Stage 1 with chemo and radiation for my 71 year old grandmother

kepperson

My grandmother (age 71) was recently diagnosed with Stage 1 breast cancer. They went ahead with a double masectomy and the good news was that it didn't spread into the lymph nodes.  Well, we thought that would be the end of it, but now they want her to go through chemo and radiation.  They also want her to take part in an experimental drug trial during the chemo.  From the information I've found, stage 1 with a double masectomy and cancer that hasn't spread doesn't generally require chemo. I guess I'm just confused and I want to make sure they aren't putting her the chemo just to have another subject for their drug trials.  Is it normal for chemo and radition with stage 1 and a double masectomy? Anyone ever hear of this.  

By the way, this is my first time here, so I'm sorry to bombard you all, but I just can't find any answers anywhere.  If anyone has any opinions or facts, lpease let me know.

Thanks so much.  

Kristi 

Thatgirl

Hi kristi,

I'm sorry you had to find us. There are not many people on the board at night but I'm sure someone will post in the morning. It seems like they are doing a lot to your grandmother. I've only been on the board for a short which but from what vie read it seems like over treatment. What kind does she have? What grade? What size was the tumor? While you wait for others.....read as many threads as you can.



Good luck.

kepperson

I'm not sure about all of the details right now.  We're still trying to figure it all out. Unfortunately I wasn't able to attend her surgery, and speak directly with the doctors. She was given a bunch of packets on her future treatment plans, but none of them are in lamens terms and I've tried to decipher them as best as I can, but I know that she doesn't understand them either.  I'm going to try and make it to her next appointment this Friday, but its about a 4 hour drive from here.  I am definitely concerned that it's overtreatment, especially from all of the other research I've read.  She also ahs a fractured hip right now. She's up and walking around alright, but I don't evne know if they can do the chemo unless that's all healed up.  Its just so frustrating getting a straight answer from anyone and my poor grandmother has no idea what kind of decisions to make. She's so overwhelmed and nobody will explain to her (in a way that she can understand) exactly what's going on.  The tumor wasn't very big. from what I understand, I don'tknow the exact measurements off hand, and she probably could have gotten away with a lumpectomy because none of the cancer spread to any lymph nodes or anything.  I'm not sure about the grade.   Still have a lot of information I have to figure out about it all, this has all bene happening within about the last 4 weeks. 

 Thanks for the reply though!

Kristi 

BarbaraA

I think I would say no to both rads and chemo if I were her age. Stage 1 and a mastectomy 90% of the time means no rads and no chemo. 2nd opinion time, I think.

37antiques

I agree with BarbaraA, given the small tumor size with no lymph involvement.  Chemo and rads can both be really hard on the body, and rads can weaken the bones,  If she already has a broken hip, I wouldn't want to make them weaker and put her through the side effects.  For sure not the chemo, that seems like a lot of overkill, Rads can damage the heart and lungs. If she had an aggressive grade, I might consider rads, but it does depend on her overall health.

American Cancer Society's treatment guidline for a tumor smaller than 5cm with no node involvment recommends no rads or chemo unless the margins are close.  I would get a second opinion and more complete information. 

LuvRVing

Definitely get a second opinion.  There is little evidence that chemo provides any advantage for a stage 1 senior with no node involvement.   I hope you get answers that give you some reassurance. 

Michelle

ruthbru

If the information you have is right; then they would be definitely over-treating her. Many potential SE without much gain. Good for you for being her advocate!

arminavy

Hi, my mom was on this position too. I need a suggestion if she need chemotherapy if the hispatology report says no tumor found and negative for tumor involvement. Thank

Moderators

arminavy, welcome to our Community. Keep us posted on what you find out about your mom too.

BarredOwl

Hi Arminavy:

This thread is really old, so the original posters may not reply.

Even with negative nodes ("N0"), sometimes one or more "systemic treatments" are considered or recommended. When indicated, there are three main types of systemic drug treatments:

-- Chemotherapy (various combinations of small molecule drugs, such as docetaxel, paclitaxel (Taxol), adriamycin plus cytoxan (cyclophoshpamide)("A/C"), etc.);

-- HER2-targeted therapy for HER2-positive disease (antibody therapeutics that bind HER2, including trastuzumab (Herceptin), pertuzumab (Perjeta)); and/or

-- Endocrine therapy for hormone-receptor positive disease (ER and/or PR-positive) (e.g., tamoxifen or an aromatase inhibitor)

Systemic treatment recommendations (which of the three main types of drugs) for "invasive disease" are generally based on:

(a) histology (e.g., ductal, lobular, etc.);

(b) the size of the tumor in millimeters or centimeters (which may be e.g., T1mi, T1a, T1b, T1c, etc.)

