Optimal Chemo choice for ER positive, premenopausal women

Walden1

I'm currently doing dose dense chemo ACx4 and Tx4. I'm 44 And I have two 2cm lumps near each other with DCIS in the same area. I've read there are recent studies that show that dose dense is a good option for premenopausal women irrespective of hormone status. At the time I started chemo, my oncologist didn't give me much of an explanation as to why this particular chemo regimen was recommended for me. She essentially said, let's hit it with our most powerful regime, which I agreed with. Not second guessing that choice, but now I’m curious to learn more.

For my fellow ER positive, premenopausal ladies on the same regime, can you share what your oncologist had to say about selecting that regime for you?

KBeee

I did ACX4 dose dense, and then 12 weekly Taxol when I did that regimen. AC then Taxol has been shown to be a little more effective than TC in a recent study (TC was "not non-inferior to AC+T) http://www.onclive.com/peer-exchange-archive/2016-... That study was stopped early because TC was inferior. As you can see from my stats, I have done both regimens, and TC did not seem to work for me. Thus far, AC+T has.

I think the 12 weekly Taxol is at least equal to TX4. It is generally better tolerated. https://www.medscape.com/viewarticle/805220 http://www.ascopost.com/News/4213

Billb464

Kbee,

hi, I am curious , did you have any radiation the 1st time you were diagnosed?

Also, I see that you took the tomoxifen, did it help any?? Do you think it is better to go straight to ovary removal? I haven’t brought this up with my MO yet, but I have been thinking about it.

I was told that hopefully the chemo would help shrink the tumor b4 surgery, but no gaurentee. I did have ultrasound midway, and my tumor did shrink in bulk but not linear. I had a 80% change with the chemo. I still went with a lumpectomy, but we did two removals, 1st the tumor and the 2nd, more area around, which was good since I had some DCIS. We still got clear margins, but still a little worried

Walden1

Billb,

80% is a great result! My oncologist said most Er positive tumors don’t shrink that much. Did you have any pains, or other odd feelings in your breast during chemo? I’ve noticed some bruise like feelings near the tumors once in a while. It’s a little hard to describe, but my doctor is not concerned.

Billb464

Walden1:

Yes at the 1st few treatments I did hurt in the breast area, I did t have a port, we just used my arms each time, had more of a reaction at the iv site, than anywhere else. (Bruising, rash). I guess the pain might come from the chemo working on the tumors:)

muska

Hi Walden, I was older than you when I was diagnosed (54) and was offered to chose from the regimen you are on or AC+T. I chose the latter because it seemed a little easier to tolerate. If I were your age I would have done the same regimen as you are on.

Best

Okkate75

From what I can tell, stage 1 folks get offered TC and stage 2 and up get offered AC+T. My oncologist said the risks of heart damage with AC+T are not insignificant, so at stage 1 he prefers TC. I sometimes worry I wasn't give "enough" and wish I'd had the regimen you're having, but there you go. There are always trade offs, unfortunately. I hope you are tolerating your rounds well, and I wish you health!

Walden1

Thanks Muska! Just want to be sure I understand you correctly. Did you have 8 treatments every three weeks

Walden1

Thanks Okkqte75! I get that impression too from the posts, but I’ve seen some stage 2 do TC. I’m stage 2 with no nodes, so according to my doctor the TC might have been an option (she didn’t mention that until after I started). I’m getting treatment #7 this week. At this point every day feels like an eternity because I want to be finished so badly and my fatigue is pretty bad for 5 days. 4 treatments sounds pretty good right now! As it turns out, I’mallergic to taxol and had to cancel #4. I believe I would have been allergic to Taxotere too since I’ve read they are similar except Taxotere is 5 times more powerful. Like you said there are trade offs. I could not have known about the allergy, and probably would have needed to cancel and try something else. Sounds like you made a good choice for your situation: less doses, more powerful T, no heart risk! Hope everything goes smoothly with your radiation.

Okkate75

Thanks! Back at you! There's a light at the end of the tunnel!

KBeee

Billb464, I did not do radiation the first time because I was node negative and had BMX. I did it with my recurrence.

As has been mentioned, TC is often chosen of AC+T for lower risk cancers because of the potential cardiac risk of adriamycin. It a delicate risk-benefit balance. If I had any positive nodes the first time, I would have gone with AC+T. Though I had a recurrence, I was one of the rare exceptions. I would not change any of my treatment choices if I had to do it all again (which I hope not to).

Wildplaces

I did AC 4/ Taxol 4 dose dense. AC was very harsh but the Taxol was doable for me. I am 49, pre menopausal, biggish tumour and one node, so I asked for it in a sense ( I understood the options - and despite feeling shit end 2016, I would still make that choice). Multi - focal, Grade 3 and young age is probably what drove your onc initial suggestion. (Yes I still recall the chemo week being shocking, in dose dense.)

