TCH or ACT chemo for Her2+

rayhope

MRSROCKYTOP55:  I didn't fly during chemo but have worn my contacts (soft lens) the whole time.  I have my last of 6 TCH treatments this Thursday and haven't had a problem with the contacts.

Annaanne

I flew during chemo, even though it freaked my oncologist out.  I had to fly to consult with my surgeon (I had neo adjuvant chemo.)  The big thing is to avoid germs and sick people.  Just be careful.  Wipe down the food tray.  When you use a public bathroom, flush with your foot (advice from my doc!)  Wash your hands like crazy.  When I arrived at the check in desk, I asked for a seat with no one next to me and explained my situation.  When possible, I was accomodated.  Now that I remember, I think I actually wore gloves -- which I'm sure didn't help one iota.  I didn't get sick.

Annaanne 

bluedasher

I flew during chemo, but I was on TCH with a 3 week cycle. My trips were all on week 3 when my WBC was back up and I was over most chemo symptoms (except I needed an extra hour or two of sleep each night). I was careful to eat as healthy as possible and to get the rest I needed but other than that didn't take any special precautions.

I had a cold after one of the three trips but maybe I can't blame that on the trip. My granddaughter had a cold before I left and when I got home and started coming down with the cold, so did my husband and daughter-in-law so we may have all gotten it from my grandaughter.

suemed8749

Mrs. Rocky Top: Last summer, I flew from Arizona to Illinois during chemo (TCH). No problems. We also drove down to the Mexican coast for vacation - went swimming in the Sea of Cotez - with my wig on!

Best Wishes, Sue

MRSROCKYTOP55

Thank you for the info on the travel and the contacts.  What a great resource this is.  Bye for now.

MMunday

Were all of you found positive on your FISh test? I was IHC 3++ but fish negative but the IHC was only done on the core biopsy. It is now being redone on the actual tumor block as they have found (so I have been told) you can still benefit from herceptin if your IHC is 3 ++ but FISH negative. But I was also told you had to be fish positive??? Is that true? I am feeling not so good about ACT plus H and am looking at TC plus H trial (not the same as TCH).

Thanks !!

Michele 

orange1

Hi Michele,

I was ICH 2+, but FISH positive.  I saw a study that showed significant benefit for Herceptin  no matter how positivity was determined, either ICH or FISH.  My understanding is that a positive test with either method qualifies you to receive Herceptin.  I'll see if I can find the study and post.  With ICH 3+, don't let them dissuade you from Herceptin.

When you say TC plus H, do you mean they will give H after you complete TC?

Jackie

MMunday

Correct...I really wanted TCH ( with the carboplatin) but was told I had to be FISH positive.

So I am waiting for those results...I guess if I'm still IHC 3++ but fish negative it may not be an option but ACT plus H is....but I'm actualy leaning towards TC ( different then the TC in TCH...the new trial also adds Herceptin in ). Not real sure I want to go the AC way??

Trying to navigate the waters!!

Thank you so much for your reply!!

Michele 

orange1

Hi Michele,

Is the reason you cannot do TCH because your insurance won't pay (so need to do a trial to get H paid for) or because your onc isn't willing to give it?  If your onc doesn't want to give it, did he/she give you a reason? 

cindy2

It is tough to know what to do.  AC-TH or TCH.  The BCIRG 006 study looked at women with 'early stage breast cancer" rather than those with locally advanced disease.  I am concerned about the THC being quite new.  Did your doctors push you one way or the other or did they give you the choice?  How many of you got second opinions?  If so did both sets of doctors agree?

C.

IDC, stage III, multicentric disease (4.5 cm and 2.7 cm), grade III, ER+/PR+/Her2+

MMunday

Hi Ladies,

 Well from what I understand if my IHC is still high they will recommend Herceptin...but TCH was only done on true FISH positive??? The difference is FISH tests for gene amplificaition and  IHC for high protein, usualy a sign of gene amplification but not always. Both though benefit from Herceptin. So they may still recommend Herceptin but not TCH....so confusing ...see the onc again tomorrow...hopefully more answers!

orange1

Michele,

It is correct that in trail BCIRG006 inclusion criterial included being FISH positive, but there is no evidence that I've seen published that supports the theory that it won't be effective in ICH 3+.  However, there is evidence from 2 studies that giving Herception sequentially to chemo versus concurrently like your onc is recommending, is less effective.  The first study is PACS-04 study.  In this study Herceptin was given sequentially to chemo and the Herceptin arm failed to show a statistically significant improvement in recurrence.  It is the only failed adjuvant Herceptin trial.  The other study is HERA.  In this case Herceptin was also given sequentially to chemo and the risk reduction for recurrence was 36% versus about 50% when it was given with chemo in the Joint Analysis trials.

