Recommend radiation after DMX, no recon, micro met and LVI?

LuckyClover

I am trying to learn more about radiation pros/cons and would love input.

I had a double mastectomy 11/30/2016 and will not be doing any reconstruction. I had multifocal tumors, Stage IB, ER/PR + and HER2-. I won't be doing chemo due to a low oncotype score, but I will be doing Tamoxifen.

The radiation oncologist I've met with recommended radiation based on the following factors:

• micro mets in one lymph node (5 more clear)
• location of multifocal tumors closer to sternum lymph nodes
• my age-44
• evidence of lymphovascular invasion in my pathology report.

She said that because I'm not doing reconstruction, I could do low energy electron radiation to the chest wall which should reduce the impact to the lungs and heart.

I'd love to hear about others' experiences and thoughts re risks/benefits. I meet with the RO again next week, so if you have suggestions for questions that I can ask re risks, etc. please send those along as well.

Mamasha

Wondering same thing bumping up

minatabo

Hello,

I too am wondering about this question/topic.

I have bilateral breast cancer (2 IDC on right, and 1 DCIS, 1 IDC (4.4cm) on left). Since they couldn't achieve clear margins, the plan was to go for bilateral mastectomy after chemo.

I was under the impression that with mastectomy, you won't need radiation. However my rad onc said it's a maybe. For few reason:
- i'm young (<35 yo)
- Rare LVI (whatever that means) - I thought chemo would address any micro-cancer cells systemically?
- large tumor size (4.4cm)
- close margin on that large tumor (1mm - ideal would be 2mm)

Does anyone have any idea on this topic? Is my rad onc overtreating me if I get radiation AFTER mastectomy. (Its also going to affect the type of reconstruction I can have....this really sucks)

Thanks in advance!

stephincanada

Hi Minatabo,

I had radiation because my doctor said that there is a 5% reduction in risk of metastasis for each of these four factors:

-young age (<50),

-close margin (<2 mm),

-high grade,

-being her2+ Or triple negative (I was her2+),

giving me a 20% risk reduction in total. So, even though I will have a mastectomy in the future, radiation was deemed necessary. My doctor felt that I would benefit more from the radiation than the mastectomy, so she decided I should have the radiation first. As a result, I will have to wait one year fo my skin/tissue/muscle to heal from rads before having the surgery. Yes, it will restrict my reconstruction options and the outcome won't be as aesthetically appealing, but the 20% reduction in risk is well worth it, in my view.

Ps: I also had LVI.

coraleliz

I was hoping to dodge the RADs bullet. That was one of the reasons I chose a BMX. I was diagnosed at 52 & not yet menopausal. I ended up getting bilateral RADs to both sides(chest wall & axillas). My right side had LVI & isolated tumor cells in the nodes. My left side had 2 positive nodes(3mm each). I had RADs to avoid needing additional nodes removed(ALND) which carries a greater risk for lymphedema. I'm not really sure why I had my left chest wall radiated. It was over 5years ago, so maybe it's a good thing I'm forgetting some of the particulars.

I feared bilateral radiation would wipe me out & make me so exhausted I couldn't function. I had trouble finding anyone here at BCO who did "double". I did not notice being tired. I went for a run everyday following treatment. My chest walls became quite red but not my axillas. Keeping active helped take my mind off the discomfort. The weekends were more problematic than weekdays(RADs days). It seemed like the discomfort was worse on weekends, my best guess is because on those 2 days my chest started to heal. In additional to the soreness, I also had itchiness on the weekends.

RADs on both sides is very manageable(for me) & may not be much or any worse than RADs on one side. No way of knowing for sure.

mellee

I'm struggling with the rads decision too. It's not an easy one for those of us who got BMX, but then ended up with 1-3 positive lymph nodes (I also had ALND).

In late 2016, the American Society of Clinical Oncology came out with new guidelines for postmastectomy radiation: http://ascopubs.org/doi/full/10.1200/JCO.2016.69.1...

