Onco score 10 and no chemo or rads but still worried!!!

Hi Aysh1005:

The indications for loco-regional treatment with radiation after lumpectomy versus mastectomy are not the same. So, if instead of a re-excision you are having a mastectomy shortly, then you may not need radiation. Many (but not all) patients with DCIS and/or invasive disease who receive mastectomy can avoid post-mastectomy radiation. Having negative nodes is one factor already in your favor. Sending good wishes for wide margins.

I am assuming by Onco score, that you are referring to the OncotypeDX test for invasive breast cancer. It is used to inform decision-making about systemic treatments, and specifically whether to add chemotherapy to five years of endocrine therapy.*** (The features of the DCIS (e.g., size, solid) are not relevant to this question, because DCIS is non-invasive and so is not treated with systemic chemotherapy.)

An Oncotype Recurrence Score of 10 for node-negative, invasive disease is quite favorable. Will you be seeing the Medical Oncologist after the full pathology from mastectomy is available? In any event, don't hesitate to ask your medical oncologist for an explanation of how to view the information from the Oncotype test together with various pathology findings for the invasive disease (e.g., grade, degree of vascular invasion).

Meanwhile, if you'd like to read about the 5-year results from the prospective TAILORx trial for patients with node-negative (N0) disease and a Recurrence Score from 0 to 10, please see this relatively recent publication:

Sparano (2015), "Prospective Validation of a 21-Gene Expression Assay in Breast Cancer"

http://www.nejm.org/doi/full/10.1056/NEJMoa1510764#t=article

PDF version: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1510764

Best,

BarredOwl

*** There is another Oncotype test that is used in those with pure DCIS (with no evidence of invasion) following breast conserving therapy (lumpectomy). It is used to inform decisions about radiation. It is not used in patients with invasive disease or in those receiving mastectomy.

Hi Aysh1005:

It sounds like there may be concerns for both the posterior (chest) and anterior (near implant) margins? "At the chest wall" isn't very clear. You may wish to ask if there is some small distance between where the posterior margin was (formerly) located in the breast and the chest muscle fascia, and if the posterior margin might be improved by mastectomy. The final post-mastectomy margin sizes are the ones that will be used for treatment decisions.

In any case, after the mastectomy, with full information about all final margins, you can request a consultation with a Radiation Oncologist. The question of post-mastectomy radiation is specialized and fact-specific. The Radiation Oncologist can help you to understand your potential local recurrence risk (in light of all information) and the potential risk reduction benefit in your case.

In general, radiation can provide a relative risk reduction for local recurrence of around 50%, but the size of the benefit for each individual depends on their level of risk. For example, if a person's local recurrence risk was relatively small (e.g., ~5%- 6%), then the absolute benefit of radiation would be commensurately small (2.5% to 3% benefit), and may or may not be seen to outweigh the risks. Different patients may view this differently, based on their personal risk tolerance.

In addition to reducing the potential risk of distant recurrence, tamoxifen may reduce the risk of local recurrence (invasive or non-invasive) in the same breast, as well as the incidence of new disease in the opposite breast. This is the area of expertise of the Medical Oncologist. Your team should be able to help you understand the local benefits of individual or combined treatments (radiation, endocrine therapy).

As noted above, some patients may receive a recommendation for an ovarian suppression drug in addition to either tamoxifen or an aromatase inhibitor. (In pre-menopausal patients who have intact ovaries, aromatase inhibitors cannot be used without an ovarian suppression drug.) Selection of a specific approach to endocrine therapy is a specialized, case-specific question for your medical oncologist. I note that our local ASCO guidelines do not recommend ovarian suppression in certain lower risk scenarios:

2016 ASCO Update re Ovarian Suppression: http://ascopubs.org/doi/pdf/10.1200/JCO.2015.65.9573

There are probably local guidelines in the UK, and they may differ in some ways. There may be appropriate exceptions to what guidelines provide in the individual case, so do not hesitate to seek current case-specific, expert professional advice regarding all appropriate options for endocrine therapy in your case.

BarredOwl