Post-BMX - Stage 1a IDC HER2+ - Facing Herceptin/Chemotherapy

I agree totally with Scrabblelady's post.  My wife will have TCH (with Cytoxan) and not AC - TH.  Herceptin is a targeted therapy against HER2 and tamoxifen and ariimidex are hormone therapies.  However I am curious that Scrabblelady had Adriamycin with a small tumor of less than 1 cm.  Scrabblelady is ER negative and my wife is ER positive.  Scrabblelady - would you be kind enough to share your medical oncologist's thinking with us.  I am very glad that you are almost finished and sounds like you are doing well.  However, the adriamycin treatment sounds like a more aggressive treatment for Stage 1a.

http://journals.lww.com/oncology-times/Fulltext/2009/02251/Short_Course_of_Docetaxel_Cyclophosphamide__.10.aspx

I found a research study on Taxotere + Cytoxan + Herceptin.  Overall encouraging results.

My wife had no trouble with the mastectomy because she thought everything would be over at once.  It has not turned out that way.  My wife is open to chemo.  The one area she would be very resistant to would be radiation and so far radiation has been deemed to not be necessary.  I have not even looked at my wife's chest because she does not want me to yet.  I am grateful for susieq58.  Can we get more posts - especially before next week with my wife's second opinion, tests, and visit with the first oncologist.

Dear TheLadyGrey - Everyone must do a benefit versus risk analysis.  I am hoping that somebody will post the statistics on heart problems from Herceptin.  What percent of patients has this happened with?  Was taking Adriamycin first which can also cause heart problems a factor.  That is a major risk.  On the other side, HER2 positive cancer that is not treated with Herceptin has a 25 to 30 percent chance of reoccuring and with Herceptin only a 2 to 3 percent chance of reoccuring.  The first medical oncologist spoke in terms of side effect management.  Things like the use of demexthasone - a strong steroid - before the first treatment to reduce the possibility of an infusion reaction and anti-nausea medicine.  And I am reading many posts with advice on how to reduce side effects.  And it is important to realize that it is my wife who has breast cancer and is a woman, not me.  My wife starts slow but then she takes charge.  With DCIS diagnosis, she took charge and visited the second reconstruction surgeon on her own and made the decision for a double mastectomy and immediate reconstruction with gummy implants.  And she now has made the decision to get a second opinion on the treatment recommendations.  She is talking to her friends, her support group, our neighbors who are doctors, etc.  I am greatly encouraged by the second oncologist.  She was trained at the Dana Farber Cancer Institute at Harvard and asked my wife to bring all the pathology slides.  She probably will spend 1-2 hours with my wife reviewing and explaining everything Monday.  So it will be interesting if the two opinions concur or disagree and in what sense.  We like the first oncologist and we like the proximity to our home and again the first oncologist won a Best Doctor Award in our state.  And my wife next week will get additional tests, MUGA scan of the heart, full body scan, blood tests including I hope the blood cancer marker test (A27/29 or something like that) and bone density test.  All my research and bulletin board posting of course is to help my wife but also to be well prepared during the doctor visits.  It helped me a lot with the Breast Surgeon and Reconstruction Surgeon and it helped me a lot (to be well prepared in both cases) with the medical oncologist.  These decisions put women between "the devil and the deep blue sea" and are very difficult.  But I believe at least as of today my wife has made the decision to do the recommended treatments adjusting them for the second opinion which she plans to take back to the first oncologist.  I just hope I can find some statistics on Herceptin heart problems and if I do I will share them here.  In the meantime, every person and should I say every woman with breast cancer has to go through the risk benefit analysis and make tough decisions.

Here is a study stating that only 3.8 percent of patients on Herceptin had heart problems.

Heart Problems From Trastuzumab (Herceptin®) Do Not Increase in the Short Term

Key Words

Breast cancer; HER2; trastuzumab (Herceptin®); congestive heart failure. (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)

Summary

It's known that women with HER2-positive breast cancer who take the drug trastuzumab (Herceptin®) in addition to chemotherapy are at greater risk of heart problems during treatment. Now a study has shown that the incidence of such problems does not increase in the short term and that many women regain heart health after an initial decline. However, the long-term effects of trastuzumab on the heart remain to be determined.

