Stage 1b with 1 micro node. Oncdx is 21 chemo or no chemo

zfirebird · April 2016

My MO is pushing chemo as I'm 46 and she feels I can tolerate it. However, my RO and SO aren't quite sure. With no chemo my % of recurrence is 10...with chemo is 4.7. With 21 being on the low end of intermediate I'm seeking a second opinion on the chemo as no one can really tell me the benefits of chemo out way the risks.

Are there any other survivors with micro node involvement and did you opt for chemo?

Kessa619 · April 2016

Hi, zfirebird. I am sorry you are having to make this decision. I made a similar one back in January, electing to skip chemo. My oncotype was 18. It is so tough being in the gray zone. My MO thought that chemo would not be effective as my cancer was luminal A. Have you had a Mammaprint test done? Mine came back "low risk," and that helped a little in making my decision. I am curious to know where your doctorsfound the percentages they gave you...maybe Adjuvant Online?

Anyway, I wish you best of luck. Just wanted to chime in to let you know you are not alone

ladsgma · April 2016

I decided no chemo for me. The RO said the whole breast rads would put the risk down to 5%. So I am seeing a nutritionist and cut down on alcohol to hopefully lower that 5%. Good look to you with your decision, it's a hard one.

zfirebird · April 2016

Thanks Kessa619 and ladsgma,

I'm going to ask for the Mammaprint as I'm getting a second opinion in 2 weeks. Hopefully the second opinion will answer all the questions I need to make the best decision I can live with.

Cowgirl13 · April 2016

I would get a second opinion from another oncologist. The oncologist's specialty is oncology and likewise surgeon is surgery and rad is rad. I think it's important that the path report lists reports 1 positive node. Good luck.

Meow13 · April 2016

zfirebird, I would go with what you feel is the right treatment. Doctors can advise but you need to decude. I had an oncodx of 34 and I decided no chemo against what mo recommended. I was in such good health at the time and felt I wasn't willing to risk dangerous side effects. Now that being said, others feel chemo is an insurance policy that has killed a bunch of cancer cells. There is no definite right answer.

Anonymous · April 2016

I had 4mm of cancer in the node so it was considered positive. My oncotype was 15. I was also pushed to do chemo because of age (I'm post menopause) and the node, but the oncotype was helpful for me and I decided to go on hormonal therapy. I would seek a second opinion maybe at a Breast Cancer center if there is one nearby. That's what I did. But having an intermediate oncotype like yours, the mammaprint should really help in telling you if you are low or high risk.

Best of luck going forward!

zfirebird · April 2016

Thanks sooo very much ladies. I'm scheduled to have a second opinion next week. I just feel I'm not getting all the available options to me. The oncotype of 21 is one thing then I learn today that by being an African American woman the risk of recurrence is higher regardless of stage. I was like "what's up with that?" Regardless, I'll make my decision after I visit the cancer center next week.

This board is so helpful as this dx can wreak havoc on your life if you let it. I've got a breast cancer survivor manual that has survivalist defined as follows:

"Survivalists are realistic. They accept their cancer diagnosis but refuse to ccept it as an automatic death sentence. Rather, they view it as a caution light, warning them to take actions to better manage their health and build an even better quality of life."...Judy Kneece, RN, OCN

This is how I choose to see cancer and it's helped me tremendously. Blessings to us all.

Thanks

Z

Hopeful82014 · April 2016

Thanks for that quote, Z. I like it!

Good luck with your 2nd opinion and your decision making. I hope you'll keep us posted. Take care!

Anonymous · April 2016

I love the quote Z. Wishing you peace with your decision.

Sunnyone22 · May 2016

zfirebird:

See the chart (below) from the OncotypeDX website. It's just an example of how OncotypeDX, in the manufacturer's opinion, is a better tool for treatment decisions than tests which just say "low" or "high" risk of recurrence. In short, it shows that those on the low end of 'intermediate' range might have a different set of considerations than those on the high end of intermediate range. Also, please note that there is a calculator on the OncotypeDX website which will allow your MO to enter other factors besides Oncotype score (such as age, tumor size, etc.). This calculator can only be accessed by a registered medical professional so your MO can register on the website and plug in your specific details. It gives recurrence risks predictions using more factors than just the Oncotype score. Just another tool to consider in your overall decision...................

BarredOwl · May 2016

Hi Sunnyone22:

Just a head's-up that the source and citations for the graphic you posted are Paik et al. N Engl J Med. 2004 and Paik et al. J Clin Oncol. 2006 (see links below*) in which the study populations were node-negative.

However, zfirebird has node-positive disease (1/14 - possibly a "micromet" per title of post? (pN1mi Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm))?

Here is a link to the OncotypeDX page for the node-positive group, which should be discussed with a medical oncologist to ensure understanding of limitations of intermediate scores in this setting:

http://breast-cancer.oncotypedx.com/en-US/Professional-Invasive/TheRecurrenceScoreResult/Node-Positive-Prognostic-Predictive.aspx

The citations from studies including node-positive patients on this page are provided below (#).

BarredOwl

*Node-negative (N0) setting:

Graphic with citations at bottom: http://intermediate.oncotypedx.com/en-US/The-Recur...