(c) lymph node status (e.g., pN0, pN1mi, pN1, etc);

(d) hormone receptor status (i.e., estrogen receptor (ER) and progesterone receptor (PR); and

(e) HER2 status.

More information is needed for anyone to provide you with any useful guidance.

(1) Please take the time to review the complete pathology reports from all biopsies and from the surgical pathology, and provide key details (a) through (e). It would help to indicate biopsy findings separately from surgical pathology findings.

(2) If staging information is provided on the surgical pathology report, please include it (e.g., pT1 N0 M0).

(3) Please indicate what surgical treatment was received (e.g., lumpectomy or mastectomy).

(4) Please specify what treatment recommendations were received (i.e., radiation, chemotherapy, HER2-targeted therapy, and/or endocrine therapy) and specific agents, if known.

(5) How old is the patient and what is her menopausal status (pre- or post-menopausal)?

Regarding the information above:

". . .if the hispatology report says no tumor found and negative for tumor involvement."

(i) Please explain what you mean by "no tumor found." Did she have a clearly positive biopsy, but no additional disease was found in the pathology performed on the surgical samples? What type of biopsy was performed (e.g., stereotactic core-needle, excisional or surgical biopsy)?

(ii) Were lymph nodes negative by imaging and clinical exam, and no lymph node biopsy was performed PRIOR to surgery?

(iii) Did you mean to say the sentinel node biopsy was totally negative, so the surgical pathology report shows lymph node status as "N0"?

Hopefully, with more information people here can provide relevant information about the advice she is receiving.

BarredOwl

BarredOwl

I note that Arminavy has not specified her mother's age, and age is just one factor. I think a lot more information is needed before one can conclude that either radiation or systemic treatment would be over-treatment. This is especially so, as many new members do not realize that "endocrine therapy" is technically not "chemotherapy."

BarredOwl

arminavy

Hi everyone, thank you for reading my post. My mom is 71 years old. Last April 11,2016 she complain of nipple discharge on her right breast. Upon check-up the doctor requested routine mammogram and routine ultrasound on the affected breast. Results for ultrasound was breast shows a well defined complex nodule in the 11-12 oclock measuring 1.5x1.5xx1.5 cm. Impression: Complex Breast Nodule vs Intraductal papilloma, Right. BIRADS3 (Probably benign) suggest follow up study. Benign Adillary Lumph Nodes. Mammogram: An isodense nodule is seen in the right retroareolar area with 2 small internal calcifications. Impression was Isodense Nodule with small internal calcifications, Right. Birads 3 ( probably Benign. Lumpectomy was done April 16,2016. Hispatology result shows Invasive papillary Carcinoma. On May 16,2016 Modified Radical Mastectomy was done on her right breast.

Two weeks after hispatology report: Diagnosis: S/P Modified Radical Mastectomy, Right( with previous excision Biopsy result of Papillary Carcinoma.)

-No residual tumor.

Negative for tumor involvement:

All surgical margins.

Nipple areolar complex

Skin

All three lymph nodes specimen label " axillary lymph nodes.

Soecimen labeled "Axillary fat pad"

Follow up with her Oncologist. Treatment recommendation was 6 rounds of Chemotherapy.

Need any suggestions pls. I lost my father two years ago from Pancreatic Cancer. I am totally frightened

BarredOwl

Hi arminavy:

Thank you for the additional information. I understand that the mastectomy was a second surgical procedure, and showed no residual disease and negative nodes.

Thus, the entire tumor(s) must have been removed in the prior lumpectomy (excisional biopsy). The recommendation for chemotherapy is probably based on the results of the pathology from the lumpectomy of April 16, 2016. To maybe understand the basis for that, can you please check the biopsy report from the April 16, 2016 lumpectomy again? I guess the histology from that report showed "invasive papillary carcinoma," but please include any information about it. Please also check the lumpectomy report (including all appendices or supplements) and let us know what it said about: (a) actual tumor size(s); (b) Estrogen Receptor (ER) status; (c) Progesterone Receptor (PR) status; (d) HER2 status; (e) grade; and (f) Ki-67 (if known).

Meanwhile, here is some information from this site about "invasive papillary carcinoma", which is not very common:

http://www.breastcancer.org/symptoms/types/papillary

There is a thread about Papillary Carcinoma here:

https://community.breastcancer.org/forum/137/topics/785782?page=6#idx_151

I went through something similar with my Dad and then my Mom being diagnosed a year and a half later, so I understand the fear and the worry.

