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Breast Cancer Treatments: Updates and New Challenges

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Breast Cancer Treatments: Updates and New Challenges Journal of Personalized Medicine Review Breast Cancer Treatments: Updates and New Challenges Anna Burguin 1,2, Caroline Diorio 2,3 and Francine Durocher 1,2,* 1 Department of Molecular Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1T 1C2, Canada; [email protected] 2 Cancer Research Center, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada; [email protected] 3 Department of Preventive and Social Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1T 1C2, Canada * Correspondence: [email protected]; Tel.: +1-418-525-4444 (ext. 48508) Abstract: Breast cancer (BC) is the most frequent cancer diagnosed in women worldwide. This heterogeneous disease can be classified into four molecular subtypes (luminal A, luminal B, HER2 and triple-negative breast cancer (TNBC)) according to the expression of the estrogen receptor (ER) and the progesterone receptor (PR), and the overexpression of the human epidermal growth factor receptor 2 (HER2). Current BC treatments target these receptors (endocrine and anti-HER2 therapies) as a personalized treatment. Along with chemotherapy and radiotherapy, these therapies can have severe adverse effects and patients can develop resistance to these agents. Moreover, TNBC do not have standardized treatments. Hence, a deeper understanding of the development of new treatments that are more specific and effective in treating each BC subgroup is key. New approaches have recently emerged such as immunotherapy, conjugated antibodies, and targeting other metabolic pathways. This review summarizes current BC treatments and explores the new treatment strategies from a personalized therapy perspective and the resulting challenges. Keywords: breast cancer; personalized therapies; molecular subtypes; breast cancer treatment; Citation: Burguin, A.; Diorio, C.; luminal; HER2; TNBC Durocher, F. Breast Cancer Treatments: Updates and New Challenges. J. Pers. Med. 2021, 11, 808. https://doi.org/10.3390/jpm11080808 1. Introduction Breast cancer (BC) is the most frequent cancer and the second cause of death by Academic Editor: Hermann Nabi cancer in women worldwide. According to Cancer Statistics 2020, BC represents 30% of female cancers with 276,480 estimated new cases and more than 42,000 estimated deaths in Received: 30 June 2021 2020 [1]. Accepted: 16 August 2021 Published: 19 August 2021 Invasive BC can be divided into four principal molecular subtypes by immunohisto- logical technique based on the expression of the estrogen receptor (ER), the progesterone Publisher’s Note: MDPI stays neutral receptor (PR), and the human epidermal growth factor receptor 2 (HER2) [2]. Luminal A with regard to jurisdictional claims in BC (ER+ and/or PR+, and HER2-) represents around 60% of BC and is associated with a published maps and institutional affil- good prognosis [3]. Luminal B BC (ER+ and/or PR+, and HER2+) represents 30% of BC iations. and is associated with high ki67 (>14%), a proliferation marker, and a poor prognosis [4]. HER2 BC (ER-, PR-, and HER2+) represents 10% of BC and is also associated with a poor prognosis [5]. Lastly, triple-negative BC (TNBC) (ER-, PR-, and HER2-) represents 15–20% of BC and is associated with more aggressivity and worse prognosis compared to other BC molecular subtypes and often occurs in younger women [6]. Characteristics of BC by Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. molecular subtypes are described in Figure1. This article is an open access article The 5-year relative BC-specific survival rate of BC is encouraging with 90.3% for all distributed under the terms and subtypes and stages. However, for metastatic BC the 5-year relative cancer-specific survival conditions of the Creative Commons rate is still low: 29% regardless of subtype and can drop to 12% for metastatic TNBC [7]. Attribution (CC BY) license (https:// This clearly indicates that strategies of treatment for metastatic BC patients are not effective creativecommons.org/licenses/by/ enough to ensure a good survival rate. Thus, it is crucial to find new solutions for the 4.0/). treatment of metastatic BC and especially TNBC. J. Pers. Med. 2021, 11, 808. https://doi.org/10.3390/jpm11080808 https://www.mdpi.com/journal/jpm J. Pers. Med. 2021, 11, x FOR PEER REVIEW 2 of 57 J. Pers. Med. 2021, 11, 808 2 of 54 effective enough to ensure a good survival rate. Thus, it is crucial to find new solutions for the treatment of metastatic BC and especially TNBC. TreatmentTreatment choice is based on the grade, st stage,age, and BC molecular subtype to have the mostmost personalized, safe,safe, andand efficientefficient therapy. therapy. The The grade grade describes describes the