If Chemo / Targeted Therapy, Why Radiation?

VLH · July 2016

I understand that radiation is a local treatment designed to prevent recurrence in the affected breast (and lymph nodes if appropriate) while chemo / targeted drug therapy is systemic treatment tackling cancer cells throughout the body. I've not been able to find anything that clearly explains why radiation is still needed after chemo and targeted therapies. Why would those drugs not tackle any remaining cancer cells in the affected breast vs. the risks of radiation, particularly when treatment is in the left breast putting the heart in some jeopardy? I've read statistics showing the value of radiation in reducing recurrences, but no breakdown reflecting whether the patients had chemo or targeted therapy before radiation. Thoughts? Perhaps references to helpful articles? Thanks!

Buttercup16 · November 2016

I am posting to bump this question. I was diagnosed stage IV from the start. I did the neoadjuvant treatment and had clean scans when done accept for the offending left breast. Insurance wouldn't approve a PET so did not know the status of the remaining lump. Had lumpectomy and got the pathology results a week ago. PCR in the lymph node and breast! My MO is not worried about recurrence in the breast and is focused on systematic treatments and recommended no radiation (in all fairness she also wanted mastectomy). Surgeon is going along with oncologist but originally wanted the radiation. Only time will tell. Plan of attack is to add perjeta back in along with tamoxifen and herceptinand wait and see how long NED holds. I also would love to know of anyone else on this path or I find there's are stats out there

Hernie · December 2016

Congratulations on PCR in your breast and node! And great on reaching NED! How did you handle the liver mets? I did not quite follow that.

I assume you will now add Herceptin, not penetration ;-)

The issue with breast radiation is whether it will increase survival. In early stage disease, it does by preventing a recurrence that could lead to mets. When you already have mets, a bump on the breast is not so threatening anymore. They are focussing on systemic treatment to protect your vital organs from attack. Have you consulted with a radiation onc? They will be able to give you all the latest stats on survival and side effects.

lintrollerderby · December 2016

To answer the original question, at least this is what was explained to me. Full disclosure: I had such a hard time with chemo that I went against medical advice and skipped radiation. Turns out, because I'm positive for a BRCA1 mutation, my MO said he was happy I declined radiation in retrospect. It was explained to me that radiation, because of its intensity, can be more effective in a given area than a systemic treatment like chemo. That's why the targeted field is where the tumor(s) was for most cases. The RO I consulted with said that in a specific focus area, radiation is much more effective at killing cancerous cells than other treatments, but since it's impossible to give the needed dosage to the whole body, patients are urged to undergo systemic treatments AND localized therapy

VLH · December 2016

Thanks, Lintrollerderby.

Lyn

Buttercup16 · December 2016

hernie I am so sorry about the typo. I didn't catch the auto correction from my phone. I did neoadjuvant taxotere, herceptin and perjeta. While getting ready for the surgery we dropped down to just herceptin so my body could heal for the surgery. Now that the surgery is done I will be adding perjeta back along with the herceptin as well as tamoxifen. The chemo took care of everything, at least for now.

VLH · December 2016

Studies suggest radiation reduces the risk of a local recurrence, but doesn't necessarily improve overall survival for my age and diagnosis. That makes it difficult to decide whether to risk the side effects of radiation. I think we're sometimes focused on the immediate and obvious side effects of skin damage (which concerns me greatly because I developed a nasty infection requiring daily IV antibiotics when a seroma was drained), but there are long term effects that can prove more problematic. I have very large breasts plus my tumor was on the left side.

Lyn

Buttercup16 · December 2016

VLH,

These decisions are so hard sometimes. I used to think that it should be so easy for someone with cancer. Meaning just take the medicine and swing for the fences. Since being diagnosed I have learned that it isn't always that simple. We want the cancer gone and want life but I also wonder sometimes at what cost. As much as I have tried to control them, there is emotions and desires that also weigh on our decisions. I have also learned that the standard of care was created based on percentages of people that could be helped in the best way possible but not every one falls into those percentages. Sometimes we end up outside the box and it can be a little lonely out there. It is hard to know when to follow a doctors recommendation and when to go with your gut. I wish I knew the percentages in my case but those things are never discussed. Maybe I need to push for them. I wish you all the best and a long and healthy outcome without the radiation!!

juststace · January 2017

thank you all for sharing.

i am triple positive IDC - i just finished 6 chemo treatments and now am waiting for a lumptectomy in 2 weeks. i have 2 oncologists. one said that if i am NED i should skip the radiation. the other said he recommends radiation. i responded really well to the chemo and herceptin- my 7cm tumor shrunk to 5mm only found with the use of the brest clip. they found at lease 3 lymph nodes in the biopsy and those seem gone via mri after the chemo....

i am very torn about whether or not to do radiation. it's hard not to let fear lead- in which case i would do the radiation but want to make the right decision for my body- long term effect and etc.

would love to hear your thoughts. thanks

stephincanada · January 2017

Hi Juststace,

There is a 2015 study that strongly suggests you should have radiation. Please see this abstract:

Relationship of omission of adjuvant radiotherapy to outcomes of locoregional control and disease-free survival in patients with or without pCR after neoadjuvant chemotherapy for breast cancer: A meta-analysis on 3481 patients from the Gepar-trials.

http://meetinglibrary.asco.org/content/146776-156

Note the conclusion: "This retrospective analysis suggests that patients managed without radiotherapy (radiation) after neoadjuvant chemotherapy for breast cancer have a significantly worse outcome even if they achieved a pCR (pathologic complete response)."