By the way, is your Mom being treated in the USA?

BarredOwl

arminavy

Histopathology Report: April 16,2016

Gross examination: Recieved specimen labeled breast mass, right consisting of a single fragment of cream white, doughly, irregularly shaped tissue measuring 2.0x2.0x 1.0 cm. Cut section shows a cream white solid surface with cystic areas. The entire specimen was taken for embedding. block 2(1).

Microscopic examination:

Histologically, sections show solid sheets of malignant ductal cells displaying pushing boarders urrounded by a fibrous wall at the periphery. Lympho-vascualr invasion is noted.

Diagnosis:

S/P Excision Biospsy: Invasive Papillary Carcinoma, Specimen labeled " Breast Mass, Right.

BarredOwl

Hi arminavy:

That does not appear to be a complete report. For example, it describes the size of the gross tissue sample, but not the extent of disease within the chunk of tissue removed. It describes microscopic appearance, and a conclusory diagnosis, but more descriptive text would be expected, such as grade.

The embedded tissue block would have been sliced and slides would be prepared. These would be stained with various histological stains for ER and PR, and HER2 (if tested by IHC), and the results would be set forth

This size, and ER, PR and HER2 test results are required for determining appropriate systemic treatments under applicable treatment guidelines used in the US, Canada, Europe and Australia, and must be known to her treatment team.

Sometimes only partial or summary info is shown on electronic portals or letters. Please have her contact her surgeon's office to find out how she can get "a complete copy of the pathology report from the surgical biopsy/lumpectomy of April 16, 2016, and all addenda and supplements thereto, including ER, PR and HER2 test results."

If she does not understand why chemo is being recommended or these essential details of her diagnosis, I am wondering if she has met with a "medical oncologist" yet? If not, she should request a referral to a medical oncologist. This would be a necessary next step before finalizing any treatment plan, and could help her understand why chemotherapy is being recommended, what drugs would be included in the regimen, her risk of distant recurrence, the potential benefit of chemo, whether any further tests may be of value to inform decision-making, etc. Surgeons sometimes tell patients to expect a recommendation of chemotherapy, but that is not their area of expertise or training. It is within the expertise and training of the medical oncologist

BarredOwl

arminavy

Thanks BarredOwl.

Exactly, that is why I myself was wondering why the Medical Oncologist decided to do Chemo right away without knowing the extent of the hispatology report. She requested my mom to bring the sample tissue to another hospital for second examination. I am thinking to find another Oncologist for proper treatment. Thank

BarredOwl

Hi arminavy:

If the current medical oncologist ("MO") is at the same facility as the surgeon, he likely has access to all her medical records, including a more extensive pathology report and any available test results. Or at least I would hope so. However, he has not effectively communicated the key details of her diagnosis to her nor the basis for his recommendation. If for some reason, some of the pathology information is either unclear, somehow inadequate, or was not determined on the excisional biopsy/lumpectomy, then the MO is correct to recommend further pathology assessment at another hospital. He may also be seeking confirmation from a second pathologist regarding the diagnosis of the rather unusual invasive papillary carcinoma.

In any event, a second opinion at this stage is a good idea. Look for a university hospital with a comprehensive breast cancer center. In the US, many choose an NCI-designated cancer center for a second opinion:

http://www.cancer.gov/research/nci-role/cancer-centers/find

One can seek review of all imaging, pathology and/or treatment advice at this stage. Pathology slides are physically sent for second review by an expert pathologist, and she can obtain a second opinion from a medical oncologist based on the expert pathology review. The pathologist may order further testing in case of any insufficiency or ambiguity in the results.

For more information about the second opinion process, see these sections from the main site here (multiple sections at menu in upper left):

http://www.breastcancer.org/treatment/second_opinion/why

Some NCI-designated cancer centers provide second opinion services for out-of-state (insurance permitting) or international patients, as explained on this page:

http://www.breastcancer.org/treatment/second_opinion/where

She should inform the second opinion place of the dates of her lumpectomy/excisional biopsy and mastectomy, so they can provide an appointment in a timely manner (in case chemotherapy is advisable, it should be commenced in a timely fashion). They will provide guidance of regarding what materials they need, including for example copies of all imaging to date, slides, and related written reports of the radiologists, pathologists, and surgeon.

BarredOwl

BarredOwl

Hi arminavy:

Further to my message above, this whole process is very stressful for patients and it can be difficult for them to absorb information and advice. If possible, your mom should consider taking another relative or trusted friend to her appointment to listen and take notes. Some people obtain consent of the doctor to record appointments on their phone.