the appearance appearance of tumorof tu- morcells cells compared compared to normal to normal cells. Itcells. includes It incl tubuleudes differentiation,tubule differentiation, nuclear pleomorphism,nuclear pleo- morphism,and the mitotic and the count mitotic [8]. Thecount stage [8]. The is used stage to is classify used to the classify extent the of cancerextent of in cancer the body in theand body is defined and is usingdefined the using TNM the system TNM comprising system comprising tumor size, tumor lymph size, node lymph status, node and status, the andpresence the presence of metastases of metastases [9]. For non-metastatic[9]. For non-metastatic BC, the strategic BC, the therapystrategic involves therapy removing involves removingthe tumor the by tumor complete by complete or breast-conserving or breast-conserving surgery with surgery preoperative with preoperative (neoadjuvant) (neoad- or juvant)postoperative or postoperative (adjuvant) (adjuvant) radiotherapy radiotherapy and systemic and therapy systemic including therapy chemotherapy, including chemo- and therapy,targeted and therapy. targeted Targeted therapy. therapy Targeted comprises therapy endocrine comprises therapy endocrine for hormone therapy receptor-for hor- monepositive receptor-positive (HR+) BC and (HR+) anti-HER2 BC and therapy anti-HER2 for HER2+therapy BC.for HER2+ Unfortunately, BC. Unfortunately, there is no thereavailable is no targetedavailabletherapy targeted for therapy the TNBC for the subtype. TNBC subtype. For metastatic For metastatic BC the BC priority the priority is to iscontain to contain tumor tumor spread spread as this as this type type of BC of remainsBC remains incurable. incurable. The The same same systemic systemic therapies thera- piesare usedare used to treat to treat metastatic metastatic BC [ 10BC]. [10]. ChallengesChallenges in in the the treatment treatment of of BC including dealing with treatment resistance and recurrence.recurrence. Indeed, Indeed, 30% 30% of of early-stage early-stage BC BC have have recurrent recurrent disease, disease, mo mostlystly metastases metastases [11]. [11]. Thus,Thus, it it is is crucial crucial to to develop develop new new strategic strategic ther therapiesapies to to treat treat each each BC BC subgroup subgroup effectively. effectively. ThisThis review will summarize currentcurrent treatmentstreatments for for invasive invasive BC, BC, the the underlying underlying resis- re- sistancetance mechanisms mechanisms and and explore explore new new treatment treatment strategies strategies focusing focusing on on personalized personalized therapy ther- apyand and the resultingthe resulting challenges. challenges. Figure 1. Characteristics of of breast cancer molecular subtypes. ER ER:: estrogen estrogen receptor; receptor; PR: PR: progesterone progesterone receptor; receptor; HER2: HER2: human epidermal growth factor receptor 2; TNBC: triple-negative breast cancer. a.. Frequency Frequency derived derived from from Al-thoubaity Al-thoubaity b c et al. [12] [12] and Hergueta-Redondo et al. [[13].13]. b.. Grade Grade derived derived from from Engstrom Engstrom et al. [14]. [14]. c.. Prognosis Prognosis derived derived from from Hennigs Hennigs et al. [15] and Fragomeni et al. [16]. d. The 5–year survival rate derived from the latest survival statistics of SEER [7]. et al. [15] and Fragomeni et al. [16]. d. The 5–year survival rate derived from the latest survival statistics of SEER [7]. 2.2. Common Common Treatments Treatments for All Breast Cancer Subtypes InIn addition addition to to surgery, surgery, radiotherapy radiotherapy and and ch chemotherapyemotherapy are used routinely to treat all BCBC subtypes subtypes [17]. [17]. 2.1.2.1. Surgery Surgery TheThe most most standard standard breast breast surgery surgery approaches approaches are are either total total excision of of the breast (mastectomy),(mastectomy), usually usually followed followed by by breast breast re reconstruction,construction, or or breast-conserving surgery (lumpectomy).(lumpectomy). Lumpectomy Lumpectomy entails entails the the excision excision of the of the breast breast tumor tumor with with a margin a margin of sur- of roundingsurrounding normal normal tissue. tissue. The Therecommended recommended margins margins status status is defined is defined as “no as “noink inkon tu- on mor”,tumor”, meaning meaning no noremaining remaining tumor tumor cells cells at the at thetissue tissue edge edge [18]. [18Studies]. Studies show show that total that total mastectomy and lumpectomy plus irradiation are equivalent regarding relapse-free and overall survival (OS) [19]. Contraindications for breast-conserving surgery include J. Pers. Med. 2021, 11, 808 3 of 54 the presence of diffuse microcalcifications (suspicious or malignant-appearing),
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