It's a dense read, but very informative. The takeaway is that they now recommend that women with 1-3 positive nodes "strongly consider" radiation, but with the caveat that there are subsets of these women for whom the benefits don't outweigh the risks.

Here is the summary of the recommendations for women with mastectomy + axillary lymph node dissection:

Clinical Question 1

Is PMRT (post-mastectomy radiation therapy) indicated in patients with T1-2 tumors with one to three positive axillary lymph nodes who undergo ALND?

Recommendations

1. Recommendation 1a. The panel unanimously agreed that the available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer and one to three positive lymph nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT or not requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer–specific mortality, and/or increase the risk of complications resulting from PMRT. These factors include: patient characteristics (age > 40 to 45 years, limited life expectancy because of older age or comorbidities, or coexisting conditions that might increase the risk of complications), pathologic findings associated with a lower tumor burden (eg, T1 tumor size, absence of lymphovascular invasion, presence of only a single positive node and/or small size of nodal metastases, or substantial response to NAST), and biologic characteristics of the cancer associated with better outcomes and survival and/or greater effectiveness of systemic therapy (eg, low tumor grade or strong hormonal sensitivity; type: informal consensus; evidence quality: intermediate; strength of recommendation: moderate). There are several risk-adaptive models that physicians may find useful in explaining the benefits of PMRT during shared decision making with patients. However, the panel found insufficient evidence to endorse any specific model or to unambiguously define specific patient subgroups to which PMRT should not be administered (type: no recommendation; evidence quality: low; strength of recommendation: weak). Further research is needed on how to accurately estimate individuals' risk of LRF and hence their potential reductions in LRF and breast cancer mortality.
2. Recommendation 1b. The decision to use PMRT should be made in a multidisciplinary fashion through discussion among providers from all treating disciplines early in a patient's treatment course (soon after surgery or before or soon after the initiation of systemic therapy), either in the context of a formal tumor board or by referral (type: informal consensus; evidence quality: insufficient; strength of recommendation: strong).
3. Recommendation 1c. Decision making must fully involve the patient, whose values as to what constitutes sufficient benefit and how to weigh the risk of complications against this in light of the best information the treating physicians can provide regarding PMRT in her situation must be respected and incorporated into the final treatment choice (type: informal consensus; evidence quality: insufficient; strength of recommendation: strong).

minatabo

Hello StephinCanada,

Thanks for sharing your experience! Just curious with your lumpectomy, were they able to achieve clear margins?

I'm surprised they're doing your mastectomy after your radiation. I always thought you had to do mastectomy before radiation. Was there a reason why they recommended whole breast rad with a right side cancer?

What reconstruction options did your plastic surgeon offer you?

sorry lots of questions. just wanting to weigh my options here.

Minatabo

Bright55

hi

Sound reasons as close to chest wall

consider if you had been given option of partial removal radiation is a protocal with chemo then hormone

great info from gals who have undergone rads

good luck

stephincanada

Hi Minatabo,

Yes, I had clean margins, but there was only a 1.6 mm clearance to the chest wall.

As for a mastectomy, my surgeon says that it is not medically necessary. However, I feel that I must do it. If I developed a new primary tumour or had a recurrence, I would never forgive myself. She said that the radiation, however, is necessary and shouldn't be delayed by more surgery.

I must now wait at least one year to have the mastectomy and reconstruction. We are going to try for a single step, skin sparing mastectomy (but not nipple sparing) with implants. If the implants fail, I can always have a latissimus dorsi flap reconstruction later. I wanted a minimally invasive reconstruction, and I hear that the newer implants have a longer shelf life than their predecessors. I had pretty bad burns from radiation, so I might have capsular constriction with the implants. My breast surgeon mentioned that the plastic surgeon who will do my operation is now doing over the pectoral muscle implants (called "pre-pectoral implant surgery"). I will meet with him in June to discuss.

Re: whole Breast radiation. I have no clue why this was chosen. To be honest, I didn't ask many questions about radiation and just did what was recommended. At every turn, I opted for the more aggressive treatment because I don't want to have any regrets in the future.

Hope that is helpful. Feel free to pm me if you have further questions.