Radiation ~ YES or NO?

Anonymous

Radiation ~ YES or NO?

Babybird2

Hello -

I am a 48 yo woman that has been dx with Stage 2A, Grade 3, Invasive Ductal Carcinoma this past April 2020. I found a lump in my breast. I get a mammogram religiously every year, but was a couple of months behind due to COVID. When I found the lump, I called the very next morning and made an appointment at Bay Radiology here in Severna Park, MARYLAND. Was seen in days and had mammogram, sonogram and radiologist did not like what she saw. She ordered a biopsy the next day. Biopsy was taken and sent off that same day and came back as ER & PR positive, HER2 negative.

Saw team at Mercy - had DMX in June 2020 and one sentinel lymph node removed.

Pathology came back as follows:

IDC

Stage 2A

Grade 3

Ki-67 was 76%

Tumor removed was 2.2 cm

single sentinel node w/micro met

recon w/breast loft, tissue expander and Alloderm was done on table after DMX

MammaPrint came back low-risk

Breast Surgeon - recommends no chemo/no radiation

Medical Oncologist - recommends no chemo/borderline on radiation/Letrozole for 10 years/injections monthly to suppress ovaries (until I decide to get ovaries removed)

Radiation Oncologist - recommends no chemo/radiation for 5 days/wk for 5.5 wks

There are no studies for someone like myself. I am a widow/single parent of 2 boys. What do I do? Is there anyone that sounds like my case that could give me direction? I don't was to over-treat myself, but am I being foolish not to get radiation? What tests could be done to ensure there are no cells remaining? Body Scan? My breast surgeon said he would periodically feel lymph nodes and could tell if there is more disease. DO I GET RADIATION OR NOT? Has anyone had a similar issue like myself?

Any direction would be welcomed!!

Sincerely,

Angela
Edited by Mods to remove personally identifiable information and contact info.

moth

Hi, sorry you find yourself here but it's a great resource and support network.

first tho, you're going to want to remove your full name & phone number. You might want to share that in private messages here but not in public posts.

Given the lack of consensus my tendency would be to get the oncotype test done.

Honestly given your young age, high Ki, grade3, micromet ... to me (not an oncologist!) all of that suggests treat aggressively. I'm even questioning the no chemo based on, I'm assuming, mammaprint. In my province unless they changed guidelines recently, you'd be automatic chemo + rads based on the factors I listed

There are no tests to see if small cells escaped into the body. We can only see them once they're big enough to form a small tumor

Can you get a second opinion from an oncologist and radiologist at a different facility?

Ingerp

My only comments are your BS should not be making any comments re: chemo or rads, your MO does not have purview over rads, and I'd ask your RO how much rads would decrease your probability of recurrence. As soon as I was told it would reduce it by 50% for me, it was an easy decision.

You could also try one of the predictor tools:

https://breast.predict.nhs.uk/tool

moth

I was trying to remember the calculator for radiation benefit but I can't find any for post mastectomy, only lumpectomy. so not helpful to the OP but for lumpectomy pts looking for rads stats : https://www.tuftsmedicalcenter.org/ibtr/

Beaverntx

I had a lumpectomy so radiation was a given part of my treatment plan.

With grade 3, high Ki67 and mode micromet as well as the RO recommendation, I would lean toward yes on radiation. But then my attitude tends to be let's do what will take care of (insert name of the problem).

So, I vote yes but it truly is your decision and must be the one with which you are the most comfortable. Hugs!

Spookiesmom

I say yes for rads, having done it twice. It’s not fun, but doable. The first time, it was to hopefully get any rogue cells. I’m sure it did, but still missed a few. And that’s the problem. A few cells can escape, float around for a few years, in my case 7. Then they make their presence known, again.

So, if you can live with your decision of no rads, and not beat yourself to pieces if it does come back, don’t do it.

In your case, I’d go for second or even third opinions.

Beesie

The principles of radiation are very different for those who have a lumpectomy vs. those who have a mastectomy.

The positive node is the reason why rads would be recommended after a MX, but the fact that the sentinel node involvement was micromets only is why this is not a clear decision and why you are getting differing opinions. Here are the NCCN treatment guidelines:

Looking at the first chart, usually when a positive node is found during the SNB, the option is either a full axillary nodal dissection or radiation to the nodes. But with micromets only, no further axillary surgery is recommended. Moving to the second chart, after a MX, if nodes are positive, rads should be considered, except there is the footnote stating "In the case of a micrometastasis and no axillary dissection, evaluate other patient risk factors when considering RT".

So the NCCN guidelines seem to be suggesting a consideration of rads unless there are patient factors that makes rads unadvisable.

As for your question "What tests could be done to ensure there are no cells remaining? Body Scan?", as moth said, unfortunately there are no tests which can provide this assurance. Cancer cells are microscopic and only become visible on imaging when the area of cancer develops to a certain size, so there is simply no way to know if any tiny areas of rogue cells remain in the breast area or the body. And that is precisely why rads is usually given when there are positive nodes and why chemo is prescribed to patients with aggressive cancers even when they show no signs that the cancer might have spread.

Sorry this isn't more helpful but it does show why your own doctors are uncertain - you fall right into the gray zone on rads.

Peregrinelady

I had a similar situation to you, except that my tumor was a little larger (2.5 cm) and my ki67 was 17%. Micromets in one node, but it was barely micromets at 0.26. At first they said ITC. I got opinions from 3 radiation oncologists and they all 3 said the risks outweigh the benefits in my case. I don’t know if it was because it was my left breast that contributed to this recommendation or not, but I did not have radiation. However, I have seen some women on this board have radiation with a mastectomy. It was a tough decision and I can only hope I made the right one.

Babybird2

Thank you for replying and for your information. ITC? Not sure what that is....

letsgogolf

I had a grade 1 tumor with a very low Oncotype score of 3. They removed 8 nodes and the first node had 2 micromets within measuring .3mm and .7mm. I did have radiation to my nodes and have no regrets. Wanted to do everything I could to avoid a recurrence. Best wishes!

Beesie

Babybird, ITC, "isolated tumor cells", are areas of cancer 'smaller than 0.2 mm' in the lymph nodes. It is considered node negative but it's presented on staging as N0+, with the "+" sign indicating the presence of ITC.

"Node positive" starts with micromets, which is when the cancer in the lymph node is 'larger than 0.2 mm but 2 mm or smaller'. It is classified on staging as N1mi. That's where you fall.

Thinking about your situation, maybe the answer is whether your micromet falls closer to N0+ or closer to N1. If your micromet is 0.3mm, for example, it's just a fraction larger than ITC, where the recommendation is no radiation. However if your micromet is 1.8mm, then it's just a fraction smaller than N1, where the recommendation after a MX with no axillary dissection is to do rads. Does your pathology report specify the actual size of the micromet?

Peregrinelady

Yes, such a fine line. I would definitely have done radiation if any one of the radiation oncologists had recommended it. I am still a bit nervous that it may return in the lymph nodes. Good advice from Beesie. Is your cancer on the right or left?

ctmbsikia

Also, did you have more than that 1 sentinel node tested?

Peregrinelady

It looks like baby bird just had one sentinel node removed. I had 2 removed, but the micromets was found in the 2nd node, not the first, which I thought was odd.

Edited to add that it says “single sentinel node with micromets” in original post, so perhaps more were removed