Just got the histopathology report

Please be aware there is a new test called a mammoprint that will take your DNA and your cancer and tell you what the chance of recurrence actually is. Before my lumpectomy, I was told my chance of recurrence was 5%, that percentage was based on statistics. The mammoprint is for stage 1 stage 2, less than 2cm and cervical cancers. I had a lumpectomy versus a mastectomy. I was told that I would only have radiation, however, I chose to have the mammoprint after the lumpectomy, which I did not know about prior to lumpectomy. I found out that my chance of recurrence was 28 and 1/2 percent vs 5% statistically. So I have had chemo, my last treatment is next week and then radiation. This is a new test.

The Her2 status must be determined prior to an Oncotype Dx, as it is not an appropriate test if the Her2 goes from equivocal to positive. That would be the next step before any genetic assay testing is done. Mammaprint is not that new - I had it in 2010, it is just not used as often as Oncotype, but it can be used for Her2+ patients - however, it will almost always come back high risk with a chemo recommendation on Her2+ patients.

Hi Godblessedeveryone:

The negative nodes are very good news indeed, yielding pathologic staging of Stage IA. There is some associated DCIS (quite common), but the IDC will determine treatment.

As I mentioned yesterday in another one of your threads, for a woman in her early fifties, with lumpectomy for invasive ductal carcinoma now determined to be 1.5 centimeters, a course of radiation is quite likely to be recommended. You and your mother can ask her radiation oncologist for an estimate of the risk reduction benefit of radiation in her particular case to help you both understand the potential benefit it offers her in terms of reducing her risk of loco-regional recurrence. It may be substantial.

Given the size of the tumor (1.5 cm IDC) and hormone receptor-positive status, endocrine therapy (e.g., tamoxifen or an aromatase inhibitor) will likely be recommended in accordance with guidelines from National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncologists (ASCO).

At this time, there is not enough information available to reliably predict whether chemotherapy and/or HER2-targeted therapy will be recommended or not.

As SpecialK noted, the results of HER2 testing were equivocal, necessitating "reflex testing", in this case to be done by SISH. The results of the SISH test are not available at this time. If determined to be clearly HER2-positive by SISH, then the patient would have IDC, 1.5 cm (15 mm), node-negative, hormone-receptor positive, HER2-positive disease, and under current treatment guidelines for breast cancer from the NCCN (Version 1.2016), for tumors >1 cm with those specific features, the guidelines recommend chemotherapy plus HER2-targeted therapy (trastuzumab), so in the ordinary case, that would be the likely recommendation received (if HER2-positive):

Adjuvant chemotherapy (category 1) with trastuzumab (category 1)

I note that the use of MammaPrint test is not included in the NCCN guidelines (Version 1.2016) (or relevant 2016 ASCO guideline) in the possible situation of a HER2-positive tumor that is "T1c" in size (T1c Tumor > 10 mm but ≤ 20 mm in greatest dimension). However, one should not hesitate to inquire about any test to obtain current expert advice.

If determined to be clearly HER2-negative, then the patient would have IDC, 1.5 cm (15 mm), node-negative, hormone-receptor positive, HER2-negative disease. If this was the situation, then the OncotypeDX test for invasive disease would be an excellent option, in accordance with both NCCN and ASCO guidelines, and may potentially provide very useful prognostic and predictive information helpful in decision-making about chemotherapy. The Recurrence Score information will be used to inform the choice of (a) endocrine therapy versus (b) endocrine therapy plus chemotherapy.

I am a layperson only. The above is for information only, and all information above should be confirmed with her providers to ensure receipt of accurate, current, case-specific expert professional medical advice.

BarredOwl

SOrry, I listed my info in reverse order! Determine Her2 status first. If negative, then hopefully get Oncotype test to determine the benefit of chemo...then make a decision based on all of the information in hand. These things are all tools, but not crystal balls, so ultimately,she'll need to decide, with her doctor's help and guidance, what she determines to be the best course of action.

From another thread she is 55 this year, which I considered before posting the general information above. The information above regarding what clinical consensus guidelines provide is offered as general information about what might be expected in the typical case. In certain circumstances, it may be medically appropriate to depart from what consensus guidelines provide.

