How large does Tumor gets chemo and herceptin

voraciousreader

Trastuzumab Benefit Seen Even in Small HER2-Positive Tumors

Roxanne Nelson

December 1, 2010 - The addition of trastuzumab (Herceptin) to chemotherapy is now the standard of care for many patients with early HER2-positive breast cancer, but not all; those will very small tumors are often not treated.

Women with small T1a (≤0.5 cm) and T1b (from 0.5 to 1 cm) node-negative (N0) cancers usually have an excellent prognosis and are not believed to derive a benefit from adjuvant therapy.

However, a review paper published in the December issue of the Lancet Oncology points out that there is "strong circumstantial evidence to justify some form of trastuzumab-based adjuvant therapy in most women with T1b, N0, HER2-positive breast cancers."

According to retrospective data, note authors Susana Banerjee, PhD, and Ian E. Smith, MD, from the Royal Marsden Hospital, London, United Kingdom, some small HER2-positive cancers might have a worse clinical outcome than others.

"Retrospective studies of . . . T1a,bN0 breast cancer, treated with local therapy and usually without adjuvant therapy, have consistently reported a 10-year relapse-free survival of more than 90%," the authors write. "However, many of these studies have limitations, including small sample size, short follow-up, and some patients receiving adjuvant systemic therapy."

The risk of recurrence in this subgroup of breast cancer patients and the true benefit of any adjuvant treatment remain unclear, they note. In addition, HER2-positive breast cancer, which accounts for approximately 15% to 20% of cases, is a distinct biologic subgroup and is associated with an aggressive clinical course.

Not Considered Low Risk

Drs. Smith and Banerjee note that retrospective data from several studies suggest that HER2 is a marker of poor prognosis in patients with small node-negative cancers. In fact, they point out, these tumors have a substantially increased risk for recurrence and should not be considered low risk.

As previously reported by Medscape Medical News, some researchers believe that all low-grade HER2-positive tumors should be treated with adjuvant systemic therapy, no matter what their size. Two studies that were presented at the 2008 San Antonio Breast Cancer Symposium (SABCS) found that patients with this tumor subtype have a poorer prognosis and a higher risk for recurrence.

"The biology of the tumor, and not the size or grade, matters most in these patients," Sian Tovey, MD, from the Glasgow Royal Infirmary, Scotland, who presented the results from one of the studies at the SABCS, told Medscape Medical News at the time. "Any patient who is HER2 positive should be categorized as high risk and should receive adjuvant trastuzumab therapy."

In their review, Drs. Smith and Banerjee point out that the number of women being diagnosed with T1a,bN0 primary tumors is rising because of improved breast cancer awareness and screening programs. Thus, there is a need for clarification of the optimal treatment.

Benefit Suggested, Inconsistent Guidelines

The pivotal adjuvant trastuzumab trials, which involved more than 14,000 patients, excluded women with tumors smaller than 1 cm. But there is indirect evidence that trastuzumab might benefit patients with these smaller tumors, they write. For example, a subset analysis of the Herceptin Adjuvant (HERA) trial showed that those with tumors 1 to 2 cm in size derived at least as much clinical benefit from 1 year of adjuvant trastuzumab as did the overall cohort (Lancet. 2007;369:29-36).

In another subanalysis from the Breast Cancer International Research Group 006 trial, results suggested that node-negative patients gained at least as much benefit from trastuzumab as did the overall group, both for disease-free and overall survival (SABCS 2006. Abstract 52). These results supported those from the HERA study, the authors note.

The lack of supportive evidence, however, places clinicians in a dilemma when they are trying to select appropriate therapy for this group of breast cancer patients. "Present guidelines for the systemic treatment of small, HER2-positive breast cancers are uncertain and inconsistent," Drs. Smith and Banerjee write.

Future Directions

Ideally, prospective randomized trials of trastuzumab-based treatment are needed for this population, but they are not likely to ever be conducted for a number of reasons, the authors write. Because of the low incidence of small HER2-positive breast cancers and the relatively low event rate, a large number of patients would be needed, which would be expensive. The design of trials has already proven difficult to agree upon, and successful recruitment to a randomized trial with a no-treatment group would be challenging. Finally, the choice of treatment for the investigational group is controversial.