I am going through radiation right now and it is a walk in the park compared to chemo.

Good luck.

Stephanie

gracie22 · January 2017

Stephanie, I need help understanding this. From what I am getting, radiation confers an absolute benefit of about 8 or 9% in loco-regional or disease free survival. The one sentence I am not sure about is:

"In patients with pCR, the 5-yr LRFS was 95.7%% with RT vs 86.6% without RT (HR 3.32, 95% CI 1.00-11.08; p = 0.051) and 5-yr DFS was 86.9% and 56.1% (HR 3.52, 95% CI 1.82-6.83; p < 0.001). In patients without pCR, the LRFS was 88.6% with RT vs 80.7% without RT (HR 1.86, 95% CI 1.29-2.67; p < 0.001) and 5-yr DFS was 72.6% vs 65.7%; HR 1.39, 95% CI 1.07-1.81; p = 0.014)."

The bit about 86.9% and 56.1% is the only huge stat difference (30%) and I can't tell if it is a difference between rads and not rads...it does not use "vs." as the other comparative sentences do. Thanks

excerpt from study: Results: Patients in the RT-group were older and received more mastectomies. Their tumors were more likely to be HER2-positive and there was a higher rate of pathologic complete response (pCR, ypT0 ypN0). The overall risk of locoregional recurrence (LR) was 8.3% after a median follow-up of 55.9 months. RT conferred a significant benefit in terms of 5-year LR-free survival (LRFS, 90% vs. 81.5% without RT, logrank p < 0.001) and 5-year disease-free survival (DFS, 75.4% vs. 67.4%, logrank p < 0.001). The absolute advantage of RT regarding both LRFS and DFS was highest among patients with clinically positive lymph nodes at first diagnosis (HR 2.32, 95% CI 1.54-3.50; p < 0.001; HR 1.97, 95% CI 1.48-2.62; p < 0.001 respectively). In patients with pCR, the 5-yr LRFS was 95.7%% with RT vs 86.6% without RT (HR 3.32, 95% CI 1.00-11.08; p = 0.051) and 5-yr DFS was 86.9% and 56.1% (HR 3.52, 95% CI 1.82-6.83; p < 0.001). In patients without pCR, the LRFS was 88.6% with RT vs 80.7% without RT (HR 1.86, 95% CI 1.29-2.67; p < 0.001) and 5-yr DFS was 72.6% vs 65.7%; HR 1.39, 95% CI 1.07-1.81; p = 0.014). Multivariate analyses with adjustment for baseline parameters as well as for pathologic tumor stage and pCR confirmed RT as an independent prognostic factor for LRFS (HR 0.54, 95% CI 0.35-0.82; p = 0.004) and DFS (HR 0.69, 95% CI 0.51-0.93; p = 0.016). Conclusions: This retrospective analysis suggests thatpatients managed withoutRT after neoadjuvant chemotherapy for breast cancer have a significantly worse outcome even if they achieved a pCR.

Hernie · January 2017

In patients with pCR, the 5-yr LRFS was 95.7%% with RT vs 86.6% without RT (HR 3.32, 95% CI 1.00-11.08; p = 0.051) and 5-yr DFS was 86.9% with RT and 56.1% without RT (HR 3.52, 95% CI 1.82-6.83; p < 0.001).

It is hard to present this much data in text without being hypnotically repetitive. I used to write these papers for a living, for other scientists who were not neurotic word-obsessed perfectionists like me.

BarredOwl · January 2017

KB870:

Can you please clarify your diagnosis? You noted that your sentinel nodes were "clear" (0/2), yet your profile shows "Stage IB", which requires a specific degree of lymph node involvement, specifically "pN1mi" (i.e., "Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm") as shown in lines 3-4 of the Chart on page 1 of this summary:

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

A tumor that is 7 mm in size would be "T1b" in terms of size only:

T1 Tumor ≤ 20 mm in greatest dimension - includes 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

The "T" or size component (e.g., T1b) does not determine TNM stage, which also considers "N" and "M" status.

If a person is purely node-negative ("N0"), with a "T1"-size tumor (including any one of T1mi, T1a, T1b or T1c), and M0, then they would be:

pT1 N0 M0 or Stage IA.

With a T1b-sized tumor, this may be more specifically designated as: pT1b N0 M0.

Please confirm it with your team.

BarredOwl

BarredOwl · January 2017

BarredOwl

If Chemo / Targeted Therapy, Why Radiation?

Comments

Relationship of omission of adjuvant radiotherapy to outcomes of locoregional control and disease-free survival in patients with or without pCR after neoadjuvant chemotherapy for breast cancer: A meta-analysis on 3481 patients from the Gepar-trials.

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