Common chemo protocol for triple positive BC

Roots

I just found out I am triple positive yesterday at my first oncology appointment after waiting for FISH test.

I have my DMX surgery scheduled with immediate reconstruction for April 23rd. At the onc appointment yesterday, I was expecting an introduction to possible treatments, depending on the pathology after surgery. He said that the HER2 coming back + status means that chemo will be needed no matter what, and that because i'm young (34), multi focal, he wants to be aggressive and start asap. He wants to start 2 weeks after surgery, and thinks that it's already been too long; it will have been 6 weeks by the time I get my surgery, from diagnosis. I was told by surgeons that 6 weeks is not too long to wait.

Meanwhile, the surgeons are saying that 2 weeks after surgery to start chemo is crazy, and that I have to wait until I heal, at least 4-6 weeks!

For chemo, he's suggesting 4 large doses every 3 weeks rather than smaller ones every weeks. He said it will last about 4.5 5 hours/ treatment. The combo is Taxotere (DOCEtaxel) and Procytox (cyclophospamide), with Herceptin partway through, the latter lasting for a year. When I've read through the HER2 positive threads, I've noticed a lot of people are on Taxotere and Herceptin, but instead of Procytox, people are on Carboplatin. Does anyone else have experience with the combination my oncologist is suggesting. I've looked a lot online as well, and haven;t seen that combination much.

I'm going to look for a second opinion in the meantime, but I'm hoping some of you might have some insight. Thank you in advance

VVV

Usually HER2 is treated with chemo and the monoclonal antibodies (herceptin, perjeta) first, then you have surgery, then after surgery you'd continue on the monoclonal antibodies until you reach 1 year of being on them (I think it's 18 total infusions? this is definite for herceptin, perjeta is newer so it's still evolving). From what I've seen, the standard in the USA is once you are above 2cm then you usually get AC+THP or TCHP. I'm not a doctor and guidelines could vary by country so I can't tell you if this is a good treatment plan or not, just that it doesn't seem like a common one from what I've seen and I think a second opinion would be wise. This link has some common chemo regimens for stage 1-2.

https://www.nccn.org/patients/guidelines/stage_i_i...

Debsmisto

I'm her two positive er-positive PR negative and I have looked at most of the women on these boards with a similar diagnosis and they've all had chemo first usually tchp and then surgery

SpecialK

The chemo regimen Taxotere/Cytoxan (cyclophosphamide), given in 4 doses is an unusual regimen for a Her2+’patient, but is used for non Her2+ often. If Taxotere is used it is normally combined with Carboplatin and Herceptin and/or Perjeta. Taxotere is given every 21 days, regardless of what it is combined with - it is not dosed weekly, and not the same drug as Taxol - it is a more potent taxane drug. With a tumor your size weekly Taxol with Herceptin is not an appropriate regimen - it is normally used for stage 1 Her2+ patients.

Prior to Jan 2018, in the United States, Her2+ positive patients who qualified for Perjeta (tumor greater than 2cm or node positive), received Perjeta along with chemo and Herceptin prior to surgery because it was only FDA approved for neoadjuvent administration prior to surgery. This is what drove the administration of chemo prior to surgery. Before 2013 - when Perjeta was approved for early stage Her2+ - it was more common to have surgery first unless you had a large tumor that needed to be reduced or eliminated to have a successful surgery. Perjeta is now approved adjuvently for early stage and can be given post surgically also. For some this may mean with the remaining Herceptin, but for others it may mean that they have surgery first and begin chemo with both Herceptin and Perjeta afterward.

Because of the unusual combination of Taxotere and Cytoxan for only 4 infusions I would seek a second opinion. Are you in Canada? I am not sure, but it may be that Perjeta is only currently used for advanced stage patients.

Roots

Thank you specialK. I was hoping for a few insights, and you seem to have lots! How did you learn all of this? Is there a good resource site out there that you can recommend?

I'm now looking through a lot of the signatures in the triple positive group, and seeing that most who were diagnosed in the last year and a half have done chemo first, as you and others say! I'm feeling suddenly very uneasy about my care team!

SpecialK

I was diagnosed and treated a long time ago, have learned a lot on this site, and have gathered info along the way as I have also had a number of friends treated and have accompanied them to their consults, surgeries and chemo. I am active locally with a group from this site, and we also compare treatment notes. If it makes you feel better, because I was treated prior to the use of Perjeta for early stage, I had surgery first and then chemo. If you aren’t receiving Perjeta you don’t necessarily need neoadjuvent treatment, that is the piece that was driving treatment order.You can learn a lot from this site, but make sure you look at the info on the main site in addition to the posts here in the community section.

NotVeryBrave

Most HER2 + people that I've learned of recently have had TCHP x 6 rounds, 3 weeks apart and then continued on the Herceptin for the rest of the year. More recently - some are on both Herceptin and Perjeta for the year.

Most often, chemo is done first with surgery following 4-6 weeks after completion of the heavy chemo drugs. If surgery is done first then chemo is usually started 4-6 weeks later. The idea is to let your body recover from whichever treatment before you subject it to the next one

I'm a big fan of second opinions. Even if you hear the same thing - the confirmation is so helpful.

And as far as timing of starting any treatment - it's important to know what you are dealing with first and foremost. Mammograms, ultrasounds, and MRI's give a complete visual picture. And the full biopsy results give a basis for attack. You shouldn't unnecessarily delay starting treatment once you have all of the info, but you should also be as confident in the plan of care as possible.