Taking this into consideration, they suggest that the "next best approach would be a nonrandomized prospective study." Additional supportive evidence could be garnered from ongoing trials that include patients with small HER2-positive tumors.

The authors offer 2 more recommendations. One is to create prospective databases on the management of patients with HER2-positive cancers, which would provide retrospective analyses of outcomes associated with different treatments. The second is to incorporate molecular markers and multigene assays into clinical datasets, which might help identify and stratify relative risk within this subgroup.

"As in other areas of breast cancer management, this type of approach will eventually lead to a much more accurate prediction of which systemic therapies, if any, will most benefit each individual patient with these difficult, small, HER2-positive cancers," they conclude.

Dr. Smith reports receiving occasional honoraria for lecturing from Roche. Dr. Banerjee has disclosed no relevant financial relationships.

Lancet Oncol. 2010;11:1193-1199.

melly1462

First, many thanks to you ladies providing all this info!  I know it takes an insane amount of time to do the research.

@evebarry:  I couldn't agree more.  I stay confused.  After finally coming to grips with the need for chemo, the RO casually mentions the MO waiting on my Oncotype score before seeing me.  Really??!!   According to John Hopkins and the NCCN my HER+ status trumps the Oncotype.  Furthermore, the test should NOT even be done on HER+ women. 

Appt with MO tomorrow.  We'll see.  Thank you again, these boards have been a source of comfort.

voraciousreader

Eve... When making treatment decisions there are two parts to the equation. One is Stage and the second part is based on the characteristics of the tumor. That is why the treatments are all over the place. I don't understand why you keep emphasizing that you are Stage 1A or emphasizing you are "only" Stage 1A? Your stage is only one piece of the equation. In fact, when you go to the cancermath website to look up mortality figures they do not ask for your Stage. They ask for the size of your tumor, hormonal status, histology of tumor, Grade and how many nodes. All of that information guides treatment recommendations.

voraciousreader

Eve... I want to clarify for others that based on the characteristics of your tumor, your doctor recommended chemo and Herceptin which was considered Standard of Care, based on the NCCN guidelines. The discussion we are having HERE is regarding a smaller tumor than yours which the present Standard of Care based on the current NCCN guidelines does NOT recommend chemo and Herception.

bluedasher

Iago, in that study they didn't break out results for HER2+ hormone- vs HER2+ hormone+. Since only 10% of the group were HER2+, perhaps it was too small to break into hormone positive and hormone negative. There were 38 hormone- in the 98 HER2+ cases. From the poster tables, it is possible to calculate how many hormone+ and hormone- events there were amongst the HER2+ group because they give the total events for Hormone receptor postive and negative and they give the numbers in HR-positive HER2- and TN subgroups. When I do that calculations, I get numbers that are very close for hormone+ HER2+ vs hormone- HER2-.

AlaskaAngel

The answer is, no one knows whether the chemotherapy is necessary or not.

A.A.

Rubyluby

Its a question of doing a cost benefit analysis or weighing up the trade offs associated with treatment and with not having treatment. Herceptin and chemo do have side effects. The case for having chemo and Herceptin was absolutely clear in my own situation (1 cm tumor, grade 3, hormone negative), however this treatment put me into instant chemical menopause and I gained 30 pounds which I am still struggling to lose, 3 years after diagnosis (having been a healthy weight all my adult life).  As a result, my cholesterol levels have sky rocketed and I have to take a hefty statin now. My treatment may have reduced my chances of recurrence from about 23% to about 8%, but what has the cost been my health in terms of heart disease? By what percent has my risk of heart disease gone up?  

These are difficult decisions, I realise, and I wish you the best of luck.

Lucy 

Sassa

When I was talking about a 25% chance of the HER2+ cancer spreading through the blood without lymph node involvement, I was talking about the initial presentation, not recurrence chances.

So when first undergoing staging, there is a 25% chance that BC will be found outside the breast with no involved lymph nodes.  This is true of tumors that would be considered stage one because of size.  I am not sure of the chances for larger tumors.

