Stage II - The Gray Area

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ben50
ben50 Member Posts: 46
edited June 2014 in Stage II Breast Cancer

Or maybe ‘grey’ area for the UK ladies. Anyways, I
could use some thoughtful feedback and/or stories from other Stager II-ers who
find/found themselves in similar situations. The big conundrum is radiation
after surgery or not. My wife is at an
awkward stage of BC in which the level and aggressiveness of treatment is certain
for some things and definitely not for others. Being 26, triple positive, and
having aggressive cancer plus one positive node meant equally aggressive
neoadjuvant chemo, followed the BMX, and adjuvant therapies. But radiation
remains the million dollar question. My wife is nearly on chemo cycle 6/6 and
has had an outstanding reaction to her drug cocktail – with her breast mass and
protruding node melting away completely by the second infusion. So, does having
a pCR with only one positive node beforehand warrant radiation?

Our radiation oncologist informed us there has been a
proven 8% survival statistical advantage for women who opted for post-mastectomy
radiation therapy (PMRT). Sounds good to me, however, he informed us there were
problems with these studies, including: the trails are old and possible no
longer applicable to today’s standard of care (taking place before the advent of
Herpcetion, neoadjuvant practice, etc.) and they didn’t occur in the US – Europeans
apparently had slightly different treatment standards that could have skewed data
for American pratice. Meanwhile, radiation brings it own set of risks,
primarily (for us) increased risks of certain carcinomas. This risk is exacerbated
by the fact that my wife is only 26 and has a longer time to develop these secondary
carcinomas, which lies somewhere around 2-4% range for her.

So there it is. Is a potential 8% survival advantage
that may not actually apply to my wife worth the short/long term SEs of radiation?
If my wife had more positive nodes this choice would easier. Also, if surgery shows
there is still residual disease, the choice will certainly become clear. So I
reach out to the community, has anyone else had to measure the pro/cons, risks/benefits
of this decision? I’m just looking for relatable stories and the choices you
made (or are thinking about making). I asked our Rad Doc the dreaded hypothetical
they must get all the time: “If my wife was your daughter, how would you want
her to proceed?” He said he would be banging his head against the wall – lol.

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  • Lojo
    Lojo Member Posts: 303
    edited March 2014

    Hi Ben - here's another study - looking at predictors of loco-regional recurrence risk in HER+ patients -- conclusion: omitting radiation increases the risk of local recurrence

    I'm older (at 41, still on the youngish side) and although I'm not HER+ and I had a larger tumor and close margins - my RO, surgeon, and MO all said that my greatest risk was from a local recurrence - and although many local recurrences can be caught and treated, I've read that about 25% of local/regional recurrences will progress to stage 4. 

    The numbers I was given were that without rads I had about a 20% risk of local/regional recurrence and  that adding rads dropped it to somewhere near 5%. Although there are side effects of rads (short and long term), the long term serious ones are relatively rare. The short term ones are manageable so far for me - mostly just skin discomfort and tiredness, which I expect to clear up relatively soon after I'm done.

    doi: 10.1097/COC.0b013e31829d1eb8

    Original Article: PDF Only

    Predictors of Locoregional Outcome in HER2-Overexpressing Breast Cancer Treated With Neoadjuvant Chemotherapy

    Arsenault, Daniel MD; Hurley, Judith MD; Takita, Cristiane MD;
    Reis, Isildinha M. PhD; Zhao, Wei MD, MS; Rodgers, Steven MD, PhD;
    Wright, Jean L. MD



    Published Ahead-of-Print

    Collapse Box

    Abstract

    Objectives: We identified prognostic factors for
    locoregional recurrence (LRR) in a cohort of patients with
    HER2-overexpressing breast cancer treated with neoadjuvant chemotherapy
    (NACT).

    Methods: We reviewed records of 157 patients with
    HER-overexpressing tumors who received NACT between May 1999 and
    December 2009 and collected demographics, disease/treatment
    characteristics, and clinical outcome. We estimated rate of LRR by the
    method of cumulative incidence.

    Results: Presentation was 33% stage II and 67% stage III;
    29.9% were clinically node positive. All patients received NACT, 94%
    trastuzumab containing. 90.4% had mastectomy and 6.4% breast-conserving
    surgery; 3.2% had no surgery. Among surgical patients, 48% were
    pathologically N0, 28.8% had 1 to 3 positive nodes, and 23.7% had >=4
    positive nodes. 79.6% received radiation therapy (RT) to the
    breast/chest wall+/-supraclavicular field. Median follow-up was 43
    months. Three-year cumulative incidence of LRR was 8.2%; 50% of LRR had a
    regional component. Predictors for LRR included use of RT (HR=4.70,
    P=0.006), lymph node positivity (>=4 vs. 0 HR=19.99, P=0.008; 1 to 3
    vs. 0 HR=10.8, P=0.031), and ER status (negative vs. positive HR=6.02,
    P=0.006). The only risk factor for regional failure specifically was
    residual nodal disease (>=4 HR=6.5, 1 to 3 HR=5.1, P=0.031).

