Luminal A vs. Luminal B stage 1 BC

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  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    Good point Special K... I'm so focused in, I forget us younger women are more rare.

  • SpecialK
    SpecialK Member Posts: 16,486
    edited July 2016

    Lisey - no worries! Just as they say on airplanes - "put on your own oxygen mask and insure it is working properly before assisting others", it is how we all are when newly diagnosed and in the middle of treatment, totally the norm!

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    SpecialK and others, have you heard of the blueprint test? Basically, if you get that along with the mammaprint, you will know your subtyping as well as your chance of reoccurance. I found this graph very interesting - look what happens to the Luminal B folks at year 5.

    Here's a link that discusses that with the blueprint/mammoprint test you'll know immediately if you are an A or B and can make chemo decisions based on that rather than your stage.

    http://www.agendia.com/response-and-long-term-outcomes-after-neo-adjuvant-chemotherapy-pooled-dataset-of-patients-stratified-by-molecular-subtyping-using-mammaprint-and-blueprint/

    image

  • QuinnCat
    QuinnCat Member Posts: 3,456
    edited July 2016

    DMFS = Distant Metasis-Free Survival

    The way I read that graph, I would want it to eventually flatline as in the Basal, which makes sense because I know the risk for recurrence of TN is highest the first 3 years, then goes down precipitously after that. I would want to see a little more of that flat line for Luminal B and Her2 + also.

    Is that how you read that chart?

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    kayb:

    Thanks for pointing out that the linked study is in the neoadjuvant setting, and the provider is suggesting that their molecular sub-typing can improve the stratification of patients in the neoadjuvant setting. Typically, one would want to see a separate study in the adjuvant setting (the setting that Lisey is in).

    For more information about the test suite from Agendia (MammaPrint, BluePrint, TargetPrint) which I mentioned on page 6 of this thread, see the Physician's Brochure here:

    http://www.agendia.com/media/M-ROW-010-V2_Breast-Cancer-Suite-Physicians-Brochure.pdf

    Lisey:

    I am not sure I understand exactly how BluePrint test results are used or the value in the adjuvant setting. The brochure seems to be saying there are three possible sub-types (Basal-type; Luminal-type; and HER2-type) with BluePrint. In the case of Luminal-type, it appears that the MammaPrint result (High Risk or Low Risk) is used to suggest a clinical course more similar to luminal A or luminal B:

    "A Luminal-type BluePrint result means that the tumor phenotype most closely resembles the Luminal-type intrinsic subtype.

    Patients classified as MammaPrint Low Risk and Luminal-type can be expected to have a clinical course similar to luminal A, usually treated with hormonal therapy, whereas those with a MammaPrint High Risk and Luminal-type, can be expected to have a clinical course similar to luminal B patients who usually benefit from more aggressive treatment which may include chemotherapy."

    Uninformed Layperson Speculation: Unless there is a reasonable possibility that BluePrint would serve up a surprise sub-type (Basal-type or Her2-type) (and I have no clue whether it could or not), then in your case, wouldn't the High risk or Low risk output from the MammaPrint be all you need to answer your question about recurrence risk being more akin to luminal A or B? I don't know. Seems like a question for an expert MO.

    I have not investigated the quality of validation of BluePrint (or lack thereof) for any purpose. In my personal opinion, patients considering these tests should consult with an expert Medical Oncologist with experience in using them, who keeps current with the relevant validation studies (and guidelines), and can appropriately advise one whether the tests could provide information of value in your specific case, and are sufficiently validated in the setting applicable to your case to inform your decision-making or not.

    BarredOwl

  • DaraB
    DaraB Member Posts: 945
    edited July 2016

    Has anyone had experience with the Prosthigna genome test? My onco score came back intermediate and my MO is ordering this test and said it would also give info regarding Luminal A or B to help make the decision re chemo or not. Thanks.

  • DaraB
    DaraB Member Posts: 945
    edited July 2016

    Sorry, Prosigna not Prosthigna.