I found this out in my reading, unfortunately I don't remember where I came across it.  I did confirm this with my oncologist and she said it was true.

For my next set of figures, I am talking about after mastectomy and chemo.  Herceptin was the first year after chemo so when I say two years, that is two years after finishing my AC, one year after finishing my herceptin.

As far as recurrence went, the chances she told me was 50-75% in the first year after my mastectomy with no chemo.  Mastectomy and chemo dropped the chance down to 30% during the first year.  Finishing the year of herceptin dropped the chance down to 17% in the second year after chemo.

Because I am hormone negative, my chances of recurrence started decreasing after year 2, dropped even more after year 3, and now as I approach my 5 year post chemo check up, if I am still NED, my chances will be down around 1%.  After 10 years NED, I can consider myself "cured" because mu chance of recurrence will be about 0%.

voraciousreader

Prognosis in women with small (T1mic,T1a,T1b) node-negative operable breast cancer by immunohistochemically selected subtypes. Print this page Sub-category:ER+ Category:Breast Cancer - HER2/ER Meeting:2011 ASCO Annual Meeting Session Type and Session Title:General Poster Session, Breast Cancer - HER2/ER Abstract No:546 Citation:J Clin Oncol 29: 2011 (suppl; abstr 546) Author(s):G. Cancello, P. Maisonneuve, N. Rotmensz, G. Viale, M. G. Mastropasqua, G. Pruneri, E. Montagna, S. Dellapasqua, M. Iorfida, A. Cardillo, P. Veronesi, A. Luini, M. Intra, O. D. Gentilini, E. Scarano, D. Pastrello, A. Goldhirsch, M. Colleoni; European Institute of Oncology, Milan, Italy; Division of Pathology, European Institute of Oncology, Milan, Italy Abstract DisclosuresAbstract:Background: Knowledge is limited about prognostic significance of breast cancer subtypes among women with small invasive node-negative breast tumors. Methods: We explored patterns of recurrence in 1,715 patients with pT1mic/T1a/T1b, node-negative operable breast cancer according to four immunohistochemically defined tumour subtypes: (i) Luminal A (ER-positive, PgR-positive, HER2-negative and Ki-67<14%); (ii) Luminal B (ER-positive and/or PgR-positive, HER2-positive and/or Ki-67≥14%); (iii) HER2-positive, both endocrine receptors absent; and (iv) triple negative. Results: At multivariate analysis, patients with the triple-negative subtype showed an increased risk of loco-regional relapse (HR 3.37; 95%CI: 1.31-8.70) and breast cancer related events (HR 2.17; 95%CI: 1.04-4.53). Overall, Luminal B was not associated with a significant higher risk of recurrence compared with Luminal A, while the subgroup of Lumimal B with HER2-positive has a 2-fold risk of reduced breast cancer survival compared with Luminal A subtype. HER2 was the only subtype with a statistically significant increased risk of loco-regional relapse (HR, 4.77; 95%CI: 1.65-13.8), distant metastases, and reduced breast cancer related event-free survival and overall survival (HR, 2.95; 95%CI: 1.07-8.10) if compared with the Luminal A subtype, at multivariate analysis. Conclusions: Patients with small size, node-negative breast cancer are at higher risk of relapse if with HER2-positive endocrine receptor absent or triple-negative disease.

AlaskaAngel

Please note, the information does not mention that using standard treatment with the addition of chemotherapy (and trastuzumab) results in some patients with treatment failure anyway.

"Conclusions: Patients with small size, node-negative breast cancer are at
higher risk of relapse if with HER2-positive endocrine receptor absent or
triple-negative disease."

A.A.

Hindsfeet

VR...maybe the oncologist should explain to their patients that the stage is only one factor of the treatment plan. I was told, and so many here at bco seem to be saying that staging has a lot to do with treatment plan. And, my oncologist said you are stage 1a and this is your treatment plan...chemo/herceptin. I'm scratching my head thinking last March I was 1a and now I'm 1a so staging for early cancer treatment is not all the same. And, I' don't think I'm the only one who is confused about this...for early stage staging.

