Have you declined chemotherapy and/or tomoxifen?

If the cancer is in your lymph nodes they usually suggest chemo.  Remember, the lymph nodes are only one mode of travel for cancer cells.  And not to scare you (although I am sure you already are) but we are relying on tests that may or may not be seeing everything.  So, when you are making your decision, I would suggest relying on your own research AND the imput from your doctors.

It is a good idea to get a copy of your pathology report and google all the terms that are in there.  There is so much more info in these reports than lymph node involvement and tumor size/grade.  If researching causes you to much anxiety, get someone to sift through the info for you. 

Well, there you have it.  You asked for opinions and the first two are somewhat conflicting.  That is how  it is here.  You need to get as much info, from reliable sources, as possible and determine what YOU need to do.  I would just add that you should visit the stage IV forum and check out how many of these ladies were node - or had very few + nodes.  

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Please cite the studies.

Anom

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Here are just a few for anomdenet. I would appreciate the same from you.

 Survival after adjuvent oophorectomy and tomoxifen in operable breast cancer in premenapausal women. J Clin Oncol 2009 Jan 10;26(2) 253-7

Effects of Chemotherapy and hormonal therapy for early breast cancer on recurrence and 15 year survival: and overview of randomized trials. LANCET 2005: May 14-20; 365 (9472): 1687-717

I can totally understand the fertility concerns. There is a youngsurvival.org which specifically addresses your concerns. I think there may be a section here too. I wish you all the best in your journey!

Lancet 2001 Jul 28;358(9278):277-286        
Polychemotherapy for early breast cancer: an overview of the
randomised clinical trials with quality-adjusted survival analysis.
Cole BF, Gelber RD, Gelber S, Coates AS, Goldhirsch A.
Dartmouth College Medical School, Lebanon, NH, USA.

BACKGROUND: Overview analysis involving 18000 women with breast
cancer in 47 randomised trials showed that prolonged chemotherapy
significantly reduces the risk of relapse and death compared with no
chemotherapy. Here we express the size of the benefit in terms of
quality-adjusted survival time gained. METHODS: We used the Q-
TWiST method (Quality-adjusted Time Without Symptoms of disease
and Toxicity of treatment) to provide treatment comparisons within 10
years' follow-up, incorporating differences in quality of life associated
with times patients spend with chemotherapy toxic effects, after relapse,
and without symptoms of relapse or toxicity.

FINDINGS: Within 10
years' follow-up the benefit of increased relapse-free and overall
survival for younger women (<50 years old) who received
polychemotherapy balanced the burdens in terms of acute toxic side-
effects, especially among women enrolled in trials that did not include
tamoxifen. Overall, chemotherapy-treated younger women gained
an average of 10.3 months of relapse-free survival and ******** 5.4 months
of overall survival within 10 years (p<0.0001 for both) compared with
the no-chemotherapy group.

Second opinions are so important! Many of the women in my support group also visit with a fetility specialist before embarking on any treatment and they work hand in hand with the oncologist in your treatment plans.

About the oncotype test...I was diagnosed 1.5 years ago so they were only testing node negative women. I was willing to pay for the test and was refused. Now they are doing it with women who have one or two positve nodes (that was me) and insurance is picking up the bill. I wanted to have my tissue samples tested now but was told it was not possible. I still don't believe that, but having been through treatment I am not sure it would be cost effective, except possibly to give me a little peace of mind.

To anomdenmet:  you can copy the article title and paste into www.pubmed.com and the exact article will come up for your review.

I am at work so will address the issue later. Here is just one of the many, many articles I read through. More later... 