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    Hi kayb:

    Just wanted to clarify I was saying that that particular study is in the neoadjuvant setting, and it's particular findings may not apply to those receiving adjuvant treatment. There may be other studies of BluePrint in the adjuvant setting.

    MammaPrint is used (and validated) in the adjuvant setting. BluePrint and TargetPrint can be ordered in parallel, although my sense is that they are not quite as extensively validated as MammaPrint.

    BarredOwl

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    See this is why I post.. because it spares me expensive test that won't help. :) I wrote my Onc nurse a message saying nevermind on the blueprint, just the mammaprint. Thank you. As a question, from what I'm reading, does that mean some TNs could be Luminal A-like? Am I reading this correctly that they say some TNs don't need chemo? really?

    In the Luminal A-type group (n = 90; including seven HER2-positive patients and eight triple-negative patients by IHC/FISH), the 5-year DMFS rate was 93 %. The pCR rate provided no prognostic information, suggesting these patients may not benefit from chemotherapy

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    Hi Lisey:

    The summary you linked to (from a neoadjuvant study) refers to "Luminal A-type (MammaPrint Low Risk)" and to "Luminal A-type group (n = 90; including seven HER2-positive patients and eight triple-negative patients by IHC/FISH)".

    That seems to suggest that the combined information from BluePrint and MammaPrint indicated that certain HER2+ and triple-negative patients (as assessed by standard IHC and FISH methods) are more Luminal A-like according to the microarray-based tests. I do not think that this study is sufficient to alter treatment decisions in such patients (not sufficiently validated).

    As I said above, I do not know whether a person with hormone receptor-positive, HER2-negative disease similarly has some chance of being "re-classified" to something other than Luminal-type by these tests.

    It is very easy to misunderstand by looking at summaries, and what seems intuitive may not be what happens in practice. Please ask your MO whether BluePrint could provide any useful information in your case in addition to MammaPrint to ensure you receive accurate expert medical advice.

    BarredOwl

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    My Onc never emails me back.. only her nurse does and she basically just acts as an operator. Every time I ask for a test, they do it if I"m willing to pay out of pocket or suggest it's not needed, when I feel it is - like the mammaprint. That was my idea in the first place given my low PR+ levels and higher Ki... The doc is only doing it to humor me, so she's not going to suggest the Blueprint, even if it would yield more info. She's convinced I don't need chemo and says she'll see me in 3 months. That's a wrap folks to her... So really that's why I ask you guys a lot of questions because my Onc really isn't the inquistive type.

    Also, I don't have 'team'... I have no one but the Oncologist and her nurse. I don't even have a PCP (I do, but haven't seen her in years)... so Im kind of on my own.

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    Hi Lisey:

    I've edited my last post a few times.

    Is a second opinion with another MO at an independent institution an option for you?

    BarredOwl

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    Unfortunately not. We are with Kaiser, and they've been timely and efficient so far.. but not very communicative at all. Honestly, I think I'll be better when I know as much as I can about my DNA type of tumor, waiting for the mammoprint is hard, but if that tells me the Luminal A / B question then I'm good.... Just need that final reassurence not doing chemo is the right choice.

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    Lisey:

    The output of the MammaPrint test is a MammaPrint Index ("MPI") and a binary assignment of either "High risk" or "Low risk". No written information I have seen about MammaPrint alone says that these outputs (MPI and risk assignment) can be used to assign subtype (in the absence of a second test).

    So, I do not know whether the MammaPrint alone can give you the answer regarding Luminal A/B or not. It is entirely possible that it cannot. That was a question I was asking above, not a statement.

    The second question I asked was: Is it highly likely that BluePrint would yield a Luminal-type result in your case? I simply do not know one way or the other. Again, what might seem logical in cancer treatment, is not always the case. As you pointed out, BluePrint sub-type does not always match up with IHC/FISH, at least for some HER2+ and triple-negative cases.