I suppose I am fuming over the fact the doctors with a smile say, you are lucky, you are only stage 1a, and you are cancer free BUT....you have to go through chemo and etc. If I chose to go through all that they asked me to do with all the possible side effects am I so lucky? Plus, they said your final path report was 1.8C ... my biopsy was 2C ... so 1.8C they said my tumor was small which is why I am stage 1a. I know the her2 positive is why I was encouraged to do further treatment... If I did not have the her2+++ factor, and I was grade 3, with the final path report size 1.8 C I probably wouldn't have needed more than a mx...right?

dancetrancer

Evebarry, I think they would have run an oncotype on you if that had been the case. 

I read the NCCN guidelines, and it says that the oncotype dx is:

"an option when evaluating patients with primary tumors characterized as .6 to 1 cm in size with unfavorable features or > 1 cm, and node negative, hormone receptor positive and HER2 negative." 

Sooooo, I am thinking if you had been HER2 negative, with nodes negative and your IDC being > 1 cm, they would most likely have run an oncotype on you to determine if you needed chemo.  (In my case, if my HER2 comes back negative, they most likely will not run the oncotype and tell me no chemo, since my IDC is only 3 mm.)   

P.S.  I'm confused...you are T1a?  I read that this for < 5 mm tumors.  

bluedasher

Evebarry, T1a is less than 0.5 cm and Stage Ia is that plus node negative. T1b is 0.5 cm to 1 cm. If your tumor was 1.8 cm, then it would fall in T1c and since your nodes were negative, your stage would be Ic. Chemo and Herceptin is recommended in the NCCN guidelines for T1c HER2+ regardless of ER/PR status. It's tumors that are below 1 cm that are in a gray area for chemo and Herceptin. The copy of NCCN guidelines that I have (from 2009) says no chemo below 0.5 cm and consider it depending on tumor features between 0.5 and 1 cm. Research such as the MD Anderson retrospective study make some consider chemo for tumors below 0.5 cm.

The size that you are given at biopsy is an estimate based on the external scans (e.g. mammogram and ultrasound). They can'talways tell from those what part of the lump is invasive or even cancerous. My estimate at that point was about 3 cm. My surgeon explained that it was only an estimate and that the size from the pathology after surgery might be higher or lower than that.

After surgery is when they can really examine the lump and give a more accurate number. It turned out that part of my lump was a non-cancerous cyst and part was DCIS so the size of my invasive tumor after surgery was 0.9 cm. Even that is an estimate. For example, my bipopsy was vacuum assisted which removes more than a needle biposy so it's possible that my tumor was slightly over 1 cm rather than slightly under. I was making the chemo decision before the MD Anderson study results were released and concern that the tumor might have been bigger than 1 cm helped me decide.

If your tumor was HER2-, they might have used oncotype to help decide whether to do chemo. NCCN suggests that greater than 1 cm should have chemo if oncotype isn't done or if it is done and the score is over 18. It also suggests that if it is between 0.5 and 1 cm and has bad features.

Voraciousreader, The study you just posted had results that contradict the MD Anderson study regarding hormone negative and hormone positive effect on HER2+ tumors under 1 cm. In the MD Anderson study, recurrence was about the same for HER2+ hormone negative and HER2+ hormone positive. In the Cancello, et al. study, if I'm reading it correctly, hormone positve HER2+ was less likely to recur than HER2+ hormone negative but more likely than HER2- hormone positive. I wonder what the difference was, maybe just statistical variation since most Stage Ia and Ib tumors are HER2- so the sample size isn't very large?  Or perhaps there was a difference in treatment - the second study doesn't say that they excluded women who had chemo.

suzieq60

Eve - the stage is totally blown out of the water when HER2 comes in to it - that's the difference. I did look up 1A and it aplies to tumours up to 2cm with negative nodes.

Stage IA: T1, N0, M0: The tumor is 2 cm (about 3/4 of an inch) or less across (T1) and has not spread to lymph nodes (N0) or distant sites (M0).