Effects of Chemotherapy and hormonal therapy for early breast cancer on recurrence and 15 year survival: and overview of randomized trials. LANCET 2005: May 14-20; 365 (9472): 1687-717

BACKGROUND: Quinquennial overviews (1985-2000) of the randomised trials in early breast cancer have assessed the 5 year and 10-year effects of various systemic adjuvant therapies on breast cancer recurrence and survival. Here, we report the 10-year and 15-year effects. METHODS: Collaborative meta-analyses were undertaken of 194 unconfounded randomised trials of adjuvant chemotherapy or hormonal therapy that began by 1995. Many trials involved CMF (cyclophosphamide, methotrexate, fluorouracil), anthracycline-based combinations such as FAC (fluorouracil, doxorubicin, cyclophosphamide) or FEC (fluorouracil, epirubicin, cyclophosphamide), tamoxifen, or ovarian suppression: none involved taxanes, trastuzumab, raloxifene, or modern aromatase inhibitors. FINDINGS: Allocation to about 6 months of anthracycline-based polychemotherapy (eg, with FAC or FEC) reduces the annual breast cancer death rate by about 38% (SE 5) for women younger than 50 years of age when diagnosed and by about 20% (SE 4) for those of age 50-69 years when diagnosed, largely irrespective of the use of tamoxifen and of oestrogen receptor (ER) status, nodal status, or other tumour characteristics. Such regimens are significantly (2p=0.0001 for recurrence, 2p<0.00001 for breast cancer mortality) more effective than CMF chemotherapy. Few women of age 70 years or older entered these chemotherapy trials. For ER-positive disease only, allocation to about 5 years of adjuvant tamoxifen reduces the annual breast cancer death rate by 31% (SE 3), largely irrespective of the use of chemotherapy and of age (<50, 50-69, > or =70 years), progesterone receptor status, or other tumour characteristics. 5 years is significantly (2p<0.00001 for recurrence, 2p=0.01 for breast cancer mortality) more effective than just 1-2 years of tamoxifen. For ER-positive tumours, the annual breast cancer mortality rates are similar during years 0-4 and 5-14, as are the proportional reductions in them by 5 years of tamoxifen, so the cumulative reduction in mortality is more than twice as big at 15 years as at 5 years after diagnosis. These results combine six meta-analyses: anthracycline-based versus no chemotherapy (8000 women); CMF-based versus no chemotherapy (14,000); anthracycline-based versus CMF-based chemotherapy (14,000); about 5 years of tamoxifen versus none (15,000); about 1-2 years of tamoxifen versus none (33,000); and about 5 years versus 1-2 years of tamoxifen (18,000). Finally, allocation to ovarian ablation or suppression (8000 women) also significantly reduces breast cancer mortality, but appears to do so only in the absence of other systemic treatments. For middle-aged women with ER-positive disease (the commonest type of breast cancer), the breast cancer mortality rate throughout the next 15 years would be approximately halved by 6 months of anthracycline-based chemotherapy (with a combination such as FAC or FEC) followed by 5 years of adjuvant tamoxifen. For, if mortality reductions of 38% (age <50 years) and 20% (age 50-69 years) from such chemotherapy were followed by a further reduction of 31% from tamoxifen in the risks that remain, the final mortality reductions would be 57% and 45%, respectively (and, the trial results could well have been somewhat stronger if there had been full compliance with the allocated treatments). Overall survival would be comparably improved, since these treatments have relatively small effects on mortality from the aggregate of all other causes. INTERPRETATION: Some of the widely practicable adjuvant drug treatments that were being tested in the 1980s, which substantially reduced 5-year recurrence rates (but had somewhat less effect on 5-year mortality rates), also substantially reduce 15-year mortality rates. Further improvements in long-term survival could well be available from newer drugs, or better use of older drugs.

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Thank you, lookingfor.

These are relative risk statistics, not true absolute risk stats. They are implying hormone positive women get over 57% + 45% advantage from chemo plus Tamox. That's 102%.

That shows how wildly misleading relative risk stats can be.

You need to compare: how many ER+ women out of a hundred were alive in both the chemo group and non chemo after 15 years. Period.

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Relative stats are a valid statistical measure.  Absolute risk stats vary from person to person depending on their individual initial risk. Relative stats apply to whole groups. They are only misleading if you dont undersand them.This sentence seems to be the one you are upset about, and it is perfectly clear from a statistical point of view.

 if mortality reductions of 38% (age <50 years) and 20% (age 50-69 years) from such chemotherapy were followed by a further reduction of 31% from tamoxifen in the risks that remain, the final mortality reductions would be 57% and 45%, respectively.