Bottom line is that there is evidence to support concurrent Herceptin and Chemo is superior to sequential therapy.  Your onc is suggesting an unproven regimen (which is fine if it makes sense for you).  But she is potentially denying you TCH, a proven treatment, on the the theory that it won't work for ICH 3+.  This theory has no scientific basis as far as I can tell.  The regimen she is suggesting seems more risky than the one you want.  If you really want TCH and she won't give it to you, I would consider seeing a different onc.

PM me if you would like more detailed information. 

Good luck at your appointment tomorrow. 

Jackie

orange1

Hi Michele - I copied this from another thread (my posting, copied from an editorial in "Current Oncology":

This is an editorial, but the data are worth considering.  From Current Oncology - Volume 15, Number 1 (published in 2008):

Which Approach is the Most Effective (referring to concurrent Herceptin or sequential Herceptin)?

The key trial that will answer the question of effectiveness is NCCTG N9831, which randomized patients to no trastuzumab (t), concurrent t, or sequential t with a chemotherapy backbone of AC followed by weekly paclitaxel.  The results of the unplanned interim analysis presented at the 2005 American Society of Clinical Oncology meeting demonstrated that the concurrent approach was superior to the sequential approach, and furthermore, that the sequential approach was no better than control.  However, given that the interim analysis was unplanned, most clinicians will not make treatment decisions based on its results.

Another trial presented at the 2007 San Antonio Breast Cancer Symposium also indicated that the sequential approach may not be as effective.  The randomized PACS-04 study was initially designed to compare 6 cycles of FEC100 to 6 cycles of epirubicin given concurrently with docetaxel.  Then in a second randomization, Her2+ patients were randomized to receive or not receive t after completion of chemotherapy.  The authors presented their results with a median follow-up of 4 years.  No significant improvement was observed in DFS (hazard ratio 0.86 or overall survival (hazard ratio 1.27).  There did appear to be initial efficacy in the first 18 months, but the effect was lost over the next 2 years.  Numerically, fewer metastatic events were seen on the t arm.

And so PACS-04 is the first negative adjuvant t trail (meaning did not show an improvement with t).  Why given all the previous trials, was an additional benefit of t not seen in its patients?

The PACS-04 patients all received adequate anthracyclines, and about 50% had an adequate dose of a taxane.  The results seen are similar to those from the unplanned analysis of the sequential arm of NCCTG N9831 (hazard ratio 0.87).  Also, it is concerning that, with sequential therapy, a benefit initially seen is lost with longer follow-up.  The suggestion is that t may have a cytostatic effect when given sequentially as compared with a cytotoxic effect when given concurrently.

Why was no benefit seen with the the sequential approach in the PACS-04 trial, when a benefit was observed in HERA?  One explanation may be that the patients in HERA did not receive adequate chemotherapy, ant the in the presence of third-generation regimen, the benefit of t is seen only in a concurrent and not in a sequential regimen.  The evidence from concurrent regimens has previously showed a benefit in the range of about 50% reduction in the relative risk of disease recurrence and 40% reduction in the relative risk of mortality.  And notably, these results occurred despite a backbone of third-generation chemotherapy regimens....

 Good Luck with your decision.

helena67

Why would ICH+++ be different from FISH+?

I always thought it was the same test but that ICH+++ was more 'qualitative' and perhaps prone to assay variability depending on if the analyst is experienced or not. I never did the FISH. Can one be ICH+++ without being HER2+

??

Otherwise I agree with the comments given. This is not a time to experiment or to enroll in a trial to do the oncologist a favor. Either AC-TH or TCH seems very appropriate to me.

-Helena.

orange1

Hi Cindy -

My doctors did not agree.  Here is my story...