I also wanted to provide some additional background information and information about decision-making.

Lymphovascular Invasion:

In your mother's case, although she is node-negative, the presence of local peri-tumoral lymphovascular invasion ("LVI") was noted (April 16, 2016: "Lympho-vascualr invasion is noted.")

Here is some basic information about lymphovascular invasion:

http://www.breastcancer.org/symptoms/diagnosis/vasc_lymph_inv

Lymphovascular invasion is not the same thing as lymph node involvement. Basically, the circulatory system includes two types of channels or vessels for fluids: (1) the "vascular" system for blood; and (2) the "lymphatic" system for lymph fluid.

The breast has small blood vessels and lymph vessels going through it. Either system may be used by invasive tumor cells to escape the breast.

If they have the capability to do so, invasive cancer cells may break into a nearby lymph channel in the breast and travel through the lymph system to regional lymph nodes.

Invasive cancer cells may also break into a local blood vessel and travel elsewhere via the bloodstream.

The pathologist looks at the lymph vessels and the blood vessels in the vicinity of the tumor for signs of lymphatic invasion (breaking into a lymph vessel) or vascular invasion (breaking into a blood vessel), and will note it if present (as in your mother's case). If they don't see signs of either of these in the sample, they may note "lymphovascular invasion" ("LVI") is not identified.

To ensure current, case-specific, expert professional advice, she may wish to inquire whether the LVI observed should be considered or not in connection with her treatment decisions. (Add this to a written list of questions.)

Risk of Distant Recurrence and Risk-Benefit Analysis:

A patient should never hesitate to request a reasoned explanation for the basis of any recommendation for systemic treatment, such as chemotherapy, with reference the the specific "clinico-pathologic" features of their disease that support it, including at a minimum, tumor histology, actual tumor size, nodal status, ER, PR, and HER2 status. If any of these factors are unknown or unclear, further testing and/or a second opinion review by an expert pathologist may be considered.

Age, grade, LVI, and Ki-67 (not always tested), and Oncotype or MammaPrint test results (if indicated), are examples of other information that may be considered.

Some patients wonder why they would need any additional treatment if the tumor was surgically removed and the sentinel node biopsy was negative. Many patients do not understand that surgery is a local treatment only. It only addresses the problem in the breast. In contrast, chemotherapy, HER-2 targeted therapy, and endocrine therapy are systemic treatments (they go throughout the body), and can address the possibility of distant spread.

Even though she is node negative, some possibility of distant spread remains. The tumor was in there for a while before it was removed, providing a potential opportunity for cells to escape the breast either by the lymphatic system or via the blood stream before surgery. If any cells already moved to distant sites (laying the groundwork for a distant recurrence (i.e., metastatic disease)), these can be reached by systemic treatments (and reduce her risk of distant recurrence).

Thus, the main benefit of chemotherapy is in reducing the risk of "distant recurrence" (incurable metastatic disease). The chemotherapy decision entails a personalized risk/benefit analysis, made in light of the estimated risk of distant recurrence based on clinical studies of recurrence in patients with similar diagnoses and the potential risk reduction benefit of chemotherapy. The potential benefit must be weighed against the incidence of serious adverse events of any proposed chemotherapy regimen, in light of her age, personal and family medical history, and co-morbidities (which may affect risk of certain adverse events).

- If she is hormone receptor-negative (ER- PR-), she should receive or request: (a) an estimate of her chance of "distant recurrence" without chemotherapy (and no further treatment); and (b) the estimated chance of distant recurrence with chemotherapy.

- If she is hormone receptor-positive (ER+ and/or PR+), then endocrine therapy (e.g., an aromatase inhibitor) is also option. In such case, she should receive or request: (a) an estimate of her chance of "distant recurrence" without any treatment; (b) an estimate of her chance of distant recurrence with 5-years of endocrine therapy; and (c) an estimate of her chance of distant recurrence with endocrine therapy plus chemotherapy. In appropriate cases (determined by eligibility criteria for each test), the Oncotype test or MammaPrint test might be ordered to obtain additional information about distant recurrence risk, and possibly some predictive information about chemotherapy benefit.

- In either case, to enable weighing of benefits of treatments against risks, the known incidences of serious adverse effects of the proposed drug regimen should be discussed, and consideration given whether due to her presentation, she may be at any increased risk.

