Is a general chemo treatment plan normal?

Hi, Blessed. I just read your other posts and I'm a bit confused. In the other two, you mention that she's Stage IV and in this one, you wrote Stage III. Do you know for sure which one she is?

There are several different chemo drugs that are used across the breast cancer spectrum and those are also commonly used in Triple Negative patients as well. Medical Oncologists (MOs) follow what's called a Standard of Care and most of that is included in guidelines published by the National Comprehensive Cancer Network (NCCN). Some MOs prefer certain regimens over others, but typically, any regimen chosen is within the guidelines for a particular type of breast cancer. These regimens are not individualized beyond the dosage which is usually calculated using a formula for body surface area. I guess an exception to that would be in the case of certain regimens, an MO might prefer for example a 4 or 6 dose regimen, but even in that instance, it's still part of the guidelines. So, yes, it sounds as if the treatment plan developed for her is perfectly normal, but without knowing exactly what chemo drugs were advised, I'm basing that on the fact that nearly all MOs will use a chemo regimen indicated for the subtype of cancer that the patient has.

Yes, the chemo regimen can be changed or altered in cases of extreme side effects or if it is administered in the neo-adjuvant setting (prior to surgery) where the MO can measure the tumor's response rate and isn't satisfied with the level of Pathologic Complete Response (pCR). If either of these situations occur, the MO could switch to a different chemo regimen that is indicated in the NCCN guidelines.

Just going by what you posted, it doesn't sound as if there is anything at all that is unusual about her treatment plan. Are there specifics beyond those above about which you have concerns? I know this is a difficult time. Depending on how soon she is supposed to begin treatment, perhaps it would give peace of mind to seek a second opinion. Just keep in mind that if another MO suggests a different chemo regimen, it doesn't mean that either of them have made a bad choice. In nearly every case, an MO is going to choose a regimen that is indicated for the type of cancer s/he is treating, but there are usually at least a few options to choose from. There is often a bit of wiggle room for an MO to practice some personal preference which can be based on experience, research, prior patients' experience with certain side-effects, etc.

Has your friend been advised to undergo genetic counseling to determine if genetic testing should be performed? With certain genetic mutations, such as BRCA, research is starting to elucidate the role of a platinum-based chemo such as carboplatin and the role it plays in DNA. Also, some research shows a benefit for BRCA mutation carriers with the addition of a PARP-Inhibitor to aid in chemo efficacy. The role of PARP-Inhibitors is less clear for those patients without a BRCA mutation.

Hope this helps.

Hi Blessedwith6,

Thanks for the update. I do think you both should seek clarification on the stage. Tumor size on its own will not cause a person to be re-classified from Stage III to Stage IV--or vice versa. The only requirement for Stage IV is distant spread of the tumor. Some Stage IV patients have tiny tumors under 1 cm and others have very large tumors; a patient will only be Stage IV if the tumor has spread beyond the breast tissue, skin of the breast, or regional lymph nodes and is now detectable in distant areas of the body. I want to stress the differentiation because prognosis is quite different for the two.

Here is a breakdown of the stages:

Stage 0

Stage 0 is used to describe non-invasive breast cancers, such as DCIS (ductal carcinoma in situ). In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or getting through to or invading neighboring normal tissue.

Learn about what treatments you can generally expect for stage 0 in theOptions by Cancer Stage: Stage 0 page in Planning Your Treatment.

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Stage I

Stage I describes invasive breast cancer (cancer cells are breaking through to or invading normal surrounding breast tissue) Stage I is divided into subcategories known as IA and IB.

Stage IA describes invasive breast cancer in which:

• the tumor measures up to 2 centimeters AND
• the cancer has not spread outside the breast; no lymph nodes are involved

Stage IB describes invasive breast cancer in which:

• there is no tumor in the breast; instead, small groups of cancer cells – larger than 0.2 millimeter but not larger than 2 millimeters – are found in the lymph nodes OR
• there is a tumor in the breast that is no larger than 2 centimeters, and there are small groups of cancer cells – larger than 0.2 millimeter but not larger than 2 millimeters – in the lymph nodes

Microscopic invasion is possible in stage I breast cancer. In microscopic invasion, the cancer cells have just started to invade the tissue outside the lining of the duct or lobule, but the invading cancer cells can't measure more than 1 millimeter.

Learn about what treatments you can generally expect for stage IA and IB in the Options by Cancer Stage: Stage IA and IB page in Planning Your Treatment.

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Stage II

Stage II is divided into subcategories known as IIA and IIB.

Stage IIA describes invasive breast cancer in which:

• no tumor can be found in the breast, but cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes (the lymph nodes under the arm) or in the lymph nodes near the breast bone (found during a sentinel node biopsy) OR
• the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes OR
• the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes

Stage IIB describes invasive breast cancer in which:

• the tumor is larger than 2 centimeters but no larger than 5 centimeters; small groups of breast cancer cells -- larger than 0.2 millimeter but not larger than 2 millimeters -- are found in the lymph nodes OR
• the tumor is larger than 2 centimeters but no larger than 5 centimeters; cancer has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the breastbone (found during a sentinel node biopsy) OR
• the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

Learn about what treatments you can generally expect for stage IIA and IIB in the Options by Cancer Stage: Stage IIA and IIB page in Planning Your Treatment.

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Stage III

Stage III is divided into subcategories known as IIIA, IIIB, and IIIC.

Stage IIIA describes invasive breast cancer in which either:

• no tumor is found in the breast or the tumor may be any size; cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone (found during imaging tests or a physical exam) OR
• the tumor is larger than 5 centimeters; small groups of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes OR
• the tumor is larger than 5 centimeters; cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy)

Stage IIIB describes invasive breast cancer in which:

• the tumor may be any size and has spread to the chest wall and/or skin of the breast and caused swelling or an ulcer AND
• may have spread to up to 9 axillary lymph nodes OR
• may have spread to lymph nodes near the breastbone

Inflammatory breast cancer is considered at least stage IIIB. Typical features of inflammatory breast cancer include:

• reddening of a large portion of the breast skin
• the breast feels warm and may be swollen
• cancer cells have spread to the lymph nodes and may be found in the skin

Stage IIIC describes invasive breast cancer in which:

• there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast AND
• the cancer has spread to 10 or more axillary lymph nodes OR
• the cancer has spread to lymph nodes above or below the collarbone OR
• the cancer has spread to axillary lymph nodes or to lymph nodes near the breastbone

Learn about what treatments you can generally expect for stage IIIA and operable IIIC in the Options by Cancer Stage: Stage IIIA and Operable IIICpage in Planning Your Treatment.

Learn about what treatments you can generally expect for stage IIIB and inoperable IIIC in the Options by Cancer Stage: Stage IIIB and Inoperable IIICpage in Planning Your Treatment.

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Stage IV

Stage IV describes invasive breast cancer that has spread beyond the breast and nearby lymph nodes to other organs of the body, such as the lungs, distant lymph nodes, skin, bones, liver, or brain.

You may hear the words "advanced" and "metastatic" used to describe stage IV breast cancer. Cancer may be stage IV at first diagnosis or it can be a recurrence of a previous breast cancer that has spread to other parts of the body.