My local onc would only allow me to do TCH, even though I wanted to do AC TH (for early stage cancer).  I wanted that extra 1% even though its not real, statistically speaking.  My second opinion (very famous Onc - Gradishar, Northwestern) said at Northwestern they recommend AC TH, but either is acceptable, but that was almost 2 years ago before momemtum for TCH started building and before delayed heart problems associated with adriamycin where talked about so much.  Third opinion (Mayo) said it didn't matter, just stop screwing around and start something.  I ended up with TCH and am happy with it now - after I could finally calm down and understood the data better, both with regards to effectiveness and heart damage.  But I understand the stress you are under.  I literaly had nightmares about chemo regimens while I was trying to decide.  I was on strong sleeping pills to keep from waking up at 4 am in a heart-racing panic about which regimen to go with (Northwestern is local for me, so I could have done AC TH.) 

For locally advanced, I absolutely understand why you want the treatment with more evidence behind it.  I would to.  If it were me, I would also want the AC TH because at this stage you are rightfully more afraid of the cancer than of potential heart issues.  That being said, there is really no evidence against TCH and no evidence to suggest it is any less effective that AC TH.  Also, if AC decreases your LVEF (left ventricular ejection fraction - a measure of your heart's ability to pump blood), your onc may hold the herceptin so you could end up not having what is probably the most important part of your treatment.

Just remember that there is considerable evidence that both regimens are highly effective so in the choice between TCH and AC TH either choice is good (as long as you don't have a pre-existing heart problem).  Even though BCIRG006 was only one trial, it was large and well conducted, so the data are very reliable. 

I am sorry I can't be of more help.  But I have read these studies so often I practically have them memorized.  If you have any questions or want to discuss, feel free to PM me.

Best - Jackie

mmm5

ok I would like to weigh in here as well!

I just got home from my 3 month check with ONC. It is my first 3 month appt after finishing Herceptin in May. I really drilled him today about Her2 tumors and first let me say that his findings (he is number 1 ONC in AZ) and my 2nd ONC concurs that Herceptin is the most important drug for Her2. That being said the data show an increased effectiveness if it is concurrent with chemo regimen. Before Herceptin Adriamycin was found to be more effective for early Her2 tumors. Now (and I don't have the study but can get copy) they are stating that Taxotere may be more effective than Adriam. on Her2 tumors especially when combined with Herceptin. I went through mugas and echos for a year with Herceptin and met 4 ladies that did AC-TH and 3 had some heart damage or lowered EF score. I had no decrease in EF and had TCH.

I know chemo and cancer are scary now but my closest BC friend here in AZ was stage 3 with many nodes and she went through ACTH at age 42 and she has significant heart damage, she has to keep up with a cardiologist every 3 months and take drugs. She is cancer free for 5 years and now her ONC's say had she been dxed now she would have TCH.

My Onc stated today that there is varying opinions between the east and west coast, that UCLA has really led the charge for TCH and many west coast ONCS are following suit. Keep in mind that this is where much of the Herceptin work was initiated with Dr. Slamon (spelling I think).

I have no regrets on the TCH for early stage BC like yours, your odds are good with either chemo and Herceptin for a year.

orange1

Bump for Karina

janet11

For another (corroborating) opinion:  I had TCH -- I was one of the earlier people going through that when very few on this board were on TCH.  And I had an EF problem with Herceptin alone.  If I had been on ACT and had heart problems, I might never have gotten to the Herceptin -- and for me, the Herceptin was MUCH more important.  Also, there are more possibilities of permanent side effects with the ACT (mainly cardiac).

So I'm very happy my onc chose the TCH (we discussed both protocols).  At least this way, I went through about 6 months of Herceptin before they had to take me off of it.  And the heart problems finally went away about 2 years later.  Yippee (*smile*).

I would definitely go with TCH unless there's a specific reason to go with the ACT.  Wishing all the people here working on this decision much luck!!

janet11

For another (corroborating) opinion: I had TCH -- I was one of the earlier people going through that when very few on this board were on TCH. And I had an EF problem with Herceptin alone. If I had been on ACT and had heart problems, I might never have gotten to the Herceptin -- and for me, the Herceptin was MUCH more important. Also, there are more possibilities of permanent side effects with the ACT (mainly cardiac).

