Stage IIIb: Chemo vs. iBrance?

cabland

So I am posting this for a friend who was diagnosed with breast cancer in the Fall of 2018 (note: my own wife had breast cancer - stage IIb - a few years ago and I became intimately acquainted with this great forum at that time). Anyway, she has conflicting opinions from two different oncologists and I wanted to get your take (and experience) so here goes:

Background

Diagnosed Fall of 2018, single mastectomy, ER/PR positive, HER2 negative

Tumor was 5cm, multifocal WITH skin involvement (ie. T4b)

Single sentinel node showed 2.5mm invasion (i.e. N1a)

Stage: IIIb

Treatment plan to date

Letrozole and iBrance

NO Chemo and NO Rads (so far on rads)

So, her current breast surgeon has recommended additional surgery to harvest more skin to look for additional skin involvement (note: they have done individual spots and nothing found so far). She sought second opinion (both from breast surgeon & oncologist), and the second breast surgeon concurred with the first (i.e. harvest more skin and look for cancer). The second oncologist, however, was a bit surprised at the use of iBrance (during stage 3) and recommended AC+T (chemo) instead. As you can imagine, she is a bit torn now on the whole "chemo vs. iBrance".

In my research, it definitely appears that the chemo route is what I (a layperson) would describe as the current "standard of care" for her diagnosis, but the breast cancer space continues to evolve as you all know, and I do see iBrance being used for more and more stage III cases...although, as I read on this forum, most of the ladies doing it in stage III seem to ALSO have done chemo.

Anyway, HELP! Looking for information on your experience and any advice!

Thanks!

buttonsmachine

I'd have your friend go to an NCI designated cancer center for an opinion. https://www.cancer.gov/research/nci-role/cancer-centers

Skin involvement is tricky, but it CAN be treated with curative intent if it's locally advanced and not metastatic disease. However, that would probably involve surgery, chemo, radiation, hormone medicine, and maybe Ibrance too.

Ibrance has been used in stage 3 breast cancer, but as you say, it's usually in addition to the other standard treatments. It's almost like that one Dr isn't treating her with curative intent, and that worries/confuses me if she's not metastatic.

Just my two cents based on my experience. I had a local recurrence with skin involvement and I had to go to an NCI research hospital to be fixed. The truth is that not every center is able to handle a situation like hers. Time is of the essence too, because skin involvement can spread rapidly.

Hope that helps, and I hope she finds someone who can help her.

cabland

Buttonsmachine - thanks very much for the feedback! My friend is having her second surgery to take more skin this week and I suspect she will have the pathology late in the week or early the following, so that will be yet another data point (an important one I suspect). Her second opinion was, in fact, from an NCI designated cancer center.

I don't want to discount her local Oncologist, however, as they are part of a VERY large oncology group (over 400 physicians, with 300+ being medical oncologists) that just happens to be based here. Indeed, her case was supposedly brought before a group of those folks and her treatment discussed there (vs. in isolation). Of course, with that many oncologists there are bound to be differing opinions, treatment options, etc.

Thanks again on your feedback and I look forward to feedback from any others!

IAmElaine

I had skin involvement as well. It is considered locally advanced. My onc chose the most aggressive route and I did TAC x 6, 4 were neoadjuvant and 2 were post surgery. I followed that up with rads and have been on an AI for almost 15 years. My onc told me he was going for the cure and also said you always want to hit it very hard right out of the gate because if you have to go back into treatment it is a whole new ball game. First shot is your best shot.

Maybe your friend has other comorbidities that keep her from aggressive chemo?

buttonsmachine

Hopefully they can bring your friend's case before a tumor board, if they haven't already. Treating locally advanced breast cancer is not as straightforward as for earlier stages.

I transferred my care to the NCI center, because in my case the local Drs (who were supposedly good in my area) were at a loss for what to do. However, no one actually told me that, until one particularly honest Dr told me I needed to go elsewhere to have a fighting chance. So I went.

Elaine, congrats on being so far out - that's so encouraging!

cabland

Thanks all, our friend did get the results from the additional surgery to take more skin, and they were unable to get clean margins. She sees her surgeon and oncologist this coming week so we will see what this new information does with regard to next steps for her. I will try to keep you in the loop as she finds out more. (I am cognizant of her desire for some level or privacy here of course).

buttonsmachine

For me, they took all the skin roughly 5cm out from every skin met, so the hole had to be patched with a large skin graft. I couldn't have had clear margins without the graft.

