Luminal A vs. Luminal B stage 1 BC

Lisey, the standard treatment for osteopenia, osteoporosis or combatting/preventing bone weakening from AIs is an oral bisphosphonate. Fosamax (alendronate) is the original, and must be taken weekly. Boniva is another oral that can be taken once monthly. Both, however, exacerbate preexisting cause (often severe) GERD (you must remain upright for at least 1/2 hr after each pill, preferably longer, but you will still get some heartburn). Long-term use can actually lead to gastric &/or esophageal erosions and even GI bleeds. So if you have any propensity for GERD your doctor will have to write a letter explaining that the certainty of that SE justifies the higher cost of semiannual intravenous or intramuscular bisphosphonate (Zometa, or zolendroic acid) or biologic (Prolia, or denosumab) therapy. Your insurance will cover at least the Zometa, though there would have to be some considerable hoop-jumping for them to cover the superior (milder SEs) Prolia. If you aren’t on Medicare yet, you’re likelier to be able to get the Prolia covered.

But the downsides (besides cost and time & labor) of infused or injected therapies is a slight chance of osteonecrosis of the jaw and (increasingly more commonly reported, though still relatively rare) paradoxical horizontal femoral fractures--the very fracture bone-strenghteners are supposed to prevent. The femoral fracture has been reported much oftener with Zometa than with Prolia. And though you wouldn’t get or aggravate your GERD, Zometa causes bone and muscle aches and a “flu-like” feeling for 1-3 days after infusion, which usually doesn’t happen with Prolia.

There ain’t no such thing as a free lunch. Every treatment--or refusal thereof--is a roll of the dice between benefit and risk. My MO says Zometa. My PCP urges me to avoid all bone-strengthening drugs (oral or injected/I.V., bisphosphonate or biologic) but instead take supplements and do ballistic exercise. My orthopod says weightbearing exercise is fine, but ballistic (impact) exercise is verboten: likely to loosen my knee implants before their time and necessitate revision surgery, with all its risks of DVT and infection. And a renowned bone specialist at the U. of C. whom I’d e-mailed, said adamantly “doing nothing is not an option.” I think I will pay for a consult with the latter--since he is a leader in the treatment of osteopenia & osteoporosis, a letter from him demanding coverage for Prolia would carry far more weight with my Part D carrier (or even--should he insist I get it injected under observation and supervision--as a “treatment” a la Zometa under my Part B supplement carrier).

Quinn - The TC regimen is Taxotere/Cytoxan, not Taxol and Cytoxan. Taxotere is a more potent dosing of taxane drug and is more like a dose dense version of Taxol. AC-T is Adriamycin/Cytoxan/Taxol, which is commonly given. You will sometimes see TAC given, but it is a more unusual combination of Taxotere, Adriamycin and Cytoxan and not as commonly given due to the intensity of both Adriamycin and Taxotere.

After reading that I am now wondering. I was given choice between TCAnd ACT I chose TC regimen. I was worried about heart issues from ACT. Family history. Would they have offered a regimen to choose if they thought I should have only had ACT?? Can you be in the middle or gray areas for regimen of chemo ? I have always continued to wonder and there were so many times I would bring up grade 3. 1 Node positive and Lvi present. Just kept being told its small. Great margins. We got it all. Don't focus on that.

SpecialK. Thanks for responding. I can tell you not a day goes by that I don't struggle with this and it seems to get worse the further I get from diagnosis. Do MO's normally give choices to patients who know nothing.

btw- there is a class action lawsuit that is soliciting class members for those who had permanent hair loss from Taxotere.

ThinkingPositive If there was one area I don't feel I got enough info on pre-chemo was SEs. Or I was too much in shock to absorb much of what was said or be my best advocate, at that time. If I had heard the heart issues in the manner you did, I think I would have been alarmed and drilled down on that one. I know later in chemo I remember researching the topic. It's hard to know, if I was even presented with a choice (I was not), what I would have done given my MO at OHSU said it was the second highest oncoscore he had ever seen.

I totally respect your choice Meow! I wish I had had my thinking more together, especially about Taxol as it has had a lasting affect on me. At least stopping it after the 2nd dose.

Oncoscore 39. IDC; 1.4 cm; Grade 3 (8/9 Nottingham - tubular got a 2). No LVI. 0/1 SNB. No node involvement. Brca2+ ER+PR+ (barely) Her2- on FISH. Ki67 60%+ (The MO didn't consider Ki67...that was done at the biopsy lab elsewhere.)

I had the AC/T then C in 2012. I only found one other woman that would have gotten that combo, here, but she had ovarian cancer and Carboplatin 15 years previous, so could not get carobplatin again (at Dana Farber). Another brca woman was going to MD Anderson and asked about it and they said no - not protocol. I'm please to hear that my MO was ahead of the curve on the Carboplatin in my situ (he admitted he was "going off the reservation"), but curious when did this become more routine for TN? In my case, not TN, but brca got me the Carboplatin.

lisey - the only information you will get from Mammaprint is a high or low classification, there is no intermediate or middle ground - that is why some oncologists like to use it as a tie breaker when you have an intermediate result on Oncotype. You will also receive a reconfirmation of your hormonal receptors and Her2 status. There is no specific recommendation about a chemo regimen included in the testing, that decision should be made by your oncologist based on all of your testing and pathology. My guess on why your MO is recommending TCx4 is because you have a small tumor, node negative, intermediate grade, and had a mastectomy. The crap shoot of chemo has to be a weighing of potential benefit versus potential harm. If your tumor was larger, you had node involvement, a higher grade, or were TN or Her2+ a more complex regimen of three drugs and a longer course of treatment might be warranted.

Here is a link to what a sample Mammaprint report looks like:

http://www.agendia.com/wp-content/uploads/2013/05/AGE594_US_Mamma_Under61_lowV2_UPDATED.pdf

SpecialK, can you tell me if the tumor cell percentage shown on the mammaprint is the same thing as the K167 on the pathology report. Thanks.

Quinn - here is some Carboplatin info:

http://www.medpagetoday.com/hematologyoncology/breastcancer/50925

http://www.breastcancer.org/research-news/triple-negative-may-have-new-tx-option

lisey - it is not that the Mammaprint is not as exact, it is that it is imparting slightly different information to a broader population of patients - it is an apples and oranges situation to some extent. Mammaprint looks at a much larger genetic profile than Oncotype, is less focused on receptors, but will give you definitive subtype info - not sure that would be worth the cost unless it was done instead of Oncotype if you have to pay out of pocket. Keep in mind that looking at mitosis or Ki67 are snapshots - on that slide or sample, not necessarily the whole tumor. That is why grade as a whole, node status, tumor size, etc should be considered factors. Also, important to note that endocrine therapy may offer more benefit than chemo for your stats. Did your MO run any numbers through Adjuvent or any other calculators to show you benefit percentages

Lisey - Have you considered a second opinion on the pathology? Johns Hopkibs will do it for a few hundred $$.