    Conclusions: In a cohort with stage II to III
    HER2-overexpressing breast cancer treated predominantly with
    trastuzumab-containing NACT followed by mastectomy+/-RT, we identified
    omission of RT, negative ER status, and residual positive lymph nodes as
    significant predictors of LRR, with 50% of LRR having a regional
    component.

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  • ben50
    ben50 Member Posts: 46
    edited March 2014

    Whoa you gals are wonderful for doing some research for me - thank you! 

    kayb, I've actually read that study and it pretty much correlates with what I've seen and heard in regard to the different benefits of Postmastectomy radiation between Stage II and III after achieving a pCR. As far as consulting a seconding opinion, our RO apparently has that covered for us. He is friends with the head RO at MD Anderson (Dr. Buchholz I think his name was) who he considers to be 'the smartest guy on the planet" in terms of radiology. And conveniently enough, my wife is already a patient at MD Anderson due to seeking initial seeking second opinion when all this started happening. Oh lo, to have connections! We'll take it what we can get. He'll make the call after we get our final pathology and whether or not we achieve a pCR (knock on wood).

    Lojo, now I haven't seen this study. It is interesting and applicable obviously because of our Her2 status. I do notice, however, this study fails to consider the variable of achieving a pCR or not, and what effect that would have on LLR. Nevertheless, definitely worth showing to our medical team. With a quick glance at your DX, I'm surprised your team is adamant on radiation considering you opted for a BMX, have no positive nodes, and have a Grade 1 tumor. Regardless, your team seems pretty convinced postmastectomy radiation is the best route. I will indeed ask our RO about the local/regional recurrence chances for our case. 

    Again, thanks a lot for your insight, it helps me to better evaluate our own situation. 

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  • Lojo
    Lojo Member Posts: 303
    edited March 2014

    Hi Ben,

    I think the #s are probably too small to include path complete response with Her2+ in the overall multivariate analyses. In my own case radiation was recommended because I had very close margins (<0.5mm) and because I have lobular carcinoma, and several recent publications have suggested that ILC in particular  - which is almost always ER+/PR+... (more than IDC)  is likely to benefit from PMRT to reduce local recurrence. I had some isolated tumor cells in my sentinel node - not enough to count as a + node, but all of the team (plus a casual second opinion from a friend who is a MO) recommended rads, as did my own research. My surgeon in particular was the one to send me back to the RO, because I think he was concerned about the margins.

    My sense from reading up on my particular case was that in general they are finding that radiation after mastectomy does reduce local recurrence rates, and although several studies didn't show ultimate reductions in mortality, the time horizons were only 5 years, suggesting that mortality rates would be reduced on the longer time scales. I think if you are 65, have clean margins, clear nodes, and a non-aggressive tumor, then rads can be avoided after MX, but the local recurrence rates that I was seeing from lots of different studies (in the 20%+ range over 10 yr) were too high for me - and rads knocks it back. And yes, there are potential side effects, but they're much better at targeting things now and avoiding heart/lungs, etc.

    I hope you and your wife can reach a decision soon - the absolute worst part of the whole process is being in limbo about treatment. I had a 7 week period after surgery when it was uncertain whether I'd need chemo while we waited on the Oncotype test to come back - and it was agony. Once  the treatment course was decided, it was much easier, and you just deal with it- like you're dealing with chemo now. 

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  • ziggypop
    ziggypop Member Posts: 1,071
    edited March 2014

    I'm so sorry that you and your wife are going through this and at such a young age. It's hard enough for those of us who are middle aged - you all should just not be facing this. It is great, however, that your wife is having such a positive response to the chemo - that is wonderful to hear.

    Unfortunately when studies are done each factor that is considered requires a a large number of additional participants or the margin of error just becomes so great as to render the study meaningless unless the numbers are really overwhelming. How does your wife's age factor in, and her response to the chemo, what about the stage and grade of the cancer? Each of these things matter and there isn't going to be a study that factors all of them in. So part of the decision (and it always is but moreso when it's a 'coin toss') is the personalities you both have. If your wife has radiation, will that reduce her fear that she'll have a recurrence? That is a QOL issue that is worth considering. If she doesn't have the RADS, will you both lay awake thinking that you didn't do all you could have? Where exactly will the RADS be targeted? Mine hit a large area (surpaclavical nodes, auxiliary area etc.) which means more radiation.

    Ultimately, perhaps the most important thing is that you both are at peace with the decision made - that you understand that you made the very best decision that you could with the info available to you. It may be that that decision will become clearer after the surgery. In any case, I hope that you and your wife both go on to live long, happy, and healthy lives. Many hugs.

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