The Breast Cancer Update: July 1

Today in breast cancer news, we'll wrap up the week's big story by looking at what's next for Avastin. We'll also look at a UK decision to deny cost coverage for Tykerb or Herceptin plus hormone therapy for some metastatic patients and surgical scar treatment and prevention advice.

What's next for Avastin?

There's been a great deal of activity on the LATESTBreastCancer.com Avastin (bevacizumab) news page this week. Earlier this week, an FDA advisory panel held hearings on the risks and benefits of Avastin for metastatic breast cancer. In the end, the panel voted 6-0 against the use of Avastin for breast cancer. The FDA Commissioner will make the final decision, which will likely follow the panel's recommendation.

So, what's next for Avastin?

First, because Avastin will still be available for other cancers, doctors may continue to prescribe it off-label for metastatic breast cancer. At a cost of about $8,000 a month, the real question is if insurance will continue to pay.

According to the New York Times, Medicare will continue to cover Avastin for metastatic breast cancer even if the FDA revokes approval. This may eventually change, but such a change in policy "would take at least a year and involve public input." Representatives from several private insurance companies indicated that they would review coverage after the FDA final decision. A UnitedHealthcare representative told the New York Times that it would continue to base chemotherapy coverage on National Comprehensive Cancer Network (NCCN) guidelines.

A Reuters story noted that Roche is "undeterred" and is planning another breast cancer trial for early 2012. The new trial will include a biomarker to try to identify which patients may benefit from Avastin.

Both the New York Times and Reuters mentioned that Europe expanded its approval for Avastin for breast cancer to allow it to be combined with a second type of chemotherapy, Xeloda (capecitabine). Avastin "can be used for breast cancer in more than 80 countries."

UK won't pay for Tykerb or Herceptin plus hormone therapy for some patients

In foreign regulatory news, Bloomberg reports that the UK National Institute for Health and Clinical Excellence has denied cost coverage for Tykerb (lapatinib) or Herceptin (trastuzumab) in combination with aromatase inhibitor therapy for older, HER2 positive, metastatic patients. Unlike the recent Avastin hearing, the UK decision was based on a cost/benefit analysis. Both Tykerb and Herceptin have previously been approved in the UK for use in "certain other patients."

Breast cancer surgical scar prevention and treatment

According to a recent Cure Today article, surgical scars "can be managed and minimized." Breast surgeries, such as breast conserving surgery (lumpectomy) and mastectomy, are "associated with a high incidence of scarring." The International Advisory Panel on Scar Management recommends silicone gel sheeting be used as the "first-line preventative measure" for the first month after surgery. For more severe cases, intralesional corticosteroid injections are recommended as second-line treatment. Pressure wrapping may also be an option. In some cases, surgical excision may be necessary.

Please check back on Monday for more breast cancer news updates from LATESTBreastCancer.com. You may find all the news and research on any breast cancer test or treatment option, including complementary therapies on our website anytime.

HER2 Part 3: Drugs that Target HER2

Note: This is the blog of LATESTBreastCancer.com, where you can get personalized information about the latest in breast cancer treatment.

For patients with HER2 over-expressing breast cancer, it is critical to target the HER protein. Here we'll look at an array of HER2 targeted drugs: current, new and future. If you're a patient with metastatic disease whose disease is progressing following Herceptin treatment, accessing one of these newer drugs through a clinical trial might be a reasonable option.

Herceptin (trastuzumab). "The big standard." The first drug to target HER2. Approved in 1998. Currently used for patients with all stages of HER2+ breast cancer. Picture how it works: Herceptin is a very large monoclonal antibody protein. It attaches to HER2 on the portion of the molecule that sits outside the cell. By binding to it, Herceptin effectively "flags" the cancer cell for destruction by the body's own immune system. Herceptin also seems to inhibit HER2 growth signaling more conventionally. But attracting an immune system attack is the primary way the drug works (also called, by pharma nerds, "mechanism of action" or MOA).

Tykerb (lapatinib). "The little newcomer." The second HER2 drug. Unlike Herceptin, Tykerb is a very small molecule that inhibits not only HER2 but also EGFR (HER1). Also unlike Herceptin, Tykerb attaches to EGFR and HER2 inside the cell. HER2 and EGFR still pair up with other members of the HER family, but because of Tykerb binding, the grow signal is never sent to other molecules in the "relay chain." Tykerb is used in patients with metastatic disease if they progress after using Herceptin. The other key point about Tykerb is that because it is a very small molecule, it can travel from the bloodstream into the brain, and it seems to reduce brain metastases in HER2 positive patients.

T-DM1. "Targeted AND chemotherapy." A modified version of Herceptin (trastuzumab). In this case "T" (trastuzumab) is attached to another molecule called "DM1" which is a traditional chemotherapeutic. How about this for tricky: the trastuzumab portion of the drug attaches to HER2 outside the cell. When it does, it causes HER2 to get pulled inside the cell, where there (and only there) the chemotherapy portion of the drug is released and kills the cell. So the chemotherapy only kills HER2-laden cancer cells and isn't released where it could do damage to other cells. T-DM1 appears to be doing well in clinical trials and is generating excitement.

OmniTarg (pertuzumab). "Separate, you two!" Remember that to send the grow signal inside the cell, HER family molecules on the cell membrane have to pair up. Well, Genentech has created a drug that inhibits this pairing ("dimerization"). Pertuzumab is a large monoclonal antibody like Herceptin. Like Herceptin, it binds to HER2 outside the cell. But it binds to a different part of the molecule than Herceptin, effectively inhibiting HER2 from pairing up with EGFR (HER1), HER3 and probably HER2 as well. No pairing, no growth signal. Lone HER2s just float around the cell membrane doing nothing. Cancer cell growth and proliferation slows or halts (in theory).

afatinib and neratinib "Same but (maybe) better." These two drugs are in clinical trials. They both work much like Tykerb, but they might end up being more potent and thus more effective. Like Tykerb, both are small molecules, both are taken orally as tablets, and both attach to HER2 inside the cell to inhibit growth signaling. But unlike Tykerb, they are so-called "irreversible" inhibitors of HER2. They bind and then stay attached to HER2. Tykerb is a "reversible" inhibitor that binds but sometimes detaches.

To find clinical trials for these drugs, you can go to clinicaltrials.gov. Or, better yet, try out a newer, easier-to-use site called BCTrials.org. This site provides personalized info about available clinical trials. It's sponsored by UC San Francisco.

Next: How doctors determine if you're HER2 positive