So I'm very happy my onc chose the TCH (we discussed both protocols). At least this way, I went through about 6 months of Herceptin before they had to take me off of it. And the heart problems finally went away about 2 years later. Yippee (*smile*).

I would definitely go with TCH unless there's a specific reason to go with the ACT. Wishing all the people here working on this decision much luck!!

MMunday

Hi Everyone,

 I am so frustrated....just feel kind of lost. I have been working with two Onc and really like both. One here in my smaller town and one at a research hospital. I posted a while back and am still in the same mucky water...it seems there is so much gray area or maybe it's just me...LOL! My core biopsy was a IHC 3++ but Onc here did not trust that in house lab so sent it out to a larger prominent lab (the actual tumor block) and did FISH. During this time I had gone for a second opinion at U of MD. When FISH came back negative everyone wanted to 100% sure because you don't want miss out on Herceptin if it is needed. Onc at U of MD explained how they had found you could not have the gene amplification yet still the high protein count and benefit from Herceptin. So U of MD redid the IHC on the actual tumor block..(the first was done on core biopsy) but they said the tumor block was not well preserved??? What does that mean and who's job was it to preserve it??? If IHC came back high 3++ we would redo fish on core biopsy samples...perhaps FISH came back negative because of the tumor block not being well preserved.Ok so IHC comes back positive...in the meantime we also did an Oncotype...back yesterday...recurrence rate 28 (chemo is a definite, no question we did it for the HER2 facto) HER2 negative!!!!! Ok so now I have 2 positives and 2 negatives with one more FISH to go but I'm going a little batty!! After the last IHC the tumor board had met and everyone had agreed I needed Herceptin so now if anyone comes back and says ohh never mind your HER2 negative ....how can I trust that??

I feel like I am in such limbo...surgery was July 7th and I need to get started soon. I have researched just about every chemo combo available...and who has time for this....( I mean that with a grain of salt...I know this is our lives and the most important thing but in the mean time you feel like your days are being sucked away by all the info and trying to figure out the best options...I feel like sometimes the Oncs struggle as much as we do!

I will get my port next week ...I had held off to see what chemo I would do...I just wasn't sure I wanted to go the port route but I think that is probably best. I would like to do TCH if I need Herceptin ...don't want to risk AC and not be bale to get H. If no Herceptin dose dense AC+T.

Was looking at TC 6 doses instead of 4 but most Onc seem to recommend AC+T. My cancer seems to be an aggressive booger. I am 36 and my new path report seems to point to multi focal...which is the first time I have heard that...with the largest being 2.5cm...no other sizes mentioned. I also had extensive lymphovascular invasion and 2 positive nodes ...one being 1.7 cm. Anyone else have a hard time with test results or borderline HER2 ??

Thanks so much for listening :)It's so hard to explain to people not in it though bless their hearts they try!!

I also had a revelation that I can do all the research I need but then I just need to do what feels right and makes me most comfortable...God doesn't need my help...just my faith, he can handle the rest!!

Love,

Michele

cindy2

Very similar circumstances here.  Two tumors in right breast.  Biopsies of both tumors positive by FISH for Her2.  After my mastectomy, only the larger tumor was sent off for FISH and the result can back 'equivocal'.  I just got back from my second opinion at a major research hospital.  One of the questions I had for the oncologist was--how do we reconcile the mismatching Her2 results?  Her answer was very refreshing.  She said the that pathologists at the hospital had sent materials off for retesting but that the fact of the matter was that she did not really care how the results of the retest came out.  Because of the positive biopsy specimens she was going to treat with Herceptin.  In her opinion it was too dangerous to not treat with positive results.  I had two fairly big tumors and some really big lymphnodes and she commented that within larger tumors you can have areas that are Her2 positive and those that are negative, but you have to treat if there are positive areas.  So I have come to peace with not knowing for sure and I fully agree with the oncologist that in my case we have to treat with herceptin.

MMunday

Thank you for replying Cindy . Are you going with ACTH or TCH?

cindy2

MMundy:

My second opinion said that there was no question but what I needed AC TH rather than TCH.  So I am going to go with that.

Cheers!