The 57% and 45% refer to the relative risk reduction of chemo plus tamox for the two different age groups (less than 50 and 50-69) that the study separated subjects into. 

In this example absolute reduction numbers would be meaningless because they would vary widely depending on the initial mortality risk. The relative risk allows the researcher to provide information no matter what the initial risk was.

Lookingfor,

I am not criticizing your personal decision. I am rooting for you. I hope your decision allows you to live for a very long time. I sincerely mean this.

My only concern is that people do not know what the studies really say and they are being mislead. Relative risk statistics are used to persuade people to act in a specific way. It takes months, not weeks, to read the studies so you understand them. And patients need guidance becaust most doctors don't know how to read the studies --tho a few do and are great. The National Breast Cancer Coalition gives courses on understanding studies. I've learned never to make a decision until I feel confident I understand the literature fully.

The best way is to get into a group of study readers and pitch questions about What is this study doing? What methods is it using? Are the conclusions contradicted by the findings?

Lookingfor, you may be past this now and not want to look back. You sound like a strong and kind person. Go for it!

Anom

Blessings

How else would you describe the amount by which any remaining risk is reduced by a particular treatment for a group of people who all have different risks prior to the treatment under study?

You still don't get it do you?

Relative risk statistics are not designed to fool people into thinking that treatments work better than they do. If that happens it is because the general public simply is lacking in mathematical understanding. Relative risk statistics are used so that researchers can compare across samples.

How hard it is to multiply your individual risk by the relative risk reduction percentage to obtain your individual absolute risk reduction? 

And yes, I think it is really funny that the study you cited is part of a larger on-going study that is continually updated that does demonstrate the efficacy of chemo and hormonal therapy in keeping women alive. Maybe not enough women for you. But a statistically significant number of women (Oh, and "statistically significant" is also a mathematical term. It means that an event is unlikely to have happened by chance. Researchers use a common threshold before they say something is statistically significant.) In the case of the study you cited, the chance that the extention of dfs and os was a random event and not due to the treatment was 1 in 10000. (That's what the p<0.0001 means). Treatment may not have been as effective as you like, but for a large sample of women at various stages of breast cancer this is a significant result.

Frankly, you are the one misleading people. It does not take months not weeks to understand studies. It does take a basic understanding of the scientific method and of statistics.

From the NCI: The EBCTCG performed a meta-analysis of systemic treatment of early breast cancer by hormone, cytotoxic, or biologic therapy methods in randomized trials involving 144,939 women with stage I or stage II breast cancer. The most recent analysis, which included information on 80,273 women in 71 trials of adjuvant tamoxifen, was published in 2005. In this analysis, the benefit of tamoxifen was found to be restricted to women with ER-positive or ER-unknown breast tumors. In these women, the 15-year absolute reductions in recurrence and mortality associated with 5 years of use were 12% and 9%, respectively. Allocation to approximately 5 years of adjuvant tamoxifen reduces the annual breast cancer death rate by 31%, largely irrespective of the use of chemotherapy and of age (<50 years, 50 to 69 years, ≥70 years), progesterone receptor status, or other tumor characteristics. This EBCTCG meta-analysis also confirmed the benefit of adjuvant tamoxifen in ER-positive premenopausal women. Women younger than 50 years obtained a degree of benefit from 5 years of tamoxifen similar to that obtained by older women.

Some of the most important data on the benefit of adjuvant chemotherapy came from the EBCTCG, which meets every 5 years to review data from global breast cancer trials. The year 2000 overview analysis (published in 2005) summarized the results of randomized adjuvant trials initiated by 1995. The analyses of adjuvant chemotherapy involved 28,764 women participating in 60 trials of combination chemotherapy (polychemotherapy) versus no chemotherapy, 14,470 women in 17 trials of anthracycline-containing versus CMF-type chemotherapy, and 6,125 women in 11 trials of longer versus shorter chemotherapy duration.

