Tumor Shrinkage, "Cure", Extending Life

Hi FormyMIL:

Here in the US, we have clinical consensus guidelines issued by professional organizations, such as NCCN and ASCO. Other countries may have their own local guidelines. (Patient-focused materials may not reflect the content of the most recent professional versions.) Guidelines and clinical trial publications from the scientific literature can provide useful background information, but they are not a substitute for current, case-specific expert professional medical advice from a Radiation Oncologist ("RO") and Medical Oncologist ("MO").

Benefit is often proportional to individual risk, so individualized risk/ benefit analyses are the norm. Her RO and MO should be able to provide estimates of relevant recurrence risks and the risk reduction benefit of any recommended radiation or drug regimen. She should be able to understand her risk profile with or without certain treatments. She should also understand the primary benefit of each treatment (e.g., radiation is primarily a local treatment). They should discuss side effect profiles, and help her weigh the incidence of severe adverse effects against potential benefit.

She can inquire whether there is clinical evidence for a survival benefit (e.g., breast cancer-specific survival; overall survival) with such treatments in patients with similar disease features. But for many of us, extending recurrence-free survival may add significantly to quality of life. Early stage breast cancer is treated with curative intent and often with success. However, should disease progress and the patient suffer distant metastatic recurrence, this often significantly impacts life expectancy. In addition, while metastatic disease is treatable, it is not curable, so they may face continuous treatment to control disease.

As noted above, with early stage breast cancer, in those who receive surgery first, the recommended loco-regional and systemic treatments depend on a variety of clinical and pathologic factors.

For example, clinical consensus guidelines from the National Comprehensive Cancer Network (NCCN) provide differing recommendations regarding use of systemic drug treatments (i.e., chemotherapy; HER2-targeted therapy (for HER2-positive disease); and/or endocrine therapy (e.g., for hormone receptor-positive disease) based on factors such as tumor histology (ductal, lobular, etcetera); tumor size; lymph node status; and estrogen receptor (ER), progesterone receptor (PR), and HER2 status. However, clinicians may consider additional factors, such as grade and presence of lymphovascular invasion in decisions. In the appropriate case, in some countries, the results of an additional prognostic test, such as the OncotypeDX test, MammaPrint test (plus BluePrint test), or Prosigna test, will be considered, as will certain clinical factors of patient presentation and medical history, such as age and any relevant co-morbidities.

NCCN guidelines for breast cancer are available at no cost with free registration here:

https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Radiation therapy in various situations is also addressed. In the current version (Version 2.2017), the "treatment algorithms" up front have been recently updated, but conforming revisions in the accompanying Discussion section have not yet been made (i.e., the Discussion section is out of date in some respects). They are updated frequently, so be sure to check for new versions each time.

ASCO promulgates guidelines on a variety of subjects:

Main page: https://www.asco.org/practice-guidelines/quality-guidelines/guidelines/breast-cancer

For those with Stage I or II invasive breast cancer treated with breast-consering surgery plus whole breast irradiation, ASCO endorsed an SSO/ASTRO guideline with some qualifications:

ASCO (2014): Buchholz (2014), "Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stage I and II Invasive Breast Cancer: American Society of Clinical Oncology Endorsement of the Society of Surgical Oncology/American Society for Radiation Oncology Consensus Guideline"

http://ascopubs.org/doi/pdf/10.1200/jco.2014.55.1572

SSO/ASTRO (2014): Moran (2014): "Society of Surgical Oncology–American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer"

http://ascopubs.org/