Mammaprint and oncotype dx and need for chemo

Brightness456

Hi everyone. I've been doing some reading on the possibility of skipping chemo after surgery and it appears the mammaprint may be the best test out there to determine necessity. Apparently it is for tumors less than 5cm, her2 + or - , no more than 3 nodes involved, and stage 0 or 1. It appears to be more effective than the oncotype dx, which can be more ambiguous. From what I've read, for some women the rate of recurrence or mets does not decrease with chemo.

Now, having said that, I just started reading about this a few hours ago, so I may be mistaken or I'll informed about the whole thing, thus I'm here asking for input. Does anyone know about these tests? If the mammaprint is as good as it sounds, I think I'd like to have it.

Thank you in advance. I truly appreciate the clear heads on this site that help me cut through all the stuff that I don't need to focus on so I can put my energy into the things that might make this journey a bit easier

ElaineTherese

Hi Brightness!

Aren't you HER2+? In most cases, MammaPrint will tell you that your cancer has a high risk of recurrence.

Brightness456

I am her2+, but the test is supposed to work for either + or -

ElaineTherese

Well, the test "works," but it may not tell you anything more than what is already known: breast cancer patients with HER2+ cancer have a relative high risk of recurrence.

windingshores

The Oncotype Dx is not useful for HER2+ . It is a fine test for those with clearly low or high scores but there is some uncertainty about whether those with intermediate scores should do chemo. If you are HER2+ the Mammaprint would be better.

When I was diagnosed as HER2+ (which was a mistake: thank heavens I got pathology done elsewhere as well, then a third tie breaker test), it was a foregone conclusion I would do Herceptin and chemo. Is your doctor giving you a choice? That would be unusual.

Low Oncotypes are HER2- and have high ER/PR scores so that hormonal medications are (hopefully) effective.

Brightness456

My doctors have not suggested either test specifically. I'm getting a second opinion this week and plan to ask about the tests. I'm asking here to help educate and prepare myself. I'm her2+, ER/PR- (<5.5). Stage 1, grade 3

BarredOwl

Hi Brightness456:

If you have not yet had surgery, please note that your actual pathologic stage will be determined post-surgery, and will be based in part on actual tumor size and lymph node status. In general, the actual tumor size may differ from the estimated size. Similarly, actual lymph node status may differ from what clinical and imaging assessments suggest.

Clinical consensus guidelines for the treatment of hormone receptor-negative, HER2-positive IDC provide different options or recommendations for chemotherapy plus HER2-targeted therapy, depending on tumor size and lymph node status. (Additional clinical and pathologic factors may also be considered.) Thus, information essential to the question of systemic treatment in your case will be obtained from surgical pathology.

Clinical consensus guidelines do not recommend the use of either the Oncotype or MammaPrint test for ER- PR- HER2+ disease. Instead, treatment recommendations in this situation are typically based on standard clinical and pathologic features (per the above paragraph).

(A) OncotypeDX for Invasive Breast Cancer ("21-gene test"):

This test is used for disease that is (1) hormone receptor-positive; and (2) HER2-negative:

Commercial Provider's (GenomicHealth) formal "eligibility": http://www.oncotypeiq.com/en-US/breast-cancer/healthcare-professionals/oncotype-dx-breast-recurrence-score/is-your-patient-eligible

Those with ER- PR- disease would not be eligible. Those with HER2-positive disease would not be eligible.

This is because the test for invasive disease is designed (and validated) for use in patients who will receive endocrine therapy (i.e., who are hormone receptor-positive). It is used to help inform decision the decision between: (a) endocrine therapy plus chemotherapy; or (b) endocrine therapy alone.

For those who are formally eligible, in practice, the test may not always be recommended (or if done, may be accorded less weight) in those who are formally eligible but who have lymph node metastases. This is because the formal "eligibility" of the commercial provider may be broader in some aspects than what clinical consensus guidelines include or recommend. There are differences in how the test is viewed by NCCN and by ASCO in those with (a) node-negative (pN0) disease; (b) nodal micrometastasis (pN1mi); or (c) 1 to 3 nodal metastases.

(B) MammaPrint ("70-gene test") for Invasive Breast Cancer

The formal eligibility requirements from the commercial provider are broader than what is included in clinical guidelines. NCCN guidelines (Version 2.2017) do not include use of the MammaPrint test in those with HER2-positive disease. Similarly, a recent ASCO Biomarker Guideline Update does not recommend use of the MammaPrint test for HER2-positive disease, explaining that:

2017 ASCO Guideline Update re MammaPrint in view of MINDACT trial: http://ascopubs.org/doi/pdfdirect/10.1200/JCO.2017.74.0472

"Given the small HER2-positive subgroup in MINDACT and the known substantial benefit women with HER2-positive tumors derive from the addition of anti-HER2 agents to adjuvant chemotherapy, the Panel concluded that the data do not support use of the MammaPrint assay to decide whether a patient with HER2-positive breast cancer may safely forgo adjuvant chemotherapy."

I am a layperson with no medical training. Guidelines provide what is done in the usual case, and there may be special situations or exceptions. Therefore, please confirm the above with your team as you are planning to do. Anyone interested in these tests should not hesitate to ask their medical oncologist about them to ensure receipt of current, case-specific, expert professional medical advice.