Paik et al., "A Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative Breast Cancer," N Engl J Med. 2004 (See Figure 4):

http://www.nejm.org/doi/full/10.1056/NEJMoa041588#t=article

Paik et al., "Gene Expression and Benefit of Chemotherapy in Women With Node-Negative, Estrogen Receptor–Positive Breast Cancer ,"J Clin Oncol. 2006:

http://jco.ascopubs.org/content/24/23/3726.full

# Node-positive setting:

Albain et al. (2010), "Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial":

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(09)70314-6/abstract

Dowsett et al. (2010), "Prediction of Risk of Distant Recurrence Using the 21-Gene Recurrence Score in Node-Negative and Node-Positive Postmenopausal Patients With Breast Cancer Treated With Anastrozole or Tamoxifen: A TransATAC Study":

http://jco.ascopubs.org/content/28/11/1829.long

BarredOwl · May 2016

zfirebird:

A second opinion may be very helpful in better understanding your risk profile and your test result.

Further to my post above, for completeness, as explained in more detail below, consensus guidelines treat the Oncotype test quite differently in the node-negative (N0) versus node-positive settings, which may reflect a lesser degree of consensus among clinicians regarding use in node-positive patients. This could be a point of discussion with your medical oncologist.

At this time, clinicians may be more hesitant to rely upon the Recurrence Score in node-positive patients, particularly in the intermediate range, and may consider other clino-pathologic features in their recommendations. Thus, it is important to ask the medical oncologist about the information content / limitations of the intermediate Recurrence Score in your particular case, and what other clinical and/or pathological features in your case support a recommendation for chemotherapy.

Regarding the guidelines, the NCCN guidelines prominently feature the test in node-negative (N0) patients (See NCCN guidelines for Breast Cancer, Professional Version, 1.2016, Chart BINV-6, at page 18, available for free with registration at www.nccn.org).

In contrast, on Chart BINV-6, at page 18, the NCCN guidelines refer to the test in a footnote for node-positive patients, saying it can be "considered" in select patients with 1–3 involved ipsilateral axillary lymph nodes. See also, the discussion section in the paragraph bridging pages MS-24 and MS-25 (under revision).

In addition, in February, 2016, ASCO issued the following guideline regarding Oncotype for invasive disease and other tests:

"Use of Biomarkers to Guide Decisions on Adjuvant Systemic Therapy for Women With Early-Stage Invasive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline"

2016 ASCO Guideline Document: http://jco.ascopubs.org/content/early/2016/02/05/JCO.2015.65.2289.full

Please see Recommendation 1.2 regarding node-positive disease and the Clinical interpretation of literature review and additional remarks in the Data Supplement. This guideline includes a discussion of analytical validity, clinical validity and clinical utility, and the criteria for determining these, including an assessment of the quality of the evidence based on the types of studies then available.

Clinical guidelines are snap-shots in time. Since the ASCO guideline came out, new evidence from a prospective trial became available for certain node-positive patients (with Recurrence Scores of 0 to 11), and more may become available over time. Thus, patients should always seek accurate, current, case-specific expert professional medical advice from a medical oncologist regarding the potential value of the test in each specific case in light of currently available clinical evidence.

BarredOwl

BarredOwl · May 2016

zfirebird:

A second opinion may be very helpful in better understanding your risk profile and your test result.

At this time, clinicians may be more hesitant to rely upon the Recurrence Score when there is some node involvement, particularly in the intermediate range, and may consider other clino-pathologic features in their recommendations. Thus, it is important to ask the medical oncologist about the information content / limitations of the intermediate Recurrence Score in your particular case, and if chemotherapy is or is not recommended, what other clinical and/or pathological features in your case support their recommendation.

I hope your appointment next week is helpful.

BarredOwl

Sunnyone22 · May 2016

Good catch BarredOwl! Thanks for the great research.

zfirebird · May 2016

Thanks BarredOwl,

The information you've shared is quite helpful. I've had my second opinion and he agreed with the first MO and suggested chemo due to the node positive (1/14 pN1mi ). I'm 46 and premenopausal and they both feel that since I'm young and quite healthy they'd rather err on the side of caution to kill any microscopic cells that may be present. So I'm doing chemo Taxotere with Cytoxocan. 4 rounds once every 3 weeks, then radiation therapy, then hormonal therapy.

The decision to have chemo was NOT easy by any stretch of the imagination but I'd rather have peace of mind that I did what I feel is best for me. My next step is advocacy for other women who share my exact diagnosis. We need everyone on board in this fight.

Z

BarredOwl · May 2016

Hi zfirebird:

I am glad to hear the recommendations you received were consistent, and that you have reached a decision about what you feel is right for you. There is a thread for those starting chemo in May 2016 here, which may be helpful:

https://community.breastcancer.org/forum/69/topics...

I hope you tolerate treatment well.

BarredOwl

zfirebird · May 2016

So far so good. The experience was not as horrific as I'd anticipated. I tolerated it quite well. I'll have a better assessment in a couple of days though.

Thanks Again

Stage 1b with 1 micro node. Oncdx is 21 chemo or no chemo

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