- Given her age of 71, she should request an explanation about possible limitations of clinical evidence / data to make chemotherapy recommendations for those >70 y of age. She is right on the border at 71. In this regard, a European guideline from ESMO (2015) states:

"Age should be taken into consideration in conjunction with other factors and should not be the sole determinant for withholding or recommending a treatment. Age is a continuous variable and its cut-offs in clinical trials are always arbitrarily chosen. Overall, we strongly recommend that 'younger' patients should not be over-treated because they are 'young', just as 'older' patients should not be under-treated, because they are deemed to be old."

- With information and guidance from their treatment team, the patient considers the risk / benefit and makes a choice about treatment, in light of their own personal "risk tolerance." Because of differences in risk tolerance, people with the exact same diagnosis and risk profile might make different decisions about treatment. For example, one person may wish to do everything possible even for relatively modest benefit, whereas another may not feel that the potential benefit outweighs the potential risks. These decisions can be very difficult.

With some breast cancers that present some added risk of distant recurrence, such as "triple-negative" (ER-PR-HER2-) or "HER2-positive" disease, consideration of or a recommendation for chemotherapy (or for chemotherapy plus HER2-targeted therapy if HER2-positive) would not be unexpected, even in node-negative patients. Based on individual risk/benefit profile, chemotherapy may also be appropriate in some cases of node-negative, hormone receptor-positive, HER2-negative disease. Of course, this is the type of information you do not have at this point.

Sending you and your mom good luck as you work to understand her diagnosis, risk profile, and appropriate treatment options.

BarredOwl

[Edit: added the word "personalized", added bullet re personal risk tolerance, and expanded second to last paragraph.]

arminavy

Hi everyone, Having all said mom called and informed me that she had her first round of Chemo. I was so worried about the effect of chemo to my 71 year old mom. She sound happy and telling me she was ok. I asked her " what do you mean you are ok? She replied, I don't feel nauseous or feeling sick yet. In fact I can still do my errands in the house. I'll keep posted what will happen in the next few days

retford4

Hi

Just to let you know I am 72 , finished chemo, ACT 6 weeks ago, I had Triple negative BC, your Mom will do just fine, they gave me Emend to control the nausea, part of it covered by Medicare, it is well worth it, constipation can be an issue to us oldies though and feeling a bit weary. I had a bilateral mastectomy 2 weeks ago . If she can eat and keep the nausea away it will help. I'll keep you both in my prayers.

Cowgirl13

I'm a 'baby' at 70. Just want you folks to know that 71 or 72 isn't that OLD!!

BarredOwl

Hi arminavy:

Hope your Mom continues to tolerate her treatment well.

BarredOwl

arminavy

Hi, everyone,

Second day after mom had her first dose of Chemo. She said she was vomiting but not so bad. It was tolerable. She was taking anti emetic drug to control her vomiting. She was drinking gatorade and eating little by little. She makes sure she is well hydrated. Hoping and praying that she will get over this chemo treatment. Please include my mom in all your prayers for sooner recovery. Also to all who are on the same situations like ours.

arminavy

update: Immunohistochemistry Report:

Estrogen Receptor Assay : Positive

Staining intensity: +1

Population Stained: +1

Progesterone Receptor Assay: Positive

Staining Intensity:+1

Population Stained: +1

HER 2-NEU Receptor Assay: Negative

Staining intensity: 0 staining intensity

Population stained

- Also recommendation necessitates +3 complete membrane staining in more than 10% of cancer cells to be considered positive.

Can someone interpret thiis result? Thanks

BarredOwl

Hi arminavy:

This indicates ER+ PR+ HER2- disease. These are generally favorable findings.

HER2: The result is said to be "negative", based on immuno-histochemistry ("IHC") which entails use of antibody that binds HER2 receptors to "stain" cells to look for over-expression of the HER2 protein on the surface of cells. Being negative for HER2 means that HER2-targeted therapy, such as trastuzumab (HERCEPTIN) would not be indicated.

ER and PR: The result is said to be "positive", indicating "hormone receptor-positive" disease. This result means that she will likely receive a recommendation for "endocrine therapy" with an agent that (a) inhibits the action of estrogen (tamoxifen); or (b) inhibits the production of estrogen (an aromatase inhibitor).

Regarding the specific method, please note that estrogen and progesterone receptor reporting varies from institution to institution, as explained here:

http://www.breastcancer.org/symptoms/diagnosis/hormone_status/read_results

Sometimes the pathology report includes a short explanation of the method used to assess positivity. I am not familiar with the method used here. She may wish to ask for more information about the degree of positivity for her information.

BarredOwl