Radiation if Node Negative after Neoadjuvant Chemo?

PeachyJeanne

I was diagnosed at 47 (now 48) in April with multi-centric IDC (2 malignancies in separate quadrants of the left breast) and a needle biopsy of a suspicious lymph node came back positive. Both breast biopsies came back ER+ /PR+ HER2- My treatment was neo-adjuvant chemo (dose dense AC+T) and I just had a unilateral mastectomy and sentinel nodes removed. The cancer in my breast responded well to the chemo although there was still residual cancer remaining. The 4 sentinel lymph nodes removed, however, tested negative. There is now a mention on the path report after mastectomy that one area in breast came back HER2 equivocal and FISH will be performed. I am waiting for that result. Would hate to find out it is + at this point but that's where I am.

So..now I am looking at whether radiation is needed. The RO I spoke to said that years ago the standard was surgery first and if the tumor was larger than 5cm or there was positive lymph nodes, treatment would be chemo followed by radiation and hormone therapy. Since I did have a positive node originally, this would have been my path.

Because my treatment was chemo first, and I had a pathological complete response in the nodes, it is questioned whether to treat me as node positive or node negative going forward.

There were a few small studies done that indicate there is no significant benefit of radiation that outweighs the side effects if node negative after neo-adjuvant chemo. The RO said these studies were small (one at MD Anderson) and not randomized; but, the results were so intriguing that there is now a national clinical trial to gather the data and determine if they can get the same local recurrence risk and overall survival percentages without undergoing radiation.

While the RO was pretty enthusiastic about my response to treatment thus far, and in his opinion thought I would be considered node negative, the current standard of care would be to have radiation. This is because radiation has proven known benefits despite side effects and the medical field will not take away a treatment with known benefits before there is data to show it will not be detrimental to recurrence/survival rates. They just don't have the data yet. The trial going on now will answer the question. RO said this is one of the most discussed treatment issues today and in a few years I may read an article saying radiation is not proven beneficial for my situation.

Which brings me to my choices.

1) Go ahead with current standard and have radiation and deal with any short term/long term effects including possible not so great outcome for reconstruction (I currently have a tissue expander in place and will have a silicone implant)

2) Enroll in the national clinical trial and let the decision be random whether I have radiation or not.

3) Just say no to radiation period but I would not be part of the trial.

Has anyone else faced this decision? I bounce back and forth between "throwing everything I can at it" now and not wanting to be overtreated and face possible issues later on as a result of that treatment.

ElaineTherese

Hi!

I was diagnosed with triple positive IDC. My lump was 5 cm., and one node tested positive via fine needle biopsy. Like you, I had neoadjuvant chemotherapy and I responded very well to chemo. My pathology after my surgery showed that all of the active cancer was gone, and that my nodes were cancer-free.

However, I had a lumpectomy and you had a mastectomy, so radiation was highly recommended for me. Plus, my cancer was triple positive and Grade 3 (very aggressive). My RO would have recommended radiation to me regardless of the kind of surgery I underwent.

Did you do an oncotype test? If so, what was your score? I see that you were Grade 2, so not replicating as quickly as Grade 3.

PeachyJeanne

Hi Elaine,

Agreed if I had a lumpectomy, radiation would definitely be recommended. I was not a candidate based on multi-centric diagnosis. (I've updated my profile to reflect the 2 malignancies) I'm not large and two areas in different quadrants bought me the mastectomy. The neoadjuvant chemo was primarily geared toward treating lymph nodes to limit number of nodes to be removed.

My MO told me stage was 2; . She said grade was 2/3.

My path report says:

Nuclear grade II/III (moderate variation in size and shape) and

Nuclear Grade: High.

My original biopsy for first nodule listed a Ki67 of 19.50% (the doctor that I switched to after diagnosis does not use Ki67 tests)

I did not have Oncotype test done. I did have genetic testing and I do not have any mutations.

stephincanada

Hi Jeanne:

Here are two threads that might be helpful to you:

https://community.breastcancer.org/forum/80/topics/846162?page=1#post_4876501

https://community.breastcancer.org/forum/70/topics/851553?page=1#post_4878258