Node Positive and NO chemo...any of you ladies have input?

I can understand why Sereena is comfortable with the decision to skip chemo.  She has several factors in her favor:  a tumor that was well-differentiated (Grade 1) and strongly ER+, a low Oncotype DX score (10), and a treatment recommendation based on the judgment of a panel of experienced oncologists.

There is just one thing that bothers me, though.

We, and our oncologists, are placing a lot of trust in the results of Oncotype DX testing.  It made sense to adopt it for IDC and ILC that had not spread beyond the initial site of the tumor.  But, I am concerned that there might not be enough evidence yet -- enough long-term clinical trial data -- for Oncotype DX results to trump other, more traditional factors, in node-positive BC.  Before Oncotype DX testing came along, I'll bet not one oncologist in 10 would have recommended "no chemo" for someone in Sereena's situation.  Yet, that's what we're seeing.  Even if we trust an Oncotype score when there are micromets or just one positive node, is it safe to trust it with multiple positive nodes?

There was something odd about those cells that escaped from Sereena's breast tumor and ended up in her nodes.  Her primary tumor was lazy -- it was not very big, and seemed not at all aggressive.  Yet, some of its cells managed to break free, get into the lymphatic drainage, pass all the way to her axillary nodes, attach themselves there, and grow.  That's a multi-step process that requires some serious cellular evolution (multiple mutations and selective advantages).  That's why tumor tissue found growing in a draining lymph node is considered "regional metastasis."  So.... I wonder what the Oncotype DX score would have been on the tumor tissue in those nodes?  Would it also have been a "10", or would those "metastatic" cells have shown increased growth rate and aggressiveness, corresponding to a higher Oncotype score and greater likelihood of distant recurrence?

I am not aware of anyone using Oncotype testing on metastatic BC, either in lymph nodes or at other more distant sites.  I'm not sure it could be done, or whether it would even work.  It's already been documented that metastatic BC cells can change their expression of growth-related genes -- a breast tumor might be ER+ but its mets might have turned off ER expression.  PR and HER2 status can also change.  All those characteristics factor into the Oncotype formula because they correlate with aggressiveness and metastatic potential (as well as with the benefit of chemo).

What that could mean is, even if the primary tumor seems non-aggressive, perhaps the metastatic foci -- including the cells in axillary nodes -- are not.

Food for thought, as they say....

otter

Otter, Your thoughts really have me thinking as well. I find it so interesting that our scores at different stages can vary so much. I had a small tumor grade 1 with no node involvemnt, and no lymph involvment, but my Oncotype score comes back at 24, yet Sereena has a score of 10 with some node involvment. Sereena you are so right cancer does suck!!!

When I had a MX, my surgeon was "pretty sure" there wouldn't be node involvement..when he took them out (I only allowed them to remove 4) and I woke up, he said they looked "normal."  But when the lab cut into them, they found cancer in all 4. 

Looking back, I don't think he should have told me there was likely no node involvement...I chose a MX to avoid radiation, and end up having to get it anyway.  I didn't even get a clean margin on the skin side with a skin sparing mastectomy.

I guess my point is this....I think it's better to go in to lumpectomy/MX anticipating node involvement.  I was pretty sure there wasn't any, so was fairly discouraged when there was.

Otter - interesting post. I share your concerns about Oncotype - which is not used routinely here in the UK due to lack of data regarding its efficacy.

Node involvement will always equal chemo in my book, regardless of grade. That may be old fashioned but I have an attachment to the idea of chemo as a cancer blaster - eventhough I know it can often be utterly ineffective and deeply damaging to some people.

Otter...those are good questions. The truth is the swog1408 (I think that's right) was based on 347 people. The node neg graph is based on a much bigger sample.

suepen - That is exactly what my situation is. I had a Stage 1, Grade 1 b4 my lumpectomy. My BS was pretty confident that there was no cancer in the nodes but there was in one - it was a small one but still there. My cancer is close to the nodes too. I see my BS tomorrow and an oncologist on March 10. I am sure she will recommend chemo. Of course I dont want to do it either but I will because I too am afraid one little cell might break loose and show up somewhere else. Not worth the risk to me. I am confused about the test though. It doesnt make sense to me either that you can have a low score and still have cancer in the node.

Very interesting discussion.  I appreciate all the information and different points of view.

It would also be interesting to know what kind of cancer(s) occurs after different chemo regimens and if any combinations in particular are more likely to give rise to other cancers.

I think you have to decide then move on-which it sounds like you have done.  I was node negative and had chemo at the Farber--- so there really is no rhyme or reason to this....the most important thing is that you are satisfied that you made the best decision for you.

Sereena - I had seen that 11 oncs did not recommend chemo for you. I'm not arguing against their advice at all - it's just that node positive equals chemo in my head like Greenfrog's. Treatments change over time and I'm sure you are in the best hands. I had a grade 2 cancer sitting there in my breast all the while I was having chemo for a grade 3 one in the other breast and the chemo didn't kill it. It might have kept it under control, but I do know low grade cancers don't respond well to chemo.

Sue

I am afraid this post may be a bit lengthy but I hope it will be of some interest regarding pathology of metastasised cancer - and why I think it is important to expose yourself to all available treatments.

 My friend (who sadly died last autumn) was diagnosed with liver mets from the beginning. Her 2 breast tumours were ILC multifocal grade 2, HER2 neg. There were 2 visibly postitve nodes but as she never had axillary clearance they don't know how many positive nodes she had in total. Her largest tumour was only 2.1 cm.

The liver mets were found by chance - her bloods were perfectly normal. She had a persistent cough and was x-rayed - on the x-ray they saw her lungs were fine but there was something suspicious on the liver. She had been placed on FEC x 6 which did absolutely nothing to the breast tumour. She was then put onto Arimidex and this had some small effect on the breast lump - but the liver continued to progress. Liver biopsy revealed that her liver tumour had very few ER receptors. She was in effect TN in her liver and 60% ER+ in her breast. And nobody knew what in her nodes.

With that situation what do you use as frontline treatment? Her specialists could never agree - one was in all in favour of perisisting with hormones believing that any ER+ status is better than none at all. The other onc wanted to keep going with various chemos. In truth none of the chemo options they tried worked effectively on her liver.

She was very keen to have all of her mets individually analysed. But unfortunately she deteriorated too fast for that to be an option. Her brain mets responded well to steroids and radiation. Bone mets were held in check by bisphosphonates but her liver sadly failed 2.5 years after dx.

Chemo doesn't always work, hormones don't always work - but I think it makes sense to give everything a try. You don't get second chances with this thing whatever grade your primary cancer is.

There appears to be a drive amongst the cancer community to make cancer treatment more personalised and less "chuck everything at it and see what sticks". But ultimately at what cost to some individuals who are potentially being undertreated?