Best adjuvant treatment?

Hi Topaz,

I also live in GA and I am a 2x HER+ survivor.

The first time I was diagnosed, I was stage 2 in my right breast which spread to my nodes. I had the genetic testing done, although I had no history of cancer in my family, which was negative for any genetic markers.

I had chemo, partial mastectomy with lymph nodes removed in the right arm and reduction in the healthy breast, and radiation. Ever thing looked good after surgery and my treatments. After remission, I stayed on Herceptin for 1 yr.

A year later, the cancer came back stage 4 in the bones, spine, liver, and lungs. I was on high doses of chemo for almost 6 months, no surgery.

After I went into remission, my doctors advised me to stay on Herceptin long term every 3 wks( for 10 yrs) and add Perjuta to my treatment. I have been on that protocol for 3 years and for the most part, all has been well.

If there's anyway I can be helpful, feel free to message me and I wish you all the best.

Hi Topaz15:

Glad you are feeling better as the days proceed.

Adjuvant chemotherapy is the area of expertise of medical oncologists ("MO"). Once you have reviewed the surgical pathology report with the surgeon, you should receive a referral to a medical oncologist or you should request one to fully discuss all of your questions, including the recommended regimen, the rationale and clinical evidence for combined cytotoxic (chemo) and targeted (trastuzumab) therapy, and your personal risk/benefit analysis.

Surgery and radiation are "loco-regional" treatments. They do not address the possible risk of distant spread, which might have already occurred. In contrast, "systemic" treatments, such as chemotherapy and trastuzumab, can reach cells which may have traveled elsewhere (undetected) via the blood or lymphatic system. Unfortunately, while perhaps less likely, distant spread can happen sometimes even with small and/or node-negative tumors.

Please note that under the National Comprehensive Cancer Center (NCCN) guidelines for Breast Cancer (Professional Version, 3-2015), the advice regarding "adjuvant chemotherapy with traztuzumab" (HERCEPTIN) in patients with hormone receptor negative, HER2-positive IDC or ILC varies with the size of the tumor and nodal status.

The actual size of the tumor should be available from the surgical pathology, which you are still awaiting.

Assuming the location of the lumpectomy did not likely affect lymphatic flow (e.g., not in the tail of the breast), it seems like you should still be a candidate for a sentinel node biopsy. For example, patients with DCIS who are found to have IDC at lumpectomy usually undergo the sentinel node biopsy in a second, subsequent procedure. Please inquire about the possibility of having the sentinel node biopsy performed now, because actual node status cannot accurately be predicted from tumor size and may affect prognosis and treatment recommendations.

If you are interested in reading up now, here is a brief introduction:

http://www.breastcancer.org/symptoms/diagnosis/hor...

These are the definitions of smaller "T1" tumor sizes (size only, not stage):

T1mi Tumor ≤ 1 mm in greatest dimension

T1a Tumor > 1 mm but ≤ 5 mm in greatest dimension

T1b Tumor > 5 mm but ≤ 10 mm in greatest dimension

T1c Tumor > 10 mm but ≤ 20 mm in greatest dimension

Assuming you have a smaller tumor, based on the suggestion of treatment with Taxol (paclitaxel) plus trastuzumab, this study in smaller, node-negative, HER-2 positive disease may be of interest to you.

Tolaney et al. (Dana Farber study):

Summary: http://www.breastcancer.org/research-news/hercepti...

ASCO Post article, google this title: "High Invasive Disease-Free Survival With Adjuvant Paclitaxel and Trastuzumab in Small, Node‑Negative, HER2-Positive Breast Cancers"

Original NEJM article: http://www.nejm.org/doi/full/10.1056/NEJMoa1406281...

For additional reading, see these retrospective studies. Note that these studies included hormone-receptor positive and/or HER2-negative patients as well, so be careful to focus on relevant subgroups (although small numbers may lack statistical significance):

BMJ (Large Netherlands study in varied group): http://www.bmj.com/content/bmj/351/bmj.h4901.full....

Vaz-Luis (node-negative, T1a, T1b): http://jco.ascopubs.org/content/32/20/2142.full.pd...

Fehrenbacher (node-negative, T1a, T1b): http://jco.ascopubs.org/content/32/20/2151.full.pd...

The above studies are relatively favorable. However, as noted in Fehrenbacher, survival estimates for T1aN0 and T1bN0 (T1abN0) [node-negative] HER2-positive patients who had breast cancer and were treated with trastuzumab and/or chemotherapy have been reported from older retrospective series and range from 77% 5-year recurrence-free survival (RFS) to 92% 5-year DFS. The NCCN guidelines also note this uncertainty: "The prognosis of patients with T1a and T1b tumors that are node negative is uncertain even when HER2 is amplified or over-expressed. This is a population of breast cancer patients that was not studied in the available randomized trials. The decision for use of trastuzumab therapy in this cohort of patients must balance the known toxicities of trastuzumab, such as cardiac toxicity, and the uncertain, absolute benefits that may exist with trastuzumab therapy."

If you are interested in looking at the Clinical Practice Guidelines in Oncology (NCCN Guidelines®), Breast Cancer, please note that the "Patient Version" is out of date in some respects and should not be relied upon. The current professional version (Version 3.2015) is available with registration at no charge and can be dowloaded at http://www.nccn.org/professionals/physician_gls/f_... . (Click on breast cancer, then the first option with red "pdf")

The guidelines provide an overview chart for SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR-NEGATIVE - HER2-POSITIVE DISEASE: See chart "BINV-7" at page 18 of the .pdf document. The discussion of adjuvant systemic therapy begins at page MS-23 (page 97 of the .pdf document). This document can be hard for laymen like us to understand, especially at first. If it is too confusing or not helpful to you, then just set it aside (and possibly try again later after you learn more). You can always ask your medical oncologist what the current consensus guidelines provide in a case such as yours. It is also important to keep in mind that the guidelines are a description of what is generally done. They are only as good as the data supporting them, and the strength of the various recommendations differs with the quality of the underlying evidence. In addition, in certain cases, there may be sound medical reasons based on pathology, patient presentation, including age or co-morbidities, etc. to depart from the guidelines.

The commentary in the guidelines can be quite subtle in what they are or are not saying, so it is important to use the guidelines only as an information source and always subject to confirmation of your understanding with your oncologist. Similarly, if you are influenced by the research articles, please confirm your thinking with your oncologist.

This is a thread frequented by those with T1a and T1b-size HER2+ tumors:

https://community.breastcancer.org/forum/80/topics...

Best wishes to you as you try to come to a decision.

BarredOwl

Age 52 at diagnosis - Bilateral breast cancer - Stage IA IDC - BRCA negative; HER2 status unknown.

Bilateral mastectomy and SNB without reconstruction 9/2013

Dx Right: ER+PR+ DCIS (5+ cm) with IDC (1.5 mm) and micro-invasion < 1 mm; Grade 2 (IDC); 0/4 nodes.

Dx Left: ER+PR+ DCIS (5+ cm); Grade 2 (majority) and grade 3; isolated tumor cells in 1/1 nodes (pN0i+(sn)).