AlaskaAngel

The problem here is that we are literally not all on the same page.  Take a look.  The guidelines on page 26 of the patient's NCCN guidelines do not list a T1c anymore. This is very recent.

http://www.nccn.com/files/cancer-guidelines/breast/index.html#/26/

AlaskaAngel

Is it merely a printing error? Or are they suddenly throwing those at least risk in with those at higher risk (due to greater size), since there are so few in the former T1a's that are HER2 positive.... ? This would, of couse, sway the influence for choice of therapy for the smallest tumors (by using the added much greater number count for T1c's) toward the use of chemotherapy for a new definition of "T1a's".

A.A.

AlaskaAngel

Frankly, given that the question of risk for HER2 positives who have a high AIB1 level (about 1/3 of those who are HER2 positive, as I understand it) remains open, that could actually account for the incidence of recurrence for the HER2 positive tumors that are less than 0.5 cm and have not received other systemic treatment, since that group usually received just tamoxifen.

A.A.

voraciousreader

Eve....I am going to try to make this as simple as possible.  I am sorry that your doctor told you that you are cancer free and have a small tumor and also said that you were Stage 1A.  That is INCORRECT...My tumor was 1.8cm and I was Stage 1B.  (Bluedasher...the NCCN guidelines have been updated since 2009 and now there are just TWO Stage 1 catagories.. Stage 1A and 1B.)

Now, Eve... please follow me with this one concerning ME...Despite being Stage 1B and having the same size tumor as you, 1.8 cm, and having a Grade 1 tumor AND having a "favorable" histology (mucinous), my doctor STILL recommended the Oncotype DX test to examine the genetic characteristics of my tumor to determine if Chemotherapy would benefit me.  So now you ask me if YOU would have needed more than a MX, had it NOT been HER2+, but based on a tumor of the same size as mine but one that was a Grade 3...which is the most aggressive.  And the answer to that question is....YOUR DOCTOR WOULD HAVE HAD THE ONCOTYPE DX TEST DONE ON YOUR TUMOR TO DETERMINE IF CHEMOTHERAPY WOULD HAVE BEEN OF BENEFIT TO YOU.  More often than not, many women with Grade 3, ER+ Stage 1 and Stage 2 tumors have high OncotypeDX scores and ultimately do chemotherapy.  From time to time, Grade 3  tumors do come back with low OncotypeDX scores or intermediate OncotypeDX scores and that's where the decision is always the hardest to make.  So with a Grade 3 tumor chemo would have probably been recommended. 

But your tumor, despite being "early stage" and despite being Stage 1..... is a VERY AGGRESSIVE TUMOR because it is GRADE 3 AND because it is HER2+.  And although there is NO EVIDENCE that it has left your breast, THAT DOES NOT MEAN YOU ARE CANCER FREE. 

When you mentioned that your family and friends all agreed with you that you didn't need chemotherapy along with the Herceptin...I wondered if they understood what is evident to most of us here. Were any of them with you when the doctor discussed your treatment protocol based on your tumor's characteristics? Or perhaps did you tell them all that you were "early stage" and "cancer free" and left them, like you were led to believe, when you first spoke to your "sweet" doctor, that you had done enough to keep the beast at bay.

But Eve.... let's be realistic.  First you had DCIS.  Then you had Mucinous BC and now you have a VERY AGGRESSIVE tumor.  Do you see a pattern and trend here?  You mentioned to me that you wanted to understand WHY your body was capable of making so many cancers and find ways to mitigate that.  I think we would all love to understand why we got our breast cancers.  But more importantly, we want to find a way so that we don't revisit what we've had to endure.  I know quality of life is so important to you.  It is as important to you as it is to all of us.  It is also important to the "sweet" doctor who broached the subject of doing chemo with you.  Again, had she not thought that you were a good candidate for chemo AND Herceptin, then she would never have brought it up in the first place.  She took an oath to "First, do no harm."  She would NOT want to see you suffer.

