AMRIT for Indian Breast Cancer Patients

In my previous posts, I have highlighted the misery of poor Indian breast cancer patients who test positive for HER 2 neu. These cancers are usually aggressive and need to be treated with targeted agents like Herceptin. The problem is that each dose of Herceptin costs close to 50-60 thousand rupees in our country and this drug is not available in any government medical college.

Even with the introduction of bio-similars like CANMab, the cost of treatment remained to the tune to 40-45 thousand rupees per dose. I know many families, who sold their houses & jewelry to fund for their loved one’s Herceptin treatment. One such patient was Mrs. Laxmi (name changed), who had Stage III HER-2-neu positive breast cancer. She hailed from an average middle class family and the news of diagnosis of breast cancer was a huge shock for her. To add to her woes, she got to know that she would require close to 6 lakh rupees to fund for her Herceptin treatment. After a lot of deliberation with the family, she decided to fund her treatment by selling her wedding jewelry. Fortunately, things worked out well for her and she is still alive & healthy, 5 years after her cancer diagnosis. Other patients are not so lucky, as they do not possess such reserve money to fund for their HER treatment.

The Indian government’s new AMRIT scheme (Affordable Medicine & Reliable Implants for Treatment), might turn out to be a huge boon for these breast cancer patients. This scheme aims to bring down the cost of essential cancer medicines by 50-60%. The first AMRIT center was inaugurated recently at AIIMS and soon other centers would be started all across the country. Although the list of drugs which will be made available at these centers has not been released, I am hoping that Herceptin would be one of them. This would really help us in treating HER 2 positive patients, thereby leading to increased survival rates.

If this scheme is properly implemented, it will truly turn out to be an “AMRIT” for Indian cancer patients.

amrithandsonhands

Molecular sub-types of Breast Cancer

Molecular markers are the order of the day in most cancers and novel treatments are being developed against these molecular targets. In breast cancer also, these molecular markers not only help in deciding the management but also serve as prognostic markers.

Recently, breast cancer has been divided into four major sub-types:

  • Luminal A
  • Luminal B
  • Triple negative/ basal
  • HER 2 enriched

The following table depicts the molecular profile of these tumors:

Subtype These tumors tend to be

Prevalence (approximate)

Luminal A ER+ and/or PR+, HER2-, low Ki67

40%

Luminal B ER+ and/or PR+, HER2+ (or HER2- with high Ki67)

20%

Triple negative/basal-like

ER-, PR-, HER2-

15-20%

HER2 type ER-, PR-, HER2+

10-15%

ER – estrogen receptor, PR – progesterone receptor

Luminal A tumors:

Most breast cancers are luminal tumors. These tumors resemble the cells lining the mammary ducts and they tend to be:

  • Estrogen receptor-positive (ER+) and/or progesterone receptor-positive (PR+)
  • HER2/neu-negative (HER2-)
  • Low proliferation index (Ki67)
  • Tumor grade 1 or 2

Patients with these tumors express ER, PR receptors and thus are candidates for hormonal therapy (tamoxifen, anastrozole, etc.).

Out of all the four sub-types, luminal A tumors tend to have the best prognosis and low recurrence rates.

 

Luminal B tumors:

Luminal B tumors tend to be:

  • ER+ and/or PR+ (like luminal A tumors)
  • High proliferative index (Ki67) – high number of actively dividing cancer cells
  • Her2/neu positive or negative

Women with luminal  B tumors tend to have a poorer prognosis as compared to patients with luminal A tumors and the tumor characteristics in these patients include:

  • Poorer tumor grade 
  • Larger tumor size
  • Lymph node-positivity

 

Triple negative/basal-like:

Triple negative breast cancers are:

  • ER-
  • PR-
  • HER2-

Characteristic of triple negative tumors:

  • Occur in younger women
  • More common in African American women. Indian studies have also shows a very high rate of triple negative tumors among young Indian women.
  • Aggressive tumors with poor prognosis (worst prognosis among the four sub-types)
  • Increases chances of distant metastasis
  • As these patients are ER, PR negative, they are not candidates for hormonal treatment

These tumors are also referred to as a Basal like tumors and exhibit similar characteristics to tumors found in patients with BRCA 1 gene mutations.

 

HER2 enriched tumors:

HER2 type tumors tend to be:

  • ER-
  • PR-
  • Lymph node-positive
  • Poorer tumor grade
  • HER 2 positive (although 20-30% can be HER 2 negative as well)
  • 75 percent of HER2 type tumors contain p53 mutations
  • Poor prognosis

HER2/neu-positive tumors can be treated with the drug trastuzumab (Herceptin).