Help! Oncotest 12. Chemo or No Chemo

Your score is low.  The problem with chemo is that it has side effects. And, sometimes, people die. Heart disease and leukemia are both known side effects. What my onc told me was that in my case, the statistical probability of side effects hurting me was higher than the statistical probability of chemo helping me.

You will be closely monitored for several years after treatment. With a low-grade cancer, any possible recurrence would be very likely to be caught.

The most important thing you can do is take Tamoxifen. It will do much more for you than anything else except surgery.

p22nut5,

You have a very low score.  I totally agree with ICanDoThis.  You might be interested in looking at the thread called "Oncotype Roll Call" to see what other people have done with your Oncotype score.  I had a 17 (higher than yours) and opted out of chemo with my onc's blessing.  Best to you.

Hi p22nut5.  My Dx is in my signature.  I had a lumpectomy, 33x of radiation and an Oncotype score of 12.  My MO said no to chemo but at least 5 years of Arimidex and probably more.  He told me I would have a tough time getting any doctor to agree to chemo with my Dx and score but in all honesty, I wasn't going to seek another opinion anyway because I trust my MO.  So, I'm just following his suggestions.   I'm not even a year out yet and I'm not trying to sway your opinion either way, just telling you what I did with the 12 score.  Best of luck with whatever you decide.  : )

Hi p22nut5,

My onco type score was a 10, so no chemo. Had a double mastectomy in January of 2011, no reconstruction Every day when I take my tamoxifen, I look at it as my very own little pac man eating up any stray "bad boys" that may be sneaking around my body.

I wish you the very best of luck in your decision. I too was also very ER and PR + and HER2-

Vikki

p22n5, your Oncotype DX score of 12 represents a recurrence risk of only 8%.  That 8% is the likelihood that you will get a distant recurrence in the next 10 years even if you take tamoxifen or an AI for the first 5 of those 10 years.

The thing is, chemo won't reduce that risk very much. My onco said it's typical for chemo to decrease the recurrence risk by about one-third.  So, if the recurrence risk is 8% if you don't have chemo, it will be 1/3 less, or around 5 - 6%, even if you do have chemo.  (One third of 8% is 2.6%.)

When trying to decide if that 2.6% is enough of an absolute benefit to justify putting up with the SE's and cost of chemo, you also need to factor in the risk of bad things happening as a result of chemo.  Someone upstream mentioned acute problems developing during the infusion; I guess I didn't even worry about that because there are so many skilled nurses hovering around and doctors within shouting distance.  Depending on the chemo drugs, though, there could be a risk of cardiac problems (sometimes irreversible) and/or leukemia (a type that is very difficult to treat). Even the chemo drugs that aren't normally associated with life-threatening heart or blood disorders can cause neurologic problems, like peripheral neuropathy.  There is the usual laundry list of less serious but truly aggravating SE's, such as baldness, mouth sores, fingernails falling off, ...

Honestly, I don't mean to scare you, or anyone else who's looking at chemo in her future.  I did 4 rounds of Taxotere/Cytoxan four years ago, and I'm fine now.  All I'm trying to do is encourage everyone to think about the math.  As much as we'd like to ignore those numbers, I think we need to understand that sometimes they're important and can help us make decisions.

For instance, it wouldn't make much sense to go through chemo for, say, a 3% reduction in the risk of our tumor coming back, if there was a 4% chance we'd have heart damage as a result of the chemo drugs.  (I made those numbers up -- the actual risk of heart damage from chemo is not that high.)

So, if it were me, I would not do chemo with an Oncotype score of 12.  But... (and this is important):  I was 55 when diagnosed, and my oncologist said that was "young".  Young means you have more years of life to preserve; and the risk statistics aren't as trustworthy in young women as they are in oldsters.  That's why 2nd (and 3rd) opinions are important.

otter

P22Nut5... Join us again on the Stage 1, Grade 1 Premenopausal thread. Our biggest discussion involves ovarian suppression... You will feel right at home there!

HealingDreams:  I had been told to expect a low Oncotype score; my doctor seemed fairly certain that we wouldn't be looking at the need for chemo, but because I was Grade 2 and my tumor had grown fairly quickly, he was concerned enough to offer me 4x Taxotere/Cytoxan, "but only if I wanted to do it."  He didn't seem to feel there was an urgent need.  When my Oncotype score came back at 42, chemo became a necessity.  I have a 28% met recurrence rate without chemo/Tamoxifen; that drops to 18% with treatments (close to that 1/3 drop that otter mentioned).  Anyway, sorry for the digression.  My point is we can't always know what's to come, but I'll be crossing my fingers and toes that your score is very low and chemo isn't necessary.  Will be thinking about you on Friday - good luck!

Nancy

galsal:  Until recently, a number of physicians were using the CYP2D6 genetic test to measure a patient's ability to metabolize Tamoxifen.  The test was controversial.  In March, these researchers (see below) confirmed that for Post-Menopausal women, the test is not a good indicator of Tamoxifen metabolization.  Furthermore, it was believed before this research was conducted, that those patients who had MORE hot flushes were better metabolizers of Tamoxifen as well.  Their research found this idea to be incorrect.  While the test has limitations that it didn't include premenopausal women, IMHO, I think the test is considered now out of favor.  Next week is the annual ASCO meeting and I'm wondering if they are going to discuss this topic some more.  One note, though, physicians are concerned about Tamoxifen and the interaction of other drugs and how that may effect the metabolization of Tamoxifen, so one needs to discuss whatever meds they are taking with their doctor BEFORE they begin Tamoxifen.