    I am a layperson with no medical training, never had either test, and professional input is essential to making the most informed decision. When that is not easy to access, it places patients in a real bind.

    BarredOwl

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    Well, I already emailed the nurse and told her nevermind, so I guess I'll take my chances on just the Mammaprint. I mean that test alone is $4200... I started having panic attacks of them charging me $8400 for both. The Onc Nurse says once Kaiser declines paying for the test, they will reduce it down to $500, but that may not be the case with the Blueprint, and honestly I have nothing in writing so I'm prepared to pay the $4200... But I need to save some cash if I do the chemo for the cold caps, so I suppose I've been looking for an excuse to cancel the Blueprint, just needed others to echo my thoughts. I'll go by the mammaprint results, The onc is betting it's low... praying it is. sigh.

  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2016

    I'll add my prayers to yours for a low risk result.

    BarredOwl

  • Moondust
    Moondust Member Posts: 510
    edited July 2016

    Lisey, I know that some of the big BC places will do online second opinions for way less than $4200. I think less than $1000. I don't have the names of the ones that do it at hand and no time to google, but please look into it.

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    Moondust, the $4200 is the cost of the mammoprint, which I hopefully won't have to pay.. but am prepared for it if I do. It's not for a 2nd opinion, but another DNA test since my oncotype was 20

  • She
    She Member Posts: 503
    edited July 2016

    Lisey, forgive me if I'm asking questions you've already answered as I haven't read every page of this thread. Factors also assessed when considering chemo are lymphovascular invasion and post surgical margins.

    Did you have vascular invasion (direct blood supply to tumour) and/or lymphatic invasion (again direct supply to the tumour)?

    Did you have clear margins? (No cancer cells on pathological inspection of the outside margins of the tissue & tumour removed).

    Based on your posted stats for tumour size, node status and grade, if your margins were clear and you didn't have lymphovascular invasion; and both ER and PR are considered positive you would meet the criteria for tamoxifen (premeno) or AI (post meno), not chemo. Obviously your PR status is the wild card here and I too would recommend a second opinion.

    I was diagnosed Luminal B metastatic a year ago. I had a very rare form so treatment recommendations weren't standard. Ultimately my choice was tamoxifen. Yes, I found all the studies that say it's ineffective for Luminal B but my onc is way ahead of me. Tamoxifen is being successfully used subsequent to surgical intervention, to (best case) prevent recurrence, or at least lengthen the timeperiod between recurrences. There's also a new drug in trials that increases tamoxifen's efficacy in Luminal B treatment (of course I've forgotten the name). I hope this info provides you a little confidence and comfort with the tamox as you ultimately sort out your PR status to define Luminal A or B.

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    She, I welcome any advice you give.. obviously, the typical disclaimers we are laywomen apply. :) I had no LVI, and good deep margins >3cm from chest wall and 1cm from nipple/skin. My Mitosis is 1, Tubules 3, and Nuclei 2 = 6 / Grade 2. My age is younger 41 and my Biopsy ER+ 90% / PR+ 5%... My Oncotype threw me, that was a 20, and the Oncotype showed different ER/PR percentages on my actual tumor, and while they don't use the oncotype for percentages, it lowered my ER down a little and bumped up my PR a little. My Ki-67 on the tumor was 30-35%, but the oncologist said that could be due to healing wounds on the biopsy so she wasn't as concerned as I was, since Ki of that level is high! I think my Oncotype is high due to my age, the ki, and the low PR... but that to me, signals Luminal B, though my doc disagrees.

    So I told her I just can't make a decision based on that limited info and requested the Mammaprint to get me out of the intermediate. She ordered it but warned me Kaiser would refuse since they did the Oncotype...

    I want to believe in my Drs optimism, I'm just a fact person and want numbers, not bets and gut feelings.

    (edited because I type too fast.)

  • gerrib
    gerrib Member Posts: 163
    edited July 2016

    I think I am in a similar position to lisey. Today I have travelled 400km to get 2nd opinion in Melbourne Australia.