I started feeling better at 2-3 weeks after the last dose and good at 6 weeks - 2 months, back to work 3 months (had radiation after the chemo). Hang in there 😊 this is hopefully the roughest patch as you round up chemo.

Walden1

Thanks Wildplaces! I feel a lot better after reading your comments. Its very inspiring to hear you got through it and started to feel better quite quickly. So grateful great people like you are open to sharing your stories. did you do Onco testing? My onco said she wouldn’t use it because of my age and grade, but I know it can be used in those cases

Wildplaces

Walden1,

No I did not - it would have made no difference to me because of the tumour size and one node positive.

And you are correct - an oncotype or mammaprint could help if no node spread ( and this is now being extented a little).

Still here lie two potential problems:

1. You had two lesions of 2 cm - do those two lesions give you a 1 bordering 2 stage or do we take them together - literature not wildly clear on that - aka what to do with multi focal

2. Oncotype analyses 21 genes from a breast cancer tissue but the truth be told that is NOT the entire volume of cancer that you have and we know there is considerable tumour heterogeneity. Add to this grade 3 and you know you have busy tumour material. So my personal view on oncotype - great for small cancers no nodes - and if below 10 - helps with making decision wrt chemo. Tumour gets bigger and lymph nodes, young age - it gets messier to be use. Someone is going to pull me up on that super scientific term - let's just say the sensitivity and specificity of the test is less. Which is why is recommended for...

You are good - keep focusing on getting stronger. Are you finished with chemo??

Walden1

hi Billb. Just noticed you had a second diagnosis after chemo. Was that the result of the pathology report? Just curios because you had a great response but the tumor looks bigger than the initial diagnosis.

Walden1

hi wildplaces,

Thanks for your words of encouragement. My oncologist called me stage 2 because they also suspect DCIS near the two tumors totalling around 5cm. As for point number 2 that is pretty much the perspective of my oncologist. I’m node neg, but size of disease and age were her justification for chemo. It has been bothering me that I didn’t do onco, but would be unlikely that I am low risk (below 11). ive heard some oncologist will still recommend chemo in a case like mine even with low to intermediate onco type scores especially because of my age . I also have a strong family history, but no gene mutation. I have a chemo today, and my last one is on April 12. It’s too late to worry, but considering point #2 I will sleep better.

Trying to stay strong! only a few more weeks. Good to know you are doing well after all your treatments.

Slam627

I am 38, diagnosed about 6 weeks ago with IDC in both breasts. Had bilateral mastectomy last week (4/5).

Ultimate results post-surgery were left side .6cm, grade 1 tumor, no nodes. Right side, 1.1 and 1.4 cm IDC, both grade 3, DCIS 1.0cm, grade 3, and 1.6mm in right sentinel node. No other nodes removed bc biopsy during surgery was negative.

All ER+, PR+ and HER2-.

Oncologist has recommended AC+T, but standard schedule over 24 weeks (ACx4/3weeks and Tx12 weekly). He said that he wasn't convinced about the dose dense studies because they used multiple variables and he felt the harshness of the treatment was not justified.

I have a friend about 3ish years older than me who had very similar tumors and received AC in the dose dense (every other week) with a different doctor, same hospital, just last year.

So...who knows. I start in May.

muska

@ Walden: I had four treatments of AC every three weeks (no Neulasta shots) followed by 12 weekly Tamils.

Slam, u can get a second opinion re chemo regimen if u r in doubt. I think your MO recommends the same regimen I had.

Wildplaces

Although I had dose dense - my understanding is that in ER positive disease the dose dense schedule does not have an additional advantage. So I think your onc opinion on AC 3 weekly and Taxol 12 weeks is spot on.

Slam - you are good to go. It's will be crap for a while but you will get through it! The Taxol even dose dense is manageable. I hated the AC to be honest.

momand2kids

Hi

I am almost 10 years out-had lumpectomy, A/C x4 over 8 weeks and radiation. At the time, surgeon and onc said it was the "standard of care"... I was pre meno- so also had lupron shots when I went on AI (could not do tamoxifen).... I was done with chemo in 8 weeks.

Sjacobs146

My doc recommended TC for me because Adriamycin can cause leukemia and she felt at my relatively young age I'd have more time for that Leukemia to develop. I wasn't given a choice though. I suppose I could have gone for a second opinion, but I wasn't looking for reasons to have tougher chemo than I was already getting

Sophiemara

I did dose dense AC and T. My onco advised it was the most effective regime for pre-menopausal, which tends to be aggressive, because 2 week infusions doesnt givecancer much of a chance to regrow before getting blasted again, whilst still enabling your immune system (red and white cells) to endure it. It is the most aggressive and superior treatment I suppose for young high risk cancer.

https://www.sciencedaily.com/releases/2016/03/1603...