So Eve...I am going to say this once again, loud and clear.  Be angry at your doctor for telling you that you are "cancer free" and offering false hope to you ESPECIALLY after what you've gone through in the past few years.  But understand that with an early stage tumor, despite being aggressive, with Standard of Care treatment, according to the NCCN 2011 guidelines, you have the chance to live a long, healthy life.  Not doing the Standard of Care, in your situation is brave.  Again, I'm not as brave as you are.   

I know someone will come along and dismiss EVERYTHING I have said to you. That's okay. But even if I can't change your mind, at least I hope I have enlightened YOU and others who might happen to come upon this thread. The only way to make an informed decision is with enlightening information.  At least with all of this information, I hope you can comprehend it and accept the wise counsel of your "sweet" oncologist. I also hope that you get other opinions from other MO's and truly listen and understand what they tell you. 

And step back for a moment and look at THIS thread!  Here we are discussing a tumor way, way smaller than yours and debating the need for aggressive treatment.  Your tumor is 4 times GREATER!  That should give you pause to reconsider......

Regardless, we'll be here for you, no matter what you decide to do.

voraciousreader

bluedasher...you raise a good question.

" I wonder what the difference was, maybe just statistical variation since most Stage Ia and Ib tumors are HER2- so the sample size isn't very large?  Or perhaps there was a difference in treatment - the second study doesn't say that they excluded women who had chemo."

  Why not email the lead authors?  From time to time, I email researchers and they are kind enough to answer my questions....I try not to read between the lines.  Why not give it a shot and let us know the answer.  Believe me, researchers LOVE hearing from people!!

bluedasher

Okay, apparently either the staging has changed or, more likely, I was wrong about how tumor size relates to Stage I substages. Everything I look at now says that Stage Ia includes all tumor sizes up to 2 cm - it doesn't matter if the tumor size is T1a, T1b or T1c.

However, if you look at pages 74 and 76 of the NCCN guidelines that AlaskaAngel linked, you will see that the treatment recommendations for HER2+ are still based on whether the tumor was less than 0.5 cm (T1a), between 0.5 and 1 cm (T1b) or greater than 1 cm (T1c and larger). They don't use the terms T1a, T1b and T1c but they are differentiating treatment based on those sizes. I don't think it is an error - the NCCN older NCCN guidelines just use size without using the terms T1a, T1b and T1c too even though in the staging part of the document they mentioned them.  

There is one strange anomaly in the treatment tables that I don't understand. The older doctor's NCCN guidelines that I have say consider chemotherapy and Herceptin for HER2+ hormone negative tumors between 0.5 and 1 cm and either consider endocrine therapy or chemotherapy, Herceptin and endocrine depending on tumor features for HER2+ hormone positive between 0.5 and 1 cm.

This new patient guideline (they only had the doctor's one when I was treated) says the same as that for HER2+ hormone negative, but for HER2+ hormone positive it says Herceptin, hormone and chemo for anything above 0.5 cm. They removed the differentiation between T1b and T1c treatment for hormone positive but still have a lesser recommendation for T1b hormone negative HER2+. That makes no sense to me. Perhaps it is a mistake?

bluedasher

I just checked the doctor's version of the NCCN guideline and it's the same as the patient guideline.

For hormone+ HER2+, 0.5 cm and above all have the same recommendation: Herceptin, chemo and hormone therapy.

For hormone- HER2+: 0.5 to 1 cm is consider chemo and Herceptin; above 1 cm is chemo and Herceptin. 

I don't understand why they would have a stronger recommendation for chemo and Herceptin for hormone+ HER2+ than for hormone- HER2+ between 0.5 and 1 cm. I would understand changing the recommendation for 0.5 to 1 cm HER2+ to chemo and Herceptin (taking away the "consider") in light of the MD Anderson study and others, but not making a weaker recommendation for hormone negative HER2+ than hormone positive.

voraciousreader

Like I said...the NCCN guidelines are a moving target and are updated as need be.  With so much controversy...you see with sisters who have the SMALLEST tumors why it is such a dilemma.....  Again, you can appreciate why it would be difficult to definitively answer the question because of the difficulty in designing a clinical trial......  Again, it is important to look at several years of NCCN guidelines to obtain a trend.  And, more and more current studies are indicating more treatment....