The type of surgery I had isn't appropriate in all cases, and of course I have no idea if that's appropriate in your friend's case, I'm just throwing it out there in case that information is helpful. When I was in that situation it was really hard to find someone who could help me.

I hope your friend is okay, and that she finds a good solution.

Misstic

Cabland,

The most important in your question according to the context you describe is the KI67 of the tumors of your friend and her ER+ rate. In case of a low Ki and a high percentage of ER+, the treatment plan of your friend is perfectly fine. Agressive chemo is NOT a solution for very low Ki67.

cabland

buttons - thanks very much for that info. That is a LOT of skin (as a layperson)! I feel for you on that. I'm not sure how much my friend had removed.

Misstic - Her prognostics markers indicated:

ER - Positive 3+ in nearly 100%

PR - Positive 2+ in 80%

Proliferative Index (Ki-67): 75-80%

The Ki-67 in this case seems fairly high to me, but there also seems to be a lot of churn around Ki-67. Based on my VERY LIMITED research, there does seem to be evidence that a higher number warrants chemo.

buttonsmachine

Yes, a Ki-67 of 75-80% is definitely high. My Ki-67 was 87%, which seems ridiculous. In any case, if I remember correctly, "high" is anything over 20%.

One thing I learned is that there are not clear solutions for locally advanced disease. As one MO put it in my case, we were in "uncharted territory." There are very few studies saying that doing X has better outcomes than doing Y in cases like ours. In situations like this doctors really need to practice medicine as an art form, and think outside the box. If they haven't already done so, your friend should also ask that they bring her case before a tumor board.

Best wishes going forward, and please keep us posted if you have a chance.

cabland

Hello all - Just a quick update. It looks like they are going to change treatment somewhat. The oncologist and tumor board decided to temporarily stop the iBrance, and go with radiation (supposedly a significant course) coupled with Xeloda (during rads) - note: the MIB-1 had dropped relative to the original path (suggesting the iBrance was helping).

Once that completes, she will be back on the iBrance. They are good with the proposed treatment after talking at length with their oncologist.

I really appreciate your feedback and relayed several of the items from this thread to them!

Misstic

I think the first idea of the board with Ibrance was to use the 100% ER+ . But the Ki67 is very high as Buttonsmachine explained. Xeloda + rads is an agressive path and rads are a very significant treatment for skin involvement. Believe me regarding this matter, my as*ho*e RO forgot to do rads on one portion of my chest wall and I had an immediate recurrence under my skin. I am going to sue him for that.

buttonsmachine

Misstic, it's horrible that that happened to you! I feel for you because I ended up in this situation because of a combination of bad luck, and mismanagement by my original Drs. It's hard to accept that although I found my cancer early, other people's mistakes might cost me my life. Most the time I try not to think about it too much... but it's crushing.

Cabland, I'm sending gentle hugs to your friend. I found radiation and Xeloda to be more tolerant than the big IV chemos. I hope your friend feels as well as possible, and that it's effective!

cabland

I should probably start a new thread on this, but a quick update - 2+ years later - and question on this thread. My wife's friend did have radiation and has been on iBrance and Letrozole now for the last 2 1/2 years or so. She currently has no evidence of disease (hooray!).

She is, however, wondering if she needs to stay on the iBrance indefinitely or if she can drop off. Her oncologist is retiring and she'll be seeing someone new, but given the way she has to monitor her white counts while on iBrance (and be extra vigilant in our new pandemic world), she is wondering if the Letroozole is really doing the heavy lifting here at this point. Obviously, there is no way to know for sure, but any thoughts or experiences are appreciated!

Thanks and I hope you ladies had a Merry Christmas yesterday!

Spookiesmom

I’ve been on ibrance/letrozole for about 2 years. I asked MO at the beginning how long I would be on it. You know you’re stage 4. Have been NED all this time. How much longer? Who knows. If I have 3 reoccurrence it’s back to I’ve chemo. I’ll take the pill.