Oncotype 24, indecisive on chemo, please help

so hard to advise you. I think really is up to you. Personally at 53 I chose no chemo and my oncodx was 34.

Mimi, Honestly, you need to know more than just the basics to decide. I'm learning that genetic testing is important when we are in the gray area and You really need to find out your Ki67 level as well. I want a black and white answer so I'm getting the mammoprint to remove the intermediate of the Oncotype, and I'm also getting a Blueprint (same company as mammoprint) to determine if I'm Luminal A or B through genetic testing of the tumor / cut and dry.. no guessing.. If you are following some of the oncotype threads, you'll see that there are a ton of variables in determining if chemo is appropriate.

For example: Ki level? Mitosis level within the grade? How ER+ /PR+ are you? (if you are low PR+ that is more concerning than a higher PR+), Luminal A vs. B, Tamoxifen or AI with OS? What were your margins from surgery? LVI? Do you have chemo limiting diseases/issues?

There's new tests coming out all the time, that are honing in people who benefit from chemo or not. I would suggest looking into your path report and getting more details from your doc.

Back in 09, I had a postive node and an oncotype of 22. It was sort of assumed I would do chemo. I just couldn't get myself there. I had a deep sense that something was wrong, I felt like a gun was pointed to my head. It was December during the big conference. Oncotype came out with a press release that for node positive intermediates, there was no statistical proof of chemo benefit.

That was it for me. It was a hard call. Later on my PS and someone else at my cancer center told me I had made the right decision. About a year ago a fellow asked me how I made that choice because in 09 it was the cutting edge.

Don't get me wrong, I had to learn to live with having a 14% chance of mets. But it just wasn't the right choice for me. I sometimes struggle with a learning disability at work and chemo brain would have maybe been the end of doing my job.

I will say this, the benefit on the node postive choice for chemo kicks in at 20.5. So that tiny slice of triangle wasn't enough for me. At 24 chemo does have a bit more benefit.

Honestly you could flip a coin and that would be ok too. I actually did flip one.

My Ki67 was 30-35%, my mitosis =1, Er=95%, pr=5%, same other stats as you... and my Oncotype was 20. I'm getting a mammoprint and blueprint, as well (waiting on results). My decision is no chemo. If the mammoprint comes back back and blueprint says I have luminal B (which with your high PR, you wouldn't have), I'll switch Tamox to an OS + AI, since it's equally effective with Luminal A and B. You can always use chemo a second time if it comes back... I guess I"m saving that weapon for the future. Lumiinals take a while to return typically, so I'm counting on new research at that point that will have better treatment options than poison. I also had melanoma that needs an immune system to keep it in check.. so no poison for me yet. I'm younger - 41.. with 3 little kiddos.

Mimi, please let us know what you decide. Also, there are a lot paths to becoming a mom. You could still have a little one yet.

KBeee.. how is it that you were a Stage 1B but had no nodes 2013? I"m confused. If you had no nodes, then you'd be a 1A with that size tumor.

As for the chemo, some studies have shown that certain subsets of early stage Luminal A are not helped with chemo, so it's harmful because there's no benefit and the SEs are dangerous. See: http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=804#.V5UVZ7grLRY

To me, waiting for the subset info on the blueprint will make a big difference in how I proceed. I know Tamoxifen isn't processed well with Luminal B (low PR / high Ki etc) and if blueprint says I'm Luminal B, I'd immediately get the hysterectomy / Ooph and go with an AI. AI's have been shown to be equally effective with Luminal A / B, so that would help a lot I think. I think throwing the book at it, can actually make matters worse for some cancers, and open doors to new ones. I tend to believe immunology is going to be replacing chemo fairly shortly. Genetics is the way to go in making educated decisions, as you get to understand exactly how your tumor functions and what treatments work best for it.

For example, a TN woman posted this list of subtypes for TN... Look at the differences. You could have 6 TNs all in the same stage / size / stats everything, but the cancers need to be treated differently. The same applies to Luminal A and Luminal B. There is no longer a one size fits all when it comes to stage and chemo.

https://www.jci.org/articles/view/45014

Cluster analysis identified 6 TNBC subtypes displaying unique GE and ontologies, including 2 basal-like (BL1 and BL2), an immunomodulatory (IM), a mesenchymal (M), a mesenchymal stem–like (MSL), and a luminal androgen receptor (LAR) subtype.

BL1 and BL2 subtypes had higher expression of cell cycle and DNA damage response genes, and representative cell lines preferentially responded to cisplatin.

M and MSL subtypes were enriched in GE for epithelial-mesenchymal transition, and growth factor pathways and cell models responded to NVP-BEZ235 (a PI3K/mTOR inhibitor) and dasatinib (an abl/src inhibitor).

The LAR subtype includes patients with decreased relapse-free survival and was characterized by androgen receptor (AR) signaling. LAR cell lines were uniquely sensitive to bicalutamide (an AR antagonist).

My Oncotype was 23. After surgery, I was Stage 1, Grade 3 ER/PR+, HER2-. Although chemo only lowered my recurrence rate by another +/- 4%, I wanted to feel like I had done all that I could do to prevent a recurrence.

My prayers are that it never comes back, but if it does, I will face that then.

No one can make the decision for you, but I hope that reading other people's stories will make the choice a bit easier.