Interestingly, for my type of cancer, Mucinous... the trend is favoring LESS treatment.....

Minnshark

Evebarry. I couldn't agree. I am a Stage1a no node but .5cm so no chemo with a BMX. For me, the choice between a lumpectomy and BMX was very easy to make.



Vora.. Thank you for this article.

AlaskaAngel

The word that comes to mind is "gerrymandering".... 

When someone like evebarry sees the lack of congruence in it, and is left to try to figure it out when it doesn't make sense, while others miss seeing it entirely, I really give her a lot of credit for expressing that confusion.

A.A.

voraciousreader

Minnshark..for a very small tumor it really is such a tough call.  I am so glad you got several opinions and have made peace with your decision.  I truly believe that is the essense of what THIS is all about.  We arrive at a decision with the best evidence available and move on with our lives and all accept, graciously, our "new normal." 

Hindsfeet

VR...I hear you, but I posted on this thread because I was told my tumor was small. In regard to mucinious tumors...mine was 1 C and they did not do a oncotype on the mucinicous because in the end my bc surgeon said you don't do them for those types of cancers...although I asked for one due to past discussions we had.  

My friends know that I have early cancer, with the aggressive her2+++ component. Because most have seen friends or family suffer due to chemo they said for me not to go there. My family are very well aware of my dx and risk. They also have done research and feel that I am doing the right thing...in fact, they would be angry if I choose to do chemo.

I have made a request for my mx tissue to be sent to the original lab where I had the biopsy sent to. I do plan to have a second opinion. You are given about 5 minutes with your bc surgeon for post op telling you the good news. I had hoped my oncologist would have had the time to answer my questions, but seem a little frustrated in me asking...and again only talked about the 5 lines that were readable on the 5 page report...node 1, negative, node2, negative, node 3, negative, node 4, negative, tumor, postive, stage 1 with hormone positive, and her2+++ .... that's about it and the rest is for me to figure out for myself.

I also addressed the whole staging topic on the early cancer as I believe the whole staging topic is confusing...especially since there apparently so many opinion even amongst oncologist.

I misplaced the biopsy report...several pages, very detailed. I've requested another and hopefully it will soon all make sense. Sorry for being on the wrong thread.

voraciousreader

Eve... This past year my 86 year old mother was diagnosed with lung cancer.  She's a very active woman.  At NO point was chemotherapy ever mentioned as a treatment.  Her case was presented to a tumor board and it was decided that all she needed was radiation.  Today she is NED and enjoying her life.  Doctors do not recommend chemotherapy lightly.  If they truly believe the evidence is there that you will do well with it... then they will recommend it.  If there is no evidence that chemo will help you, then they will make that recommendation as well.....

I think you need to depend less on hearing the emotional pleas of people who have seen others suffer during and after chemotherapy.  Instead, come HERE and see how others are thriving.

Get those MO opinions and by all means, have your case presented to a tumor board, like my mother and have them help you make an INFORMED decision.

I truly wish you well.....

voraciousreader

One more thing Eve,  others would be angry if you went there?  How selfish of them.  It's YOUR life.  When I was diagnosed...I never discussed with anyone what I was going to do.  Not even the DH.  He came with me to my meetings with the MOs.  The decision was entirely mine and mine alone...Furthermore, outside of my immediate family and my brother and sister, I told only a handful of people that I am a breast cancer survivor.  My mother doesn't even know that I was treated for breast cancer.

Perhaps you have too many people in the mix...

bluedasher

Minnshark, whether the surgery that you received was a lumpectomy or a mastectomy doesn't enter into the decision on whether chemo is recommended or not. Surgery addresses the local breast cancer as does radiation. Having a lumpectomy or a mastectomy affects whether you should have radiation. Lumpectomy should generally be followed by radiation to clean up any stray cancer cells that didn't get removed from the breast. Mastectomy may not need radiation, though that decision is also affected by how close the tumor was to the chest wall and whether it was in the nodes.

Chemo is a systemic treatment that can kill off cancer cells that have already gone past the breast. Having a mastectomy or a lumpectomy doesn't affect those cells so the decision isn't dependent on which surgery that you had. For example, if you look at the NCCN treatment guidelines, which kind of surgery one had doesn't enter into the adjuvant chemo decision. 

