Onco score 10 and no chemo or rads but still worried!!!

Aysh1005

hi all

Had onco score of 10 which I'm really pleased about but can't get my head round no rads.

I had a 15mm grade 3 idc tumour with dcis grade 3 which made full size 35mm I had lumpectomy had clear nodes but not clear margins so having a masectomy in the near future.

On my pathology report it says both idc and dcis grade 3 and vascular invasion plus necrosis which I researched to find it means the cancer was aggressive as there were some dead cancer cells also in the report it says the dcis is solid which I believe it to mean it's filling the full cercumfrance of the duct. My npi score was 4.3 too.

I'm worried that the tamoxifen may not mop up everything especially not having rads as well.

Any advice would be welcome thankyou

Ayshea

Meow13

You might get another opinion. I am starting to hear more people going on lupron then AI drugs instead of tamoxifen.

BarredOwl

Hi Aysh1005:

The indications for loco-regional treatment with radiation after lumpectomy versus mastectomy are not the same. So, if instead of a re-excision you are having a mastectomy shortly, then you may not need radiation. Many (but not all) patients with DCIS and/or invasive disease who receive mastectomy can avoid post-mastectomy radiation. Having negative nodes is one factor already in your favor. Sending good wishes for wide margins.

I am assuming by Onco score, that you are referring to the OncotypeDX test for invasive breast cancer. It is used to inform decision-making about systemic treatments, and specifically whether to add chemotherapy to five years of endocrine therapy.*** (The features of the DCIS (e.g., size, solid) are not relevant to this question, because DCIS is non-invasive and so is not treated with systemic chemotherapy.)

An Oncotype Recurrence Score of 10 for node-negative, invasive disease is quite favorable. Will you be seeing the Medical Oncologist after the full pathology from mastectomy is available? In any event, don't hesitate to ask your medical oncologist for an explanation of how to view the information from the Oncotype test together with various pathology findings for the invasive disease (e.g., grade, degree of vascular invasion).

Meanwhile, if you'd like to read about the 5-year results from the prospective TAILORx trial for patients with node-negative (N0) disease and a Recurrence Score from 0 to 10, please see this relatively recent publication:

Sparano (2015), "Prospective Validation of a 21-Gene Expression Assay in Breast Cancer"

http://www.nejm.org/doi/full/10.1056/NEJMoa1510764#t=article

PDF version: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1510764

Best,

BarredOwl

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*** There is another Oncotype test that is used in those with pure DCIS (with no evidence of invasion) following breast conserving therapy (lumpectomy). It is used to inform decisions about radiation. It is not used in patients with invasive disease or in those receiving mastectomy.

Aysh1005

thankyou ladies for your information

I have never heard of that treatment meow13 they didn't give me any options other than tamoxifen.

Barred owl I didn't realize they did a pathology report after the masectomy but I will ask about that. I think I worry about no rads as the surgeon said one of the positive margins was at my chest wall so if any dcis left after masectomy will this be mopped up with the tamoxifen? One of the reasons for masectomy is that I have breast implants and it was right upto the pocket so they think it will be better rather than another lumpectomy. The implant hid part of the tumour and dcis so I have also asked for an mri before the op incase there is anything in my other breast they are taking the request to mdt meeting on Wednesday I hope they agree as this will help me settle with it all. I will take a look at the info you have messaged and thankyou again for taking the time out to answer.

Sending love

Ayshea

BarredOwl

Hi Aysh1005:

It sounds like there may be concerns for both the posterior (chest) and anterior (near implant) margins? "At the chest wall" isn't very clear. You may wish to ask if there is some small distance between where the posterior margin was (formerly) located in the breast and the chest muscle fascia, and if the posterior margin might be improved by mastectomy. The final post-mastectomy margin sizes are the ones that will be used for treatment decisions.

In any case, after the mastectomy, with full information about all final margins, you can request a consultation with a Radiation Oncologist. The question of post-mastectomy radiation is specialized and fact-specific. The Radiation Oncologist can help you to understand your potential local recurrence risk (in light of all information) and the potential risk reduction benefit in your case.

In general, radiation can provide a relative risk reduction for local recurrence of around 50%, but the size of the benefit for each individual depends on their level of risk. For example, if a person's local recurrence risk was relatively small (e.g., ~5%- 6%), then the absolute benefit of radiation would be commensurately small (2.5% to 3% benefit), and may or may not be seen to outweigh the risks. Different patients may view this differently, based on their personal risk tolerance.

In addition to reducing the potential risk of distant recurrence, tamoxifen may reduce the risk of local recurrence (invasive or non-invasive) in the same breast, as well as the incidence of new disease in the opposite breast. This is the area of expertise of the Medical Oncologist. Your team should be able to help you understand the local benefits of individual or combined treatments (radiation, endocrine therapy).

As noted above, some patients may receive a recommendation for an ovarian suppression drug in addition to either tamoxifen or an aromatase inhibitor. (In pre-menopausal patients who have intact ovaries, aromatase inhibitors cannot be used without an ovarian suppression drug.) Selection of a specific approach to endocrine therapy is a specialized, case-specific question for your medical oncologist. I note that our local ASCO guidelines do not recommend ovarian suppression in certain lower risk scenarios:

2016 ASCO Update re Ovarian Suppression: http://ascopubs.org/doi/pdf/10.1200/JCO.2015.65.9573

There are probably local guidelines in the UK, and they may differ in some ways. There may be appropriate exceptions to what guidelines provide in the individual case, so do not hesitate to seek current case-specific, expert professional advice regarding all appropriate options for endocrine therapy in your case.

BarredOwl