How do they measure whether adjuvant chemo is working?

paloverde

Hi to all of you who are more experienced in this area than I,  

This may seem like a really basic question, and I'm going to ask my MO on Thursday, but as a science professional it's been on my mind for a while.  With neoadjuvant chemo, it sounds like there's immediate "clinical response" feedback based on tumor shrinkage and whether some affected nodes clear up.  With adjuvant chemo, how do they measure whether the regimen is effective, once the tumor and the dirty nodes are out?  What is there to look at during treatment or in the short term?  

I assume with my red-hot Grade 3 cells the odds of effectiveness should be high, but it just seems like there should be some way to be more definite, other than monitoring over time.  Anything you can share would be great.  Thanks!

warrior70

I was wondering this too, since I'll be done with adjuvant chemo in about a month.

ziggypop

They can't tell. Presumably you have no cancer in your body - scans have not shown distal metastasis, and the cancer in your breast and node has been removed. In this circumstance chemo is used as a systemic prophylactic measure to treat any small cancer cells that may have found there way into the rest of your body. If you have rads - it's the same thing but focused on a local recurrence. The same it true of AIs and SERMS (systemic). 

I had neoadjuvant chemo & my surgeon said that to his mind there is no reason not to do neoadjuvant when you know somebody is going to have chemo. One of the reasons is because there are ways of measuring how well the chemo is working.The thing is that they often don't know whether someone will need chemo until after the surgery. There is one drawback to having it prior to surgery & that is that the 'staging' becomes more difficult.  I don't know how many nodes were positive so I'm either 3a or 3c. Overall, it doesn't matter because the treatment will be the same regardless.  Also you have to have an AND because they don't know if there are some cells in the axillary nodes (although it seems like it would be possible to have a SNB prior to starting the chemo, but that would put off the chemo for awhile). 

warrior70

Thanks, Ziggypop.

paloverde

Was afraid of that ... if I were in a cynical mood I might say it sounds like a giant, expensive pair of crossed fingers.  Maybe I'll have a different perspective when it's over. 

I suppose in the grand scheme, having the cancer out is better than not having the cancer out!

elindy

I've been wondering that too!  I was diganosed in June, 1 cm and clear nodes- I didn't know enough in the beginning to ask questions- wish I had found this site earlier.  My MO did not order ANY scans -  I assume becasue my nodes were clear.  But I sure wish I had them- just to know for sure. I finished chemo in October, rads 3 weeks ago, and now just follow up appointments. Should I insist on a scan now, and if so, which kind?

flannelette

I had a lung xray, a bone scan (not a bone density scan), I think an MRI of abdomen and pelvis around the time of dx, but this is in Ontario where i guess it's automatically ordered. All came out negative. Then no scans. No scan is ordered until you present with a symptom. At 4 yrs out  on my annnual mammogram of "good" breast a lymph node of 1.2 cm showed up in the axilla.  Then a 1.5 cm one. (over 1 cm is suspicious). then I was scanned to pieces including to tips of fingers bone scan and each side of my cranium. Nothing. Except 1 teensy "granule" in a lung, which they followed for about a year. I actually forgot to go to the last scan for that a month ago, and am wondering if I should re-book, as it does give me concern when I cough a little. My bs, who originally ordered it, said it was probably just a leftover from some old infection (I've had a few bouts of pneumonia in the past). when I last saw my onc, just prior to the date for that scan, she wondered why it had been ordered & then said oh you might as well go since you're booked, but too much scanning is not the greatest thing.

so my experience is after initial tx there are no scans, they have no idea, and then maybe one day voila - the Hunt for Red October, at which point you are stage 4 if they discover anything. They do not wish to bombard you with routine scans as they have concerns about too much radiation and an overload of testing which leads to a lot of anxiety often for no reason. You just have to go around wondering, or maybe not, if some little buggers are building a fort you don't know about.

I'm sure there are more scientific reasons involving mortality statistics but i don't understand them. Someone else might explain.

ziggypop

elindy - if your nodes were clear, then there's no reason for a scan, your risk of mets is extremely low - if you have mets they wouldn't likely show up on a scan anyway (particularly if you had chemo) and a lot of stuff does show up on scans - old injuries, etc.  And you're exposing yourself to extra radiation. Unlike breast cancer, there isn't any survival benefit to finding mets early (although I can understand why people would want them done). There's actually a reason to not treat mets before symptoms occur - basically it's that there are a number of treatments that they can use on mets - but eventually the cancer cells become immune to those treatments and then they can't be used again. So if you 'use up' a treatment on some tiny little bits of cancer cells then you're taking one treatment out of your arsenal for when you need it. (That's the argument anyway). 

It like if you had 5 types of weed killers to dump on your lawn & each one would 'work' for a year and then stop working. You wouldn't want to use up one type of weed killer when the weeds weren't doing anything to interfere with your lawn. Especially if dumping the weed killer on also left some nasty brown spots. 

paloverde

That's a great explanation, thanks ziggypop!

ziggypop

paloverde - rather than a giant pair of crossed fingers - I think of it as a very expensive condom used by somebody at a high risk for HIV. There are no guarantees - there are some people who have chemo who never needed it in the first place (they're like the people who have casual sex and always use a condom but never would have contracted HIV because they didn't happen to end up with somebody who had it). There's some people who are considered low risk who actually should have had chemo and didn't (they're like the married woman who doesn't wear use a condom who's husband goes out and cheats on her & brings HIV home). Then there are the people who are high risk who wear the condom but find out later that it didn't work. And then there's the last group - the ones who are high risk and use the condom which actually prevents them from being killed by a disease that could have been prevented.