For women younger than 50 years, polychemotherapy reduced the annual risk of disease relapse and death from breast cancer by 37% and 30%, respectively. This translated into a 10% absolute improvement in 15-year survival (HR = 42% vs. 32%). For women aged 50 to 69 years, the annual risk of relapse or death from breast cancer was decreased by 19% and 12%, respectively. This translated into a 3% absolute gain in 15-year survival (HR = 50% vs. 47%). The absolute gain in survival for polychemotherapy versus no adjuvant therapy in women younger than 50 was twice as great at 15 years as it was at 5 years (10% vs. 4.7%), while the main effect on disease recurrence was seen in the first 5 years. The 15-year cumulative reduction in mortality from 6 months of an anthracycline-based regimen (e.g., fluorouracil, doxorubicin, cyclophosphamide [FAC] or fluorouracil, epirubicin, cyclophosphamide [FEC]) was 38% in women younger than 50 years, and 20% in those aged 50 to 60 years.

The role of adding taxanes to adjuvant therapy

A number of trials have addressed the benefit of adding a taxane (paclitaxel or docetaxel) to an anthracycline-based adjuvant chemotherapy regimen. A literature-based meta-analysis of 13 such studies demonstrated that the inclusion of a taxane improved both DFS and OS. Five-year absolute survival differences were 5% for DFS and 3% for OS in favor of taxane-containing regimens. There were no differences in benefit observed in patient subsets defined by nodal status, hormone receptor status, or age/menopausal status. There was also no apparent difference in efficacy between the two agents. However, none of the studies reviewed involved a direct comparison between paclitaxel and docetaxel.

I am definately NOT a mathmatical whiz, I definately need to read things on an everyman level. That said, I copied my adjuvent online read out when I was diagnosed. It shows that with no treatment my chance of dying was over 30%. With chemo and tomoxefin that chance went down to  roughly 13%. I don't have any problem looking back at all. I felt like I would take my best shot for the circumstances in my life which included three kids, one who was only 9 years old. I figured (and forgive me for sounding depressing) that if I ended up losing my battle against breast cancer I wanted to be able to say to them that I tried everything and it was God's will. It may sound simplistic but thats what I felt. I suffered through a tough treatment plan and still have some residual effects even today (although its getting better). But I was of the school of thought that even for a 2 or 3 % bump it was worth it for me. I appreciate everyone's passionate and detailed responses. God bless!

 

How to Use This Information

The estimates shown on these sheets may be a useful supplement to a discussion with your

doctor about some of the different adjuvant treatment options you may consider.

The decision of whether to get some type of adjuvant therapy involves taking into

consideration information about the amount of benefit and risk involved in getting such

therapy.

The estimates given here may be modified by additional information your doctor has about

your state of health and the characteristics of your cancer.

We live in a time of changes and improvements in the basic understanding of how breast

cancer grows and sometimes spreads. At this time the treatments for breast cancer are also

improving. Therefore in the future the estimates of the risk of relapse may become more

accurate and the effectiveness of therapy may improve.

Shared Decision Making

Name: _________________________________________ (Breast Cancer)

Age: 46 General Health: Fair

Estrogen Receptor Status: Positive Histologic Grade: 2

Tumor Size: 3.1 - 5.0 cm Nodes Involved: 1 - 3

Chemotherapy Regimen: Third Generation Regimen

Decision: No Additional Therapy

63 out of 100 women are alive in 10 years.

34 out of 100 women die because of cancer.

3 out of 100 women die of other causes.

Decision: Hormonal Therapy

10 out of 100 women are alive because of therapy.

Decision: Chemotherapy

17 out of 100 women are alive because of therapy.

Decision: Combined Therapy

22 out of 100 women are alive because of therapy.

Wendy, you hit it right on.  Actually, I've always found that a fascinating question.  Read a study once showing that a large number of American's would take chemo for an absolute survival benefit of 1%.  (Whether they could find an Onc willing to give it for that is a different question.).  I always thought you'd have to give me a very high number until I got BC myself.  My perspective quickly changed.  I'd do it again, even knowing now how very ill I got.  Time will tell if I made the correct decision.  After seeing what I went through my DH says you couldn't give him a number high enough to get him to do it.  As a friend of mine said, that's why this is America we're all entitled to make our own decisions.  (Actually she said, this is America, everyone is entitled to make a stupid decision.)