Thus, for any particular individual, the ultimate decision regarding any intervention should include consideration of the relevant clinical and pathological factors, as well as personal medical history, family history, age, and co-morbidities, etc.

Such decisions include a risk/benefit analysis. One should inquire about estimated personal risk of loco-regional recurrence, estimated risk of distant recurrence, the purpose of the intervention, the risks associated with the intervention, and the estimated benefit of the intervention in terms of risk reduction that may be achieved in her case. The possible risks of treatment must be weighed against the possible benefits, in light of one's personal risk tolerance.

I found it helpful to know what is likely to be recommended, so I wouldn't be shocked when it naturally came up, and so I could prepare questions in advance.

BarredOwl

Hi JuniperCat:

The short answer is usually the ER, PR and HER2 status determined according to validated pathology methods.

ER and PR Status:

In general, is it appropriate to override the results of a validated IHC test with individual oncotype ER score and/or PR score with regard to endocrine therapy decisions? In my layperson's view (no medical training), the answer is no, not in the typical case.

Usually, the validated pathology methods ("IHC") used to measure Estrogen Receptor protein and Progesterone Receptor protein look at whole cells. Results are reported as percent positive cells in a field of view (i.e., some cells are stained by a "molecular tag" and are seen as "positive for staining," and some cells are not stained). The percentage of cells that do stain is reported.

Oncotype uses a completely different method ("qRT-PCR") to measure mRNA from ground-up cells. It gives a numerical score in "units", where particular unit values falling below a specified positive/negative cut-off of X units are considered "negative" by Oncotype (arrow in the orange range at left).

The methods and molecules measured are distinct, and the outputs cannot be directly compared. The individual ER and PR scores can be confusing to clinicians as well. See for example, the Discussion in this 2012 paper:

http://www.nature.com/modpathol/journal/v25/n6/ful...

"The additional reporting of qRT-PCR ER and PR results on oncotype report confuses clinicians and unnecessarily creates doubt about validated immunohistochemistry assays."

The individual oncotype ER and PR scores appear to have limited application, and relatively much poorer validation than the central output of the test (i.e., multi-gene Recurrence Score).

There may be specialized cases where it is appropriate to consider the Individual ER and PR scores. Such a case would probably warrant seeking a second opinion (to ensure correct interpretation and because a risk of contravening hormone-receptor positive determination by IHC would be under-treatment).

HER2 Status:

Those who are hormone receptor positive, HER2-negative by standard pathology methods are eligible for the OncotypeDX test for invasive disease. The individual oncotype HER2 score is derived from measurement of mRNA levels, whereas standard pathology methods examine whole cells and assess protein (IHC) or DNA amplification (FISH). Again, the methods and molecules measured are distinct, and the outputs cannot be directly compared.

The following documents highlight concerns regarding the use of the individual HER2 score to determine HER2 status, including the possibility of false-negatives (which could lead to under-treatment by depriving a person of HER2-targeted therapy).

FDA document (pp. 14 -15): http://www.fda.gov/downloads/AboutFDA/ReportsManua...

http://onlinelibrary.wiley.com/doi/10.3322/caac.21133/full

Again, there may be specialized cases where it is appropriate to consider the individual oncotype HER2 score, and such a specialized case likely warrants a second opinion.

The above issues regarding the individual Oncotype ER, PR and HER2 scores do not apply to the multi-gene Recurrence Score ("RS"), which is better validated.

I am a layperson with no medical training. Therefore, patients should always consult their MO regarding the significance of their pathology results and Oncotype test results to ensure receipt of current, accurate, case-specific, expert professional medical advice. In more specialized cases, a second opinion may be warranted.

BarredOwl

I had significant discrepancies between original path (ER+ 50%, PR+ 10%, Her2-) and Oncotype (score of 42, ER+ borderline 6.6 where 6.5 is negative, PR-, Her2-). My MO says heterogeneity in BC is the reason for difference in scores. I now have a local recurrence that is TN, and no one seems particularly surprised, even given my previous ER+ status.