_____________________________________________________________________________________________________________________

J Natl Cancer Inst. 2012 Mar 21;104(6):441-51. Epub  2012 Mar 6.

CYP2D6 genotype and tamoxifen response in postmenopausal women with endocrine-responsive breast cancer: the breast international group 1-98 trial.

Source

IBCSG Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA 02215, USA. mregan@jimmy.harvard.edu

Abstract

BACKGROUND:

Adjuvant tamoxifen therapy is effective for postmenopausal women with endocrine-responsive breast cancer. Cytochrome P450 2D6 (CYP2D6) enzyme metabolizes tamoxifen to clinically active metabolites, and CYP2D6 polymorphisms may adversely affect tamoxifen efficacy. In this study, we investigated the clinical relevance of CYP2D6 polymorphisms.

METHODS:

We obtained tumor tissues and isolated DNA from 4861 of 8010 postmenopausal women with hormone receptor-positive breast cancer who enrolled in the randomized, phase III double-blind Breast International Group (BIG) 1-98 trial between March 1998 and May 2003 and received tamoxifen and/or letrozole treatment. Extracted DNA was used for genotyping nine CYP2D6 single-nucleotide polymorphisms using polymerase chain reaction-based methods. Genotype combinations were used to categorize CYP2D6 metabolism phenotypes as poor, intermediate, and extensive metabolizers (PM, IM, and EM, respectively; n = 4393 patients). Associations of CYP2D6 metabolism phenotypes with breast cancer-free interval (referred to as recurrence) and treatment-induced hot flushes according to randomized endocrine treatment and previous chemotherapy were assessed. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided.

RESULTS:

No association between CYP2D6 metabolism phenotypes and breast cancer-free interval was observed among patients who received tamoxifen monotherapy without previous chemotherapy (P = .35). PM or IM phenotype had a non-statistically significantly reduced risk of breast cancer recurrence compared with EM phenotype (PM or IM vs EM, HR of recurrence = 0.86, 95% CI = 0.60 to 1.24). CYP2D6 metabolism phenotype was associated with tamoxifen-induced hot flushes (P = .020). Both PM and IM phenotypes had an increased risk of tamoxifen-induced hot flushes compared with EM phenotype (PM vs EM, HR of hot flushes = 1.24, 95% CI = 0.96 to 1.59; IM vs EM, HR of hot flushes = 1.23, 95% CI = 1.05 to 1.43).

CONCLUSIONS:

CYP2D6 phenotypes of reduced enzyme activity were not associated with worse disease control but were associated with increased hot flushes, contrary to the hypothesis. The results of this study do not support using the presence or absence of hot flushes or the pharmacogenetic testing of CYP2D6 to determine whether to treat postmenopausal breast cancer patients with tamoxifen.

Comment in

• J Natl Cancer Inst. 2012 Mar 21;104(6):427-8.

P22, so surprised to hear an Oncologist say that tamoxifen is optional with an IDC diagnosis, when the protocol is always to take antihormonals with any IDC.  What was her reasoning for why it was optional?

Hi p22nut2,

Congrats on your decision and best of luck with Tamoxifen!  I skipped chemo too and currently doing rads (BMX, but close chestwall margin), a third way through.  Will start on Tamoxifen once I'm done with rads, and my MO is against ovarian suppression too.  Wishing you the BEST, my BC twin sister!!!

I havent been on this website in months but this particular topic is really interesting to me given I had an Oncotype score of 11 which followed a lumpectomy and 33 rounds of radiation. Chemo was discussed after the first Path report and pre-Oncotype test because a micromet had shown up in the SN. Luckily for me the Onc ordered the Oncotype test. Had it not been for that test chemo would probably have been the treatment of choice. I think the Oncotype test is a godsend. Of course there are no guarantees but it has served as an invaluable tool for Oncologists in their determination of treatment. I hazard a guess a lot of women have dodged chemo because of it. My sister has BC as well(she has lobular), had a MX and because of the test she avoided chemo as well. With a score of 12 I would think chemo would not be advantageous. There are truly no right or wrong answers - we all do what we think is best for us and dont second guess ourselves.

Waiting for my results right now on the Oncotest ....The lab called me to go over cost and insurance.  I was so suprised at how expensive the test is.  

Belinda-  Just wanted to let you know that if your insurance does't cover the cost in full, the genomic health people who run Oncotype have a sliding scale payment option. Even with a 6 figure income, I was able to get my portion of the  payment down to 50$ total.

They (Insurance companies) want you to use this test. Its a lot less expensive than chemo and Insurance companies know this.  Most will pay a good portion of it as it means with a low score they dont need to shell out thousands of dollars in chemo care.

My only fear with Oncotype is they someday use it to eliminate our choice in the matter. And you will not be allowed to have chemo if you have score of X.  Right now, in the USA we the patient still have the choice.

Good luck to you.