BarredOwl

Italychick

I always said I would say no to chemo, but when my tumor came back ER/PR negative and Her2 positive, I couldn't wait for chemo to start. Herceptin is such a game changer for Her2 positive breast cancer. how large is your tumor estimated to be? Over a certain size (don't know what that size is), there may also be a recommendation to do neoadjuvant chemo and Herceptin and perjeta before tumor removal to see how well your body responds. And with a grade 3 Her2 positive tumor, chemo is more effective.

Don't be afraid of chemo. It isn't pleasant, but it is doable, and they have so many options to manage and minimize side effects. I worked, kept grandchildren (3 under the age of 5), and rode my bike 3,000 miles during the year I had chemo treatments. Chemo did not change my day to day life, other than feeling some funky short term side effects which went away a few months after chemo ended. My doctor said hit it now and be aggressive in treatment, and I was a grade 2, not a grade 3. She also said it reduced my risk of return/metastasis from 30% to about 10-15%, and I wanted the reduced risk. But there are no guarantees, just statistics based on women and men who have received treatment. With negative estrogen and progesterone receptors, there is only Herceptin and chemo, no long term anti-hormonal treatments.

Everybody has to take the path most comfortable for them, but I am glad everyday I took the chemo treatments and Herceptin. As I said chemo isn't pleasant, but it is doable. And now, over two years later since chemo ended, it is just a memory in my past.

I am relating my personal experience and in no way trying to tell you what to do as we each have to make our own decisions.

Best of luck with whatever you decide!

Brightness456

Italychick, how lucky that you were able to keep your hair and feel so good during chemo. Not everyone is so lucky.

Barredowl, thank you for the interesting information. I'll update after I meet with the new team of doctors.

Italychick

Brightness, I did not keep my hair, most of it fell out. If was halfway down my back before chemo. I looked like a newborn with scraggly wisps. But it came back great.

windingshores

Now I am wondering about the Oncotype versus Mammaprint, after reading the new ASCO guidelines which read in part (small part):

"People diagnosed with hormone-receptor-positive, HER2-negative breast cancer with no cancer in the lymph nodes, but with clinical characteristics that indicate a high risk of recurrence may use MammaPrint test results to make decisions about chemotherapy after surgery."

I had grade 3, highish Ki67% and LVI but my Oncotype was 8. So my Oncotype conflicted with the clinical characteristics of my pathology. I wonder if I should have had a Mammaprint! I was down to the wire with my 4th opinion when I decided against chemo two years ago.

LAmargarita

Hi BarredOwl,

Thanks for the info. I'm just about to embark on that part of the journey after Mx and reconstruction. I've been doing lots of reading but your post summarizes the pro/cons + eligibility quite nicely.

Cheers!

BT39

Hi windingshores and others,

I am also trying to decide what to do. My Oncotype came back high (54), grade 3 tumor, with high Nottingham score (8), and high ki-67 (60%). I started out with widespread DCIS in one breast, had a bilateral mastectomy, and a 4mm invasive tumor was found, clear margins and node. It seems like the recs will be to do 4 rounds of chemo and hormone therapy. It's so challenging to sort through this and the odds. It does seem like women with aggressive small tumors, esp. under age 40 or early 40s, have issues with an aggressive cancer showing up down the road. Trying to sort this out with my decision to have chemo, and if it will help.

Fedders

Hi BT39,

I totally understand why saying yes to chemo seems like a big step. Like you, I had a high oncotype score (47) and had neoadjuvant AC-T chemo to shrink the tumor before a lumpectomy, which I had a month ago. When I first learned about the Oncotype score, it took me a while to understand what they meant by 'risk of recurrence'. I thought it would come back as another type of cancer somewhere else in my system but I realized that it will still be breast cancer, no matter where else it goes. So with the chemo therapy and the endocrine therapy, you're treating the cancer systemically and not just locally.

I had 8 treatments of AC-T (4 AC and 4 T) in the spring. While it wasn't exactly pleasant, it was nowhere near as bad as I had feared. Most of the side effects I had read about in the literature they provided never materialized. I had no mouth sores, no nausea beyond the first day or two after treatment, no major side effects overall. I did lose all my hair (including eyebrows and lashes - not a good look) and I won't lie, that's a pain in the neck! But it's all manageable. I was able to work remotely almost full time and my husband and I were going out and doing other social things (as usual) while I was in chemo. While you're in the middle of it, it will seem like a long time. But once you're out of it and you have a full head of hair/set of brows and lashes, which in my case was within six weeks of my last chemo, it will seem like a relatively short time in the grand scheme of things. I also found that a attitude, exercise, diet, hydration and sleep helped me in a big way during the process! I have no doubt that being relatively young (41) helped me combat side effects but it sounds like you are as well.

All that is to say that if I were you, I would opt to have the chemo and help reduce the risk of spreading and recurrence. It's 3-4 months (typically) that could be a really good investment in the rest of your life. And you are stronger than think!

Those are just my two cents! I'm convinced that you will make the decision that is right for you .

Sending lots of warm thoughts your way!

Meow13

What I would like to see from oncodx, I would like to see a database that goes with more actual outcomes and reassess the statistics on a periodic basis. Including risk vs other drugs than tamoxifen. In this age of big data this could be done and be beneficial to so many breast cancer patients.

It would benefit oncologist who determine treatment some more information to pull from. It seems like many just look at their clients results to make determination as well as standard of care.