It stinks that we don't know - but at least when I think about it this way I understand why I went through the chemo nightmare. y risk were really high & I cut them in half with the chemo - that's worth it for me.  

Kicks

Ziggypop - maybe I miss read what you wrote "there isn't any survival benefit to finding mets early".  'There's actually a reason to not treat mets before symptoms occur".  Where did you find that medical information?   

encyclias

I had originally posted this on another thread where the same question had come up:

My chemo was neo-adjuvant on the recommendation of my MO and surgeon.  What it did was shrink my two tumors (totaling 5cm), to just a single 3mm bit -- less than the size of half a greenpea.  My LX afterwards was quite easy and totally unnoticeable with such a small crumb to remove.  The margins were wide and clear.  The SNB showed there was no longer cancer in the nodes -- actually, there had been several nodes involved originally rather than just the big one that was felt by the onc.  My doctors felt confident that the chemo had done its job and also clobbered any other cancer cells which may have been floating around in my body just as it had clobbered the two breast tumors and the nodes.  I then went on to request radiation just to make sure there weren't any strays locally still in my breast.

I had a PET scan last month, and very different from my first one in Oct 2012, this one was clear of cancer.  Hope it will last.

Had I done it the other way, with adjuvant chemo instead, I would have had to have a MX or settle for a LX and a very deformed breast (I am not big-breasted).  I am a diabetic and as such, it is well known that we don't heal wounds very easily in general; so certainly a MX or BMX would not be a first choice -- and certainly not reconstruction either. It wasn't an issue of vanity; it was more an issue of potential healing problems.  Also ripping out a bunch of lymph nodes could certainly cause future permanent complications, such as lymphedema.  And then, as has been brought up, there would be no way of knowing if the chemo actually worked!  This board has many threads titled  --  (your choice of: taxol, taxotere , A/C) -- "didn't shrink my tumor."  What if this happened during adjuvant rather than neoadjuvant chemo?  How would the doctors know, except waiting to see if the cancer shows up somewhere else in the future?

But doctors have their own protocol which they feel works for them.  Hopefully, theirs will work for you.  Good luck!  The choices can drive you crazy.

Carol

ziggypop

 Kicks - you didn't misread it, I wondered early on why I would not be getting routine lab work or scans done following treatment (I go to the cleveland clinic & my onc is considered one of the best in the country). I researched it & found this & then had a very long discussion with him (my onc)  about it & about how treatments on metastasized cancer 'work'. With breast cancer finding it 'early' can be very beneficial - you find DCIS before it becomes invasive & cut it out, radiate the area & that's that. That is very different once the cancer has metastasized. Consider (for instance) that it goes to the liver. Well - it's more than likely that you will have signs of jaundice before that shows up in blood work or scans. But lets say it doesn't, the way that BC metastasizes to the liver is in little inoperable spots & the treatment will be just as effective regardless of whether you find this pre or post symptoms. In addition, by doing scans - risk is added (more radiation, more sometimes unnecessary invasive procedures, etc). This is why in the US (and canada and most other countries) standard protocol is to not do routine scans. 

Question: What is the standard for three-month checkups with the oncologist? What tests are run? What do they look at in the blood work that can indicate recurrence?

Dr. Lin: I am assuming you had a diagnosis of stage I, II or III breast cancer and completed chemotherapy and radiation, if either were necessary. You may still be taking hormonal therapy with tamoxifen, anastrozole (Arimidex), exemestane (Aromasin) or letrozole (Femara). If so, your oncologist is now transitioning you to the survivorship phase of your breast cancer care.

Typically, oncologists see patients every three to six months, depending on patient needs, symptoms, etc. I typically see patients two to three times the first year and then twice a year thereafter if things are going well.

Although it may seem counterintuitive, other than yearly mammograms and physical examination at each visit, I do not do routine scans or blood tests to look for cancer recurrence. Two large studies compared women followed with usual care (that is, doctor’s visits, physical examination, review of symptoms, mammograms) to women followed with “extra” testing (that is, blood tests, liver scans, bone scans, chest X-rays). These studies found no difference in a woman’s chances of survival or length of survival after breast cancer with the “extra” testing. Even with patients in the “extra” testing group, most recurrences were found between tests, when a woman brought a symptom to the doctor’s attention or a doctor noted something during a clinic visit. So, all the professional oncology organizations actually recommend AGAINST routine blood work or scans as part of follow-up, with the exception of mammograms.

This can create anxiety. I encourage you discuss your concerns with your doctor. In addition, it is often useful to have a discussion about the types of symptoms that should prompt a call to your doctor.

Question: Is there a difference in follow-up care for patients with more aggressive types of early-stage breast cancer?

Dr. Lin: There is generally no difference in routine testing. That is, patients with more aggressive types of cancer have not been shown to benefit from extra blood tests or scans.

One difference is I worry more about symptoms in patients who had more aggressive types of cancer, or in patients who had a higher stage of breast cancer at diagnosis, and I would be more likely to order tests if that patient had new or worrisome symptoms.

Holeinone

Ziggypop, thanks for that info, I have read it before, but it needs to sink in still...

Shalimar630

Flannelette: I see that you were also treated with Arimidex, which is what I believe I will be starting next week. Are you still on it, and could you give me some info as to how you handled it? Did you have side efffects, etc?

Kathryn