Chemo and Oncotype accuracy for recurrence

Lily087

I'm not sure exactly where to start. My first breast cancer diagnosis was in 2017, I was 29. It was ER/PR+ and HER2-, Stage 2B. My oncotype was 17, (which meant I fell in the low to intermediate chance for recurrence, meaning their wasn't any indication that showed I would benefit from chemotherapy) and my Onco didn't want to put me through that without proof of benefit. So treatment plan was a lumpectomy, 33 rads and tamoxifen for at least 2 years. Which I completed. In November 2019 my onco agreed to me stopping the tamoxifen to try to get pregnant.

In November 2020 my MRI showed a tumor, after the biopsy, it was clear it was cancer. The pathology was very similar to before it was ER/PR+ and HER2- but stage 1A, we caught it very early. No lymph node involvement.

So this month, I've had a DMX with direct to implant reconstruction. But what I am really needing advice/guidance on is chemo (which would be 4 rounds of TC over 12 weeks) No one can seem to tell me if this is a new cancer or recurrence so they are hesitant to depend on the Onco type this time to determine the benefit of chemo. Which at this point the only reason to do chemo would be to reduce recurrence. My issues is no one can seem to tell me that doing chemo would reduce my chance of recurrence. It might it might not is the answer I'm getting.

So what I'm asking is what would you do in this situation would you do the chemo or not? Or has anyone been in this position and what did you do and why?

Beesie

Hi Lily,

Welcome!

So I'm a bit confused. You say, "No one can seem to tell me if this is a new cancer or recurrence so they are hesitant to depend on the Onco type this time to determine the benefit of chemo.". Has a new Oncotype test even been done on this second diagnosis?

If your current diagnosis is a local recurrence, it does not mean that the 17 Oncotype last time was wrong - even though you were told that chemo wasn't necessary and yet you've ended up with this new diagnosis. The Oncotype test predicts distant recurrence risk, not local recurrence risk. So your previous Oncotype score had absolutely no predictive value on whether or not you might develop a localized recurrence. However, if this is a recurrence, because cancer cells sometimes change as they develop, I would think it would be worth having the Oncotype test done again, to see if the score is similar or different. A similar or lower score would confirm little benefit from chemo, whereas a higher score would indictate that chemo would provide metastatic risk reduction benefit.

And if this second diagnosis is a new primary and not a recurrence, then having an Oncotype test done on a sample from your new diagnosis could yield a very different result, possibly lower or possibly higher.

I don't think the Oncotype test should be the only factor that determines whether or not chemo should be recommended. The recently released study on RSClin suggests that combining the Oncotype score with patient age and clinical pathology factors results in a more individualized risk projection. But the Oncotype score remains a critical factor in determining the benefit of chemo for those with ER+/HER2- cancers. So it seems to me that you are being asked to make this decision while missing a critical piece of information.

Is your MO recommending the 4xTC protocol or leaving the decision entirely up to you? If you did not receive a Oncotype score for this diagnosis, can you ask for one? Or can you get a second opinion?

Rambros

I haven’t been in your situation, but yes I would do chemo without a doubtif I was you. You’re so young and if there is even the smallest chance it would help you should take it. Maybe consider ovarian suppression plus an AI as well. Good luck and I wish you well.

moth

I just want to say that I agree with everything Beesie posted.

I think it also depends on what your plans regarding hormone therapy / pregnancy are. I believe the NCCN guidelines recommend 5 yrs of tamox or ovarian suppression & there are some indications that it should be extended as the risk of recurrence for ER+ cancer persists beyond 5 years. Chemo might, as I'm sure you know, also have permanent effects on your fertility. Tough decisions. I'm sorry you're dealing with this at such a young age.

On the whole though, I have to say that I'd lean to chemo. Have you tried using the Predict calculator to see the overall survival benefits to the various treatments? https://breast.predict.nhs.uk/tool

Lily087

Hi Beesie,

Thank you so much for replying and all of your advice, I truly appreciate it. At this time no, I don't have the oncotype results from this diagnosis. After some debate it was finally sent, I should have it back soon. But I really want to thank you, I had no idea that the Oncotype was based on distant recurrence not local. No one had ever explained that to me, and I think that added to my confusion. My MO stated she wanted to discuss it with her panel and wait for the oncotype results before she would make a recommendation. But yes she did say if I were to have chemo it would be the 4XTC. I have debated about a second opinion, that is something I need to look into.

Lily087

Hi Moth,

I was told my treatment regardless of chemo would for sure be a minimum of 5 years of ovarian suppression and AI. Which I am totally in agreement with, but that is pushing me to 39 to try have have a baby after this treatment. And you are correct I have a fear that chemo will affect compromise my fertility further. I will check out that website, thank you for sharing it with me!