http://www.medscape.com/viewarticle/855765

Narrow margins are OK!

http://mobile.philly.com/health/?wss=/philly/health&id=361563751

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Skip Chemo in Young Women With Common Breast Cancer Subtype?

Kate Johnson

SAN ANTONIO, Texas — Premenopausal women with Luminal A breast cancer, a common, intrinsic subtype, can consider skipping chemotherapy altogether and still expect a good prognosis, even when they are node positive, according to a new analysis of an old Danish study.

"This is clearly part of a body of evidence [in breast cancer] that's building up…that we can probably back off on the aggressiveness of our treatments and still achieve the same results," said investigator Torsten Nielsen, MD, PhD, from the University of British Columbia, Vancouver, British Columbia, Canada.

The new findings from the Danish Breast Cancer Cooperative Group 77B DBCG77B) study, which Dr Nielsen presented here at the San Antonio Breast Cancer Symposium (SABCS), raised some eyebrows given that chemotherapy is considered standard in premenopausal breast cancer.

But the question is a relevant one, noted Virginia Kaklamani, MD, of the University of Texas Health Science Center San Antonio and a codirector of the meeting.

As an investigator on the ongoing prospective SWOG RxPONDER trial (S1007) which is investigating a similar question, Dr Kaklamani said that the DBCG77B results "confirm what we thought — that we kind of don't need chemotherapy for these patients."

She also said the results expand her own sense of what is possible.

"This is another step and for me it gives me a little more confidence in my premenopausal women not to push chemotherapy. In our practice we would consider at least for a 55 or 60-year-old woman not giving chemotherapy if she had no hormone positive disease, but in premenopausal women we tend to not think about it," Dr Kaklamani said.

The new analysis used a prospective-retrospective design — in that it used tissue samples taken 25 years ago when the DBCG77B trial randomized patients to chemotherapy or no chemotherapy — a process that would not be considered ethical today (Cancer. 2010 May 1;116(9):2081-9).

At that time, 1146 premenopausal women with high-risk disease (tumors > 5 cm or positive axillary lymph nodes regardless of hormone receptor or HER2 status) were randomized to one of two active treatments — single-agent oral cyclophosphamide (C), or classic combination cyclophosphamide, methotrexate, and 5-fluorouracil (CMF); or 1 of 2 nonchemotherapy arms — levamisole, or placebo.

"They did not receive endocrine therapy, but they did however get what would be considered adequate local therapy by today's standards — a mastectomy supported by axillary node dissection and chest wall radiation," he said.

Ten-year disease-free survival (DFS) was better in the chemotherapy arms (55.5% in the C arm, 48.8% in the CMF arm) than the nonchemotherapy arms (38.6% in the control arm and 35.2% in the levamisole arm).

Immunohistochemical staining of the remaining available DBCG77B tissue samples revealed that chemotherapy improved DFS in 468 non-Luminal A patients (hazard ratio [HR] 0.50), but it had no benefit in 165 Luminal A patients (HR 1.07, P < .05).

Molecular testing is the key to differentiating between breast cancer subtypes, and Luminal A subtype can be determined by adding Ki67 to the regular biomarker panel run on every breast cancer, Dr Nielsen told Medscape Medical News, adding that this test is frequently available at local pathology labs.....

http://www.medscape.com/viewarticle/855703

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i also want to add one more comment....Due to earlier studies such as SOFT and TEXT, younger premenopausal patients are being given the choice of ovarian suppression. So the question being raised is....will there ever be a study that can truly nail down which premenopausal women can safely avoid chemo if the landscape of treatments rapidly changes? I think the next round of TAilLORX and the RxPONDER results might be the game changers....

cora....I don't think that is where they are heading until they can safely conclude that the data meets the highest level of evidence. That's what the NCCN and the other major groups guidelines are for. It is all about building on the evidence and creating a Standard of Care.....

cora....I think the landscape has begun to change in the last 4, 5 or even 6 years with respect to not recommending chemo for slow growing cancers. I think with the oncotypeDX test now NCCN recommended since 2011, physicians are growing stronger in defending the lack of benefit of chemo for those patients. But again, the evidence still hasn't reached that critical level.

With respect to lumpectomy and radiation vs. Mastectomy....since the first published data a few years back on this subject, I've been following this data as well. I find it interesting....that is all I will say. That said, this subject really presses lots of people's buttons as well! Oy! If only it was THAT simple.....

Rose .....there are no simpleton questions! Everyone's questions deserve answers. That said, taking the time to read these studies and then formulate questions is admirable. I just wish the answers were more straight forward. I like what Doxie said....sometimes the lines are "fuzzy."