Source

American Society of Clinical Oncology (ASCO) annual meeting, Chicago, June 4, 2007 (see the meeting abstract). See also results published online June 7, 2010, in the  Journal of Clinical Oncology (see the journal abstract).

Background

About 20 percent of breast cancers make too much of (overexpress) a protein called HER2. Such tumors tend to grow faster and are more likely to come back (recur) than tumors that don't overproduce the protein.

The targeted drug trastuzumab kills cells that overexpress HER2. In 2005, results from several randomized clinical trials showed that taking trastuzumab in addition to chemotherapy reduces the risk of breast cancer recurrence by about half for women whose tumors overexpress HER2 (called HER2-positive breast cancer).

However, these trials also found that women who took trastuzumab had an increase in congestive heart failure (where the heart has trouble beating normally because of damage to the heart muscle) or other heart problems. In the study described below, investigators examined the data from five years of follow up from a randomized clinical trial of trastuzumab to see if this risk of heart damage changes over time.

The Study

The investigators looked at data from five years of follow up from the National Surgical Adjuvant Breast and Bowel Project trial NSABP-31. This trial randomly assigned women with HER2-positive breast cancer that had spread to nearby lymph nodes to receive chemotherapy with the drugs doxorubicin (Doxil®) and cyclophosphamide, followed either by the drug paclitaxel (Taxol®) and 52 weeks of trastuzumab (experimental group) or paclitaxel alone (control group).

In order to be eligible to take trastuzumab, participating women had to have normal heart function and no past or current heart disease. All women had scans of the heart before the start of treatment, and at 3, 6, 9, and 18 months after the start of treatment. The investigators compared the difference in number of cardiac events-defined as either congestive heart failure or death due to heart problems-between women taking trastuzumab and women in the control group for up to five years after the start of treatment.

The trial was organized by the National Surgical Adjuvant Breast and Bowel Project (NSABP). The author of the five-year follow-up study is Priya Rastogi, M.D., from the NSABP.

Results

At five years after the start of treatment, 3.8 percent of women in the trastuzumab group had experienced a cardiac event, compared to 0.9 percent of women in the control group. These numbers remained essentially unchanged from those seen at three years of follow up (4.1 percent in the trastuzumab group and 0.8 percent in the control group), showing that the cumulative incidence of cardiac events did not increase.

In addition, substantial recovery in heart function was seen in approximately two-thirds of women who experienced an initial decline in function.

The investigators identified three risk factors for congestive heart failure in women taking trastuzumab: age (women over the age of 50 have higher risk), the use of hypertensive medications (medications taken to lower high blood pressure), and low normal heart function.

Limitations

Importantly, explained Sharon Hunt, M.D., professor of cardiovascular medicine at Stanford University, who presented a discussion of these results at the ASCO meeting, doctors still do not know what the long-term effects of trastuzumab on the heart will be.

"I don't think that a three-year follow up or a five-year follow up are adequate to tell us the real natural history of any chemotherapy-related cardiotoxicity," she stated. "We don't know...the predicted 10-year cumulative toxicity of the chemotherapy. I think this is incredibly important data to obtain...so that when we face a patient with the option of having trastuzumab...we can be able to share with them the absolute risk/benefit ratios."

The long-term risk data will be particularly important, she explained, because even the women who recovered heart function did not recover to the levels they had before treatment. These patients may be especially vulnerable to additional damage to the heart, from conditions such as high blood pressure or viral infection.

Comments

Even though questions about the long-term effects of trastuzumab on the heart remain to be answered, "it's amazing to me how incredibly effective trastuzumab is. It has obviously been a major addition to the chemotherapy of...metastatic breast cancer, as well as [in] the adjuvant setting," said Hunt. "It is in this context of the remarkable efficacy of this drug that we need to discuss its downside."

"Trastuzumab is a very active treatment, and it's something we're all excited about in terms of treating breast cancer, so in the short term these results are reassuring," agreed Jennifer Eng-Wong, M.D., a breast cancer specialist from the National Cancer Institute's Center for Cancer Research.

http://www.sciencedaily.com/releases/2011/08/110809212433.htm

This link has many articles on herceptin including the heart problem risks.