free campaign. The result? More than 150 people were educated about these disparities and more than 85 were screened within the first year, proving that creating meaningful partnerships between health care and LGBTQIA+ communities, as well as programming patients can relate to, may help decrease health disparities in that subset.

It is educational programs and outreach such as this that Afghahi thinks could jump start the conversation and recognition of what needs to be changed in the health care system to be inclusive of all. She says, “Engaging in a two-way conversation to allow the patients to teach providers about their concerns is a way to start the conversation. I think it always starts with educating providers on the health issues that matter for this patient population, engaging in discussion with each other and having an open mind.”

Aldrich adds another important element needed to break down barriers: educating those within the health care field so that inclusivity starts at the beginning of a patient’s journey within a cancer center or hospital.

“It is important to collect sexual orientation and gender identity when we first meet a patient,” she emphasizes. “Open communication will help providers address potential concerns about treatment effects on sexual activity, body image and relationships, and will allow the team to include the important people in the patients’ care.”

Increasing education and information about patients in this subset could build a stronger patient-provider bond, allowing for more compassionate conversation and mindfulness. “Traditionally, the medical establishment has been heteronormative (the belief that heterosexuality is the normal mode of sexual orientation), and LGBTQ+ patients often have not disclosed their orientation or gender identities to their providers. We, as medical professionals, must ask the appropriate questions and allow patients to feel safe in disclosing to us, so that we can together build a trusting, nondiscriminatory relationship,” Aldrich adds.

Dr. Mitchell Lunn, an assistant professor in the Division of Nephrology of the Department of Medicine at Stanford University School of Medicine in California, agrees as both a provider and as someone who identifies as a gay man.

Fear of facing discriminatory behavior within the health care system, along with other factors, may keep members of the LGBTQIA+ community from receiving cancer diagnoses.

2021 Breast Cancer Special Issue | CURE