LBCA Scientific Advisory Board Member Discusses Ongoing Clinical Research in ILC
Breast cancer surgeons are often the first physicians to meet with patients after a diagnosis of breast cancer and help to navigate and formulate a treatment plan. It’s essential to integrate many sources of information—whether a tumor forms a lump on physical examination, how the lymph nodes feel, what the imaging studies show, the growth pattern seen on biopsy, the molecular features of the tumor, and the patient’s goals—to plan the best surgical treatment. Sometimes surgical outcomes are improved when either chemotherapy or endocrine therapy is given prior to surgery; this is called neoadjuvant therapy.
When I see patients with invasive lobular carcinoma (ILC) in particular, I know that many customary approaches may not be as reliable as we would like. While no test is perfect for any type of breast cancer, there are unique challenges when treating ILC. These tumors are frequently poorly seen on standard imaging tests and are therefore diagnosed at later stages.
Many studies show that when neoadjuvant chemotherapy is given, ILC doesn’t respond as well as other types of breast cancer, suggesting less benefit from this approach. Because people with ILC are often diagnosed with larger tumors or more positive lymph nodes, there can be inconsistency between what is termed clinical risk versus molecular risk.
This means that choosing the right order of treatments and the right type of treatment is especially challenging. Although there are now clinical trials specifically designed for patients with ILC, it can still be difficult to enroll ILC patients in clinical studies since they are relatively fewer in number or might be ineligible depending on study entry criteria.
My research focuses on improving clinical outcomes in patients with ILC. Currently, I am working on how to use different pieces of patient and tumor information to determine the best treatment for each specific patient with ILC and to quickly determine whether the patient might benefit from a given treatment.
One of my principal mentors is Dr. Laura Esserman, the lead investigator of the groundbreaking I-SPY2 Trial, a multicenter, randomized, adaptive neoadjuvant chemotherapy trial. Consequently, I am currently evaluating the rich radiomic, genomic, and clinical data from the I-SPY2 Trial to develop a clinical prediction tool for identifying ILC tumors that will benefit from chemotherapy. Other approaches will be needed for those tumors predicted not to respond to chemotherapy —some of these alternative approaches are now being tested in the Endocrine Optimization Protocol of the I-SPY2 Trial, where patients with low molecular risk tumors can receive neoadjuvant endocrine therapy in combination with novel agents.
My hope is that by developing ILC specific predictors, we can better personalize each patient’s treatment to not only improve surgical outcomes for those with ILC, but also reduce the risk of recurrence. Additionally, validating indicators of treatment response in ILC will be important for ensuring that more patients with ILC can be included in future clinical trials.
Dr. Rita Mukhtar is a breast surgeon and Associate Professor in the Division of Surgical Oncology at the University of California, San Francisco. Her research in ILC has been funded by the American Cancer Society and is currently funded by a K08 award through the National Institutes of Health. Watch Dr. Mukhtar discuss what makes lobular breast cancer different and the ILC research taking place at UCSF.