Chemotherapy Regimens - Node Positive

Dear hope8882,

I'm sorry you and your wife have to go through this. I completely understand your situation. I was only 28 when first dx. Now I'm 33 and was dx with a second bc in February. I have a 2 and half years old daughter and am currently 27 weeks pregnant with my second child.

 I had 11/30 nodes positive, am triple neg too, with two grade 3 tumors and BRCA1 thrown in just to make it worse. I was given FEC the first time round so as explained by Flalady, it'll be a different chemo combo this time round.

As a patient, we are often called unsung heroes, or the strong ones, but really, it is the husbands, the parents, the siblings and the friends who are the real unsung heroes. As hard as this is on your wife, it must have been just as difficult for you, especially when there are little children. I thank God for my husband everyday.

So you hang in there. Talk to us when it gets too much and swear all you want. we celebrate people like you.

Take care...

Nothing much helpful to add but prayers.  (I have small children so I understand how she wants to do EVERYTHING. )

Also wanted to say that your wife must be super-woman!  AC WEEKLY?? I'm doing it DD and am having a difficult time recovering for the next cycle each time. 

Oh... have you been to "nosurrender"?  That's a great forum and there's great info there regarding treatment (beyond the conventional protocols).

Michele

Navelbine is only approved for Stage iv and not response to other chemo. It is NOT the first line of treatment.

Flalady

Neoadjuvant/presurgical treatments

Ian E Smith

Breast Cancer Research 2008, 10(Suppl 4):S24doi:10.1186/bcr2184

The electronic version of this article is the complete one and can be found online at: http://breast-cancer-research.com/content/10/S4/S24

Introduction

In this article the term 'neoadjuvant' is used to describe pre-operative treatment for 3 months or more for large (usually ≥ 3 cm) operable cancers before surgery. Clinical response and pathological response are important end-points. The term 'presurgical' refers to treatment of short duration (around 2 weeks) before surgery, sometimes referred to as a 'window of opportunity' study. This approach can be used for any size of cancer provided it can be core biopsied, and the endpoints are molecular markers.

Traditional goals of neoadjuvant therapy include the following:

• to improve survival;
• to downstage so that inoperable cancers become operable or so that conservative surgery can replace mastectomy;
• to identify short-term clinical or molecular markers of response to predict long-term outcome as a prelude to (or as a substitute for) adjuvant trials;
• to predict outcome and plan further treatment in the individual patient; and
• to identify the molecular mechanisms that underlie response and resistance to treatment.

Short-term presurgical therapies can have similar aims with the proviso being that this treatment will not lead to downstaging and that clinical and pathological response rates are unrealistic end-points.

Current evidence suggests that there is no survival benefit from neoadjuvant chemotherapy [1]. The question has not thus far been addressed in a large neoadjuvant endocrine therapy trial. Neoadjuvant chemotherapy has been shown to downstage and reduce the need for mastectomy in some but by no means all women [1]. The same is true for neoadjuvant endocrine therapy; about 40% of mastectomies can be avoided with preoperative aromatase inhibitor therapy [2].

Short-term surrogate clinical and pathological markers for outcome

Clinical response

Clinical response is widely used as a primary or secondary end-point in current neoadjuvant chemotherapy trials. This, however, is misguided.

Table 1. End-points in current neoadjuvant chemotherapy trials

In our own series of 995 patients treated with neoadjuvant chemotherapy at the Royal Marsden Hospital, London, over the past 15 years, there was no significant correlation between clinical response (including clinical complete remission) and long-term disease-free survival or overall survival. Similar findings were reported for the National Surgical Adjuvant Breast and Bowel Project (NSABP)B-18 trial, in which 1,500 patients were randomly assigned to receive neoadjuvant or adjuvant chemotherapy [3]. In the subsequent NSABPB-27 trial, which involved almost 2,500 patients, neoadjuvant adriamycin/cyclophosphamide (AC) alone, four courses, was compared with the same treatment followed by docetaxel for four courses prior to surgery. The sequential arm achieved a significantly higher complete clinical remission rate than AC alone (64% versus 40%; P < 0.001) but there was no significant difference in survival [4,5].

In our own experience, neoadjuvant chemotherapy involving cisplatin or carboplatin achieved a significantly higher complete clinical remission rate in patients with triple negative breast cancer than in others (88% versus 51%; P < 0.005), but there was no improvement in overall survival, and indeed the triple negative group exhibited a trend toward inferior survival [6].

Key Words

Breast cancer, HER2, anthracycline, doxorubicin (Adriamycin®), epirubicin (Ellence®). (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)

Summary

Combined data from eight randomized clinical trials shows that chemotherapy with an anthracycline drug such as doxorubicin or epirubicin extends survival for women with HER2-positive, but not HER2-negative, breast cancer. These results suggest that women with HER2-negative breast cancer may be spared these drugs, which carry a rare risk of potentially severe side effects including heart damage.

Source

Journal of the National Cancer Institute, Jan. 2, 2008 (see the journal abstract).
(J Natl Cancer Inst. 2008 Jan 2;100(1):14-20. Epub 2007 Dec 25)

Background

Women with early-stage invasive breast cancer often receive chemotherapy in addition to surgery and radiation therapy. Several randomized clinical trials have shown that chemotherapy for breast cancer with a class of drugs called anthracyclines extends survival compared with non-anthracycline-based chemotherapy. However, the absolute increase in survival is not large and anthracycline chemotherapy can have severe side effects in some women, including heart damage and secondary leukemia.

