Poor treatment landscape for TNBC

Despite Korea's excellent breast cancer treatment record, as evidenced by a 93.8 percent five-year survival rate for breast cancer from 2016 to 2020 according to national cancer statistics, there remains a formidable challenge in triple-negative breast cancer (TNBC). 

TNBC is characterized by the absence of expression of all three important receptors: estrogen receptors (ER), progesterone receptor (PR), and human epithelial cell proliferation factor receptor type 2 (HER2). 

Unfortunately, the treatment landscape for triple-negative breast cancer in Korea is notably inadequate.

TNBC stands out as one of the least effectively treated types of breast cancer when compared to other variants. 

According to Professor Park Kyong-hwa of Hematology and Oncology at Korea University Anam Hospital, even when detected at an early stage, treatment outcomes for TNBC are notably poorer if cancer cells have disseminated to nearby lymph nodes. Moreover, what makes this form of breast cancer particularly alarming is its heightened propensity to metastasize to vital organs like the brain and lungs, resulting in a more substantial disparity in prognosis compared to other breast cancer types.

Nevertheless, the underlying causes of the challenging treatment landscape for TNBC have evolved over time.

Historically, the absence of effective treatment options for intractable triple-negative breast cancer left patients with limited options. Even when seeking care at prestigious university hospitals with robust cancer treatment infrastructure in Korea, they were unable to reap the benefits of expanded health insurance coverage for innovative drugs, a privilege enjoyed by other breast cancer types. In essence, it was a form of cancer that denied the advantages of the “Korean premium. However, the situation has undergone some changes in recent times.

Economic barriers to effective treatment

"Do you have insurance?" "Can you afford to spend some 50 million won ($37,713)?" 

In contemporary clinical settings, cancer specialists commonly ask these questions to patients diagnosed with TNBC. 

Professor Park shed light on the challenges of treating this condition during the “Policy Discussion for Resolving the Treatment Dead Zone of TNBC which Threatens Women's Lives in their 20s and 30s.”

The event was hosted by Rep. Lee Jong-seong of the People Power Party and organized by the Korean Cancer Study Group’s Breast Cancer Committee. 

Cancer immunotherapy Keytruda (pembrolizumab) and antibody-drug conjugate (ADC) Troldelvy (sasituzumab govitecan) are licensed in Korea, but both drugs are currently under review by the Health Insurance Review and Assessment Service (HIRA).

Thus, the direction of treatment is decided by the patient’s financial situation.

According to Park, it is crucial to remove all breast cancer cells through preoperative chemotherapy in TNBC.

He underscored the significant disparity in long-term prognosis between patients who receive this treatment and those who do not. 

Patients who achieve complete eradication of breast cancer through preoperative chemotherapy enjoy an impressive long-term survival rate of 80 percent, along with a similar likelihood of avoiding recurrence. 

Conversely, patients who do not achieve complete remission face a notably lower long-term survival rate, ranging from 20 percent to 30 percent, he said.

"Nevertheless, the treatment options available for this purpose are not currently covered by medical insurance in Korea," said Park, explaining why physicians should ask the financial status of the TNBC patient. 

Triple-negative breast cancer is a highly malignant form of cancer that necessitates the utilization of all available treatment options from the outset. 

The risk of recurrence with this type of cancer is notably elevated. 

Patients with hormone receptor-positive breast cancer may experience some recurrence, but the risk is lower due to the availability of long-term preventative drug treatments.

In the case of HER2-positive breast cancer, targeted therapy can be administered for a year, reducing the likelihood of recurrence. 

“However, for TNBC, when residual cancer remains after surgery, the only recourse is a six-month medication of Xeloda. Consequently, the risk of recurrence within three years is substantially heightened," he explained.

Treatment outcomes for recurrent and metastatic triple-negative breast cancer are indeed quite discouraging. While it's important to note that the prognosis for TNBC can vary significantly among individual patients, Professor Park highlighted that the recurrence pattern is marked by a particularly grim outlook. 

"In cases of recurrence or metastatic cancer diagnosis, the survival period for patients with TNBC typically hovers around one year," Park said.

The current cure rate for triple-negative breast cancer stands at approximately 5 percent, with economic circumstances exerting significant influence on the chances of achieving a cure. 

"The most critical determinant of a cure at present is, in fact, one's financial status," emphasized Park. 

Call for social consideration, policy support

The prognosis for TNBC remains exceptionally poor, even when diagnosed at an early stage, and once it recurs, patients face immense fear and limited treatment options, Park went on to say, underscoring the urgent need for societal considerations in addressing this issue.

In fact, the majority of TNBC patients in their 20s and 30s cannot receive adequate chemotherapy. 

Lee Doo-ri, a representative of the TNBC patients' association Woori Doori Guseul Hana, said in the policy discussion that a patient should pay hundreds of millions of won to receive multiple cycles of Trodelvy treatment. One cycle of Trodelvy costs around 21 million won. 

Lee shared that three patients with TNBC and brain metastases received recommendations from their doctors to use Troldelvi but they were unable to access this treatment and passed away. 

“This underscores the urgent need for expeditious reimbursement of new drugs in the market. Such reimbursement would not only provide patients with a ray of hope for extending their lives but also offer them the strength to face their battle with a sense of purpose rather than living in constant fear of mortality,” she said. 

Rep. Lee said patients with TNBC account for 11 percent of all breast cancer cases and that their five-year survival rate is only about 12 percent due to the limited efficacy of existing treatment. 

Despite the development of new drugs, their unavailability without reimbursement presents a significant barrier, he said.

“It is imperative for both the government and the private sector to engage in discussions aimed at providing policy support for those affected by TNBC who currently find themselves in a vulnerable position. Collaborative efforts are essential to find a resolution to this pressing issue,” he added.