Lisey, Different doctors use different staging guidelines; they are not all consistent (which is why one doctor may tell you one thing and another doctor tell you a different stage). My doctor uses the one similar to John Hopkins. http://pathology.jhu.edu/breast/staging.php My tumor was 1.9 cm, so that put me at Pt1c, and they always just said I was stage 1c.

They staged me at pT1c, Pn0, pMX in 2013. In 2015, they did not stage me at all because there was no imaging on my tumor and it was taken out in small chunks. Bottom line is, as you can see, just because it's stage 1, node negative and you throw the book at it, cancer sometimes does what cancer wants and comes back. I have no regrets though and would not change anything about how I treated the cancer the first or second time. It's what I felt was best for me at the time.

Hi Kbeee:

John's Hopkins appears to use AJCC staging criteria ("TNM"), like most places in the US. There is no Stage IC in the AJCC system. "T1c" is a size indicator only, corresponding to the size component "T" in the "TNM" staging system. Size-wise, Stage I tumors can be "T0" (quite rare) or "T1" (most common). "T1" is a broad size category that can be further broken down as follows:

T1 Tumor ≤ 20 mm in greatest dimension, including any one of the following:

T1mi Tumor ≤ 1 mm in greatest dimension

T1a Tumor > 1 mm but ≤ 5 mm in greatest dimension

T1b Tumor > 5 mm but ≤ 10 mm in greatest dimension

T1c Tumor > 10 mm but ≤ 20 mm in greatest dimension

Under the AJCC staging system (assuming lymph node involvement has not been detected by imaging studies (excluding lymphoscintigraphy) or not detected by clinical examination), a tumor that is "pT1" in size (including any of T1mi, T1a, T1b, or T1c) and that is pN0 M0 is considered Stage IA. See for example line 2 of the Anatomic Stage/Prognostic Groups chart at page 1, bottom, center of this summary of the comprehensive AJCC staging manual:

https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf

Under AJCC staging criteria, Stage IB requires limited lymph node involvement, specifically pN1mi (See lines 3 and 4 of the chart):

pN1mi Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm))

Pathologic staging is within the area of expertise of pathologists, and other professionals may be less well-versed in the assignment of pathological stage, because they are more focused on the clinical implications of the component parts (size and nodal status).

BarredOwl

As others have pointed out harvesting eggs before chemo is an option. You can either freeze them as eggs, or have IVF done to freeze as embryos. In most cases you will end up with something to freeze Unfortunately in my case my eggs were immature when harvested (not sure if a timing issue, or my body issue), which really set me back for deciding on chemo because I so much wanted to have children. I ended up deciding on chemo (without an Oncotype test as it was not covered at the time) out of fear. My periods did come back about 10 months after chemo while on tamoxifen. My original tumour (unfortunately I am now dealing with a recurrence despite the chemo but I did stop the tamoxifen early to try to conceive again) had "lymphatic space invasion" despite being lymph node negative - that was a factor in their recommending chemo to me.

velo- I am sorry to know yr story. Fortunately a friend of mine froze her eggs in invitro clinic and we do hope she will be undergoing ivf treatment soon in Gdansk

Misty,

Mammaprint has now been validated by the Mindact trial as having significant ability to determine who should have chemo. See: http://www.agendia.com/new-england-journal-of-medi...

With that, another study shows that many intermediate oncotypes are low risk via mammaprint. http://www.agendia.com/new-data-shows-agendias-mammaprint-can-prevent-under-and-over-treatment-of-breast-cancer-patients-with-an-intermediateindeterminate-oncotypedx-recurrence-score/

Of the 840 intermediate risk patients, MammaPrint reclassified 55% (466) of these patients as High Risk and 45% (374) as Low Risk of the individual's cancer recurring. No correlation between definitive MammaPrint results or the indeterminate 21-gene assay Recurrence Score could be identified, reinforcing the discordance between these assays and inability to use the results interchangeably. MammaPrint was shown to provide additional prognostic information independent from clinicopathological factors to support the treatment decision.

I'm very grateful I got the second opinion as I could have gone the other way as well and needed chemo. Mammaprint made my decision.

My BS has never ordered a Mammaprint or a blueprint test and is very unfamiliar with them. She says that he Oncotype test is the most reliable and that is the reason they only do that test. She is going to have my MO call me and discuss these tests and I'm going to see if I can get him to send out the samples for he two tests. I just want the most accurate information on my situation to help me decide if I should have chemo. My MO said it's an option due to the score of 25 on the onco test but admits there is no research to say whether or not it will benefit me. The percents I was given were that if I take no treatment at all from this point forward there is a 20-30% chance it will return. Taking tamoxifen lowers that by 50% and there will be a 10-15% chance it will return. Having ovary suppression added to that reduces it a bit more and having chemo lowers the risk of recurrence to about 5-8%. I've read a lot on here that the type of BC I have could return in 10-15-20 years and I know for a lot of women that would put them in their 60s or 70s but I'm in my 30s so that 20 year time span would only put me in my 50s. I'm scared by the uncertainty of it all but I think having the Mammaprint and blueprint tests done will make me a little less uncertain because it will mean that I have had every test done to help me make the best treatment decision. I don't want chemo but at this point I can't make a decision I am 100% confident in because I don't have all the facts about my situation. What should I do? If I tell my MO to order the tests does he have to follow my decision? I will pay for the tests if insurance won't but I want these tests done for my own peace of mind. I think my BS is just unfamiliar with these tests because it is not her area of expertise. I want these other two tests done but can a MO refuse to order these tests and if he can should I get another MO who will order these tests