Recent studies have suggested that women whose tumors produce too much of a protein called HER2 (called HER2-positive) may be the only ones who actually benefit from anthracycline chemotherapy. HER2-positive tumors are tumors that have HER-2 gene amplification (too many copies of the HER2 gene) or protein over-expression ( extra HER2 protein).

However, studies so far have not consistently shown a link between HER2 status (positive or negative) and the effectiveness of anthracycline chemotherapy. Many studies may have been too small to show a difference. In addition, studies have used different techniques to collect breast tissue samples and measure HER2 status, and used different chemotherapy regimens, making it difficult to compare results between them.

Knowing more certainly whether HER2 status influences the effectiveness of anthracycline chemotherapy would help physicians better personalize treatment for individual patients.

The Study

Investigators from the National Cancer Research Institute of Italy combined data (called a meta-analysis) from eight randomized clinical trials of chemotherapy for breast cancer. They found these eight trials by comprehensively searching databases of the medical literature and conference proceedings for published and unpublished clinical trials in English. All trials included in the meta-analysis had to meet three criteria:

• All patients included in the trial were randomly assigned to treatment
• The trial tested anthracycline-based chemotherapy against non-anthracycline-based chemotherapy after surgery for breast cancer
• The trial reported disease-free and overall survival rates based on HER2 status, or these rates could be calculated from the available data

The investigators then compared whether disease-free and overall survival differed for women receiving anthracycline-based chemotherapy depending on whether or not their tumors produced extra HER2.

Results

Out of 6,564 patients randomly assigned in one of the eight trials, 5,354 (82 percent) had their tumors tested for HER2 status. Of these, 1,536 (29 percent) had tumors that had extra HER2 protein or extra copies of the HER2 gene - that is, they were HER2 positive.

Six of the trials had data on disease-free survival. Seven trials had data on overall survival. When the meta-analysis was complete, the data showed that treatment with anthracycline-based chemotherapy significantly reduced the risk of relapse and reduced the risk of death from any cause compared with non-anthracycline-based chemotherapy.

Finding in early trails-

However, when the results were broken into two groups by HER2 status, only women with HER2-positive tumors actually had a significantly reduced risk of relapse and death after anthracycline-based chemotherapy.

Note from FloridaLady 

Anthracyclines are all the drugs we are treated with now. Adriamycin, taxotere, taxol, cytoxan are just a few.

Hope,

Florida Lady has been a great source of knowledge for my wife and I for a while now.  Aggressive chemo is a good way to go, when you know it is needed or is working.  God knows that my wife has had aggressive treatment.  But this because she has not had surgery, and has PET/CT, MRI's every 9 weeks.  With skin mets, you can also see results.  CTC counts on monthly basis along with CA's. 

remember, Chemo is poison..long term damage to nerves, intestines, heart, lungs, sinuses, and almost every organ in the body is a lot to pay for a prophylactic treatment.  Arsenic was one of the first chemo's for cancer. 

Cam, is beginning a phase 1 trial next week, to try working more on the bio or genetic level.  Looks good, but most all trials look good on paper.  On the clinical trial section posted by camsdh or Ibcspouse, I will keep a journal of progress.  Best wishes and success in your fight.

I had TAC when I was diagnosed in 2003. Åll 21 nodes positive and I'm still NED. The stats for both recurrence and survival that my onc threw out at me scared me. But, I also figured someone has to be on the good side of the stats. I understand wanting to be super aggressive, but I'm with FlaLady. That's a LOT of chemo.

Just wanted to give you and your wife some encouragement. 

Marlina

Which country do you live? Is there a good medical treatment? Have you yet had the second baby? My heart goes with you.

Thank you LRM216,

I got my test results this week.  Not good....I have more cancer on the chest walls skin, my neck, my right arm and on my back.  Good news...not bone/organ mets.  I'm still working to find my next course of treatment.  My doctor knows that I understand my disease and know my treatment options....if not where too look.  I do share things that I see online about what other are doing.  After you have been at this as long as I have your doctor's start asking you for help with research and making a decision on what to do next.

This is why it is so important that we all understand our disease and treatment options. Also understand that the more drugs your tumors are exposed too the more resistance they become. This makes it harder to find new drugs to treat them.

I hope to make a decision this coming week. I'm looking a hyperthermia with rads or hyperthermia with chemo.  Also looking at getting Erbitux outside of a trial through compassionate treatment. In other words insurance will not pay for it because it is not approved yet, so the drug companies need to give it to me for free.

I'll update when I make a decision.

Flalady

newalex,

Zometa is not the same kind of drug. It is doing something totally difference so I don't think it applies.  I'd don't know if they really know what the long term effect of this drug yet.  It's only about four years old.  There are other drugs like this but not the same form, or the amount or the way it is administered.

I had someone PM today about Zometa and everything I found on the trials, (Amazingly there it was actually hard to find the actual data of the results.) 

**** All the data I saw was for hormone positive ONLY. I did not see anything on triple negative in any trials.  So if anyone know where this data is let us know. I really surprised that I could not find anything for Zometa and triple negative! or for that matter homrone negative period.

I just don't know about this for triple negative.  I would ask your doctor if he has any trial info for Zometa and triple negative.

Flalady

newalex,

It's decided that I'll have the baby at 32 weeks gestation, which means on the 15th. I sure hope everything goes well because apart from my own battle, I have to care for a premature baby too. We all know about the low immune system of premature babies, and I have no breast milk to offer in that department. My firstborn has Cow's Milk Protein Allergy, and the Paed said this one may too. And of the 6 rounds of chemo I had 2004, I was warded 4 times for febrile neutropaenia. All I see in front of me is hospital stays and visits...