    The questions I have for This MO are

    Survival stats. I have been given 5 years 90%disease free with chemo and 85%without With those stats I was happy to go without chemo. But the more I have read the more it sounds like I have had luminal b. Er 30%,pr neg ki67 20%. It was ILC and grew while I was on tamoxifen.

    I am typing this on tiny phone so apologies for typos

    What questions would you suggest for my consultation today. I am 65

    I am on arimidex and had umx 4 months ago. Have paid for holiday in Italy in October so don't know what I'll do if chemo is her recommendation. Don't know if it is too late.

    2nd occurrence.

    No oncotype tests here

    Thanks

    Gerri

  • Optimist52
    Optimist52 Member Posts: 302
    edited July 2016

    gerrib, just wanted to say that I had Oncotype DX test done a year ago in New Zealand. The actual test was done in Australia, can't remember where. I had to pay AU$5000, med. insurance wouldn't cover it. So I believe it is available in Australia but you may have to pay and I realise it's a lot of money.

    Lisey, my stats are worse than yours and my Oncotype DX result was 22. My MO was quite certain that chemo wouldn't be worth it for me with that score. By the way, my two affected nodes were isolated tumour cells and two doctors I've seen told me they regard them as being node negative (which was a great relief to me).


  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    Thanks Optimist! I have 3 little kiddos to raise here... gotta stay in the picture at least 20 years! (Plus I had Melanoma Stage 1A six years ago, so this is my second damn cancer. Told the hubby I felt like a dud)

  • Nancy2581
    Nancy2581 Member Posts: 1,234
    edited July 2016

    you're no dud Lisey lol

  • She
    She Member Posts: 503
    edited July 2016

    Lisey I considered oncotype with my third primary. I can't remember if it was my Onc or the Oncotype folks themselves that told me most of the results were falling into the grey area just below the high range and it ultimately ended up being an individual's personal decision rather than a recommendation. I'd already had tamoxifen so I decided it wasn't worth the money in my case.

    With the Luminal B dx the board said they believed I could tolerate more AC but they didn't feel it was the optimum treatment.

    Have you tried searching chemo criteria for Luminal B? I haven't bothered for myself, but I did find a few white papers on LB and tamox, only problem is they were outdated. I really think a second opinion is your best option.

    Have you started your own personal cancer file? It's very wise to get copies of your reports, scans, bloodwork etc and organize them in a binder. I've even graphed different results and put the graphs in my oncs file for easy viewing of historical data. A single page visual is so much easier than reading through page after page in a file.

    Breast Cancer. The unexpected career change that pays volunteer wages.

    PS You're not a dud, I'm a BC Petrie dish lol and my typing skills ... gone.

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    I've decided that if I"m Luminal B, I'll get OS and AI, rather than Tamox. Another poster posted a very detailed study showing that AI was equally effective with Luminal A or B... whereas Tamox isn't.

  • gerrib
    gerrib Member Posts: 163
    edited July 2016

    Well had my appt for 2nd opinion and she confirmed all my own thoughts. Now have 30% chance distant recurrence in next 3 years, because of Pleomorphic, ILC, Pr neg and weakly er +. Too late for chemo. Nice to meet someone who acknowledged my concerns. She would have recommended chemo.

  • Lisey
    Lisey Member Posts: 1,053
    edited July 2016

    why is it too late for chemo Gerri?

  • cp418
    cp418 Member Posts: 7,079
    edited July 2016

    Interesting article regarding ki67 and p53 expression for Luminal A.

    http://journals.plos.org/plosone/article?id=10.137...

    I came across another article which mentioned tumors can be of mixed type and switch between luminal A vs B.


  • SpecialK
    SpecialK Member Posts: 16,486
    edited July 2016

    lisey - there is an optimal window for adjuvant chemotherapy.

    http://www.breastcancer.org/research-news/20140220-4

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