The only case where it makes a difference is that some women with larger tumors may choose to have chemo before surgery to try and shrink the tumor so that they can have a lumpectomy rather than a mastectomy. After surgery, the type of surgery doesn't matter regarding whether to have chemo.

Beesie

There are three areas of confusion that I see in the discussion that is on-going here.

1) There is confusion between tumor sizes T1a, T1b and T1c and staging.  

• When discussing invasive cancer, the tumor size is only one element in the staging and in fact a T1 tumor (whether "a", "b", or "c") can be any stage except Stage 0.  For example a T1a tumor, which is a tumor that is 5mm or less in size, can be Stage IA up to Stage IV.  What determines the rest of the staging is the nodal status and the presence of mets.
• About 18 months ago Stage I was divided into Stage IA and Stage IB.  The difference between Stage IA and IB is not the tumor size - any T1 tumor can be either Stage IA or Stage IB (or Stage II, etc.). The difference is that Stage IB includes micromets.  Until January 2010 (the changes were made mid-year in 2010 but were backdated to the start of 2010), micromets was considered the same as macromets and automatically moved the patient to Stage II.  However a review of research showed that the presence of micromets (a nodal involvement of >0.2 mm and/or >200 cells but none >2.0 mm) had only a 1% impact on mortality and as such, the decision was made to move those with micromets from Stage IIA into a newly created Stage IB. 

2) There is confusion about the role of staging and how it plays into treatment decisions.

• If you look at the staging charts you will see that each stage includes a lot of different diagnoses - which therefore require different treatment. Staging also does not make any mention of the grade of the tumor, the ER/PR status of the tumor or the HER2 status of the tumor - other key factors in the treatment decision.  
• Doctors talk to us about our stage and they talk to us about our treatment, but stage does not determine treatment.  Someone who is Stage IA with a grade 1 T1a tumor that is ER+/PR+/HER2- will not have recommended the same treatment as someone who is also Stage IA but has as T1c tumor that is grade 3 and ER-/PR-/HER2+.  On the other hand, this second Stage IA individual is likely to have the same or very similar treatment to someone who is Stage IIB or Stage IIIB who has the same tumor characteristics (grade 3, ER-/PR-/HER2+).

3) There is confusion about tumor size and whether tumor size counts either in risk, prognosis and/or treatment decisions.

• It does.
• For one individual and perhaps on average (an average of all women with Stage I HER2+ cancer) it may be true that there is a 25% chance that an HER2+ cancer will have already spread through the blood without lymph node involvement, upon initial presentation.  This doesn't mean that this is true for all Stage I HER2+ cancers and for all individuals who have Stage I HER2+ cancers. There is a big difference in risk level between a 2mm tumor and a 1.9mm tumor - even though both of these tumors are Stage I tumors. It's quite simple, really.  The more cancer cells, the greater the risk that one or two rogue cells (or more) might have slipped undetected into the vascular system (the bloodstream), only to show up later as mets.
• Let's say that there are 1000 cancer cells in a millimeter.  Someone who has a 2mm tumor has 2000 cancer cells in her breast. Someone who has a 1.9cm tumor has 19,000 cancer cells in her breast. With almost 10 times as many cancer cells, it seems pretty obvious that the risk of occult mets would be quite a bit higher for the person with the 1.9cm tumor (all other things being equal). This is why the "average" risk numbers for Stage I HER2+ tumors cannot be applied to someone like Minnshark, who has a smaller than average 0.4mm HER2+ tumor.

At lot about BC is difficult to understand and in many areas of BC diagnosis and treatment, even the best doctors don't always agree. But there are some things that are facts (TMN Staging, for example) and there are other things that are logical, intuitive and simply common sense (all other things being equal, a larger tumor with more cancer cells presents a greater risk). We have enough to debate about here on the stuff where there are no clear answers - and there is a lot of that - that I find it particularly frustrating when there is so much debate and so much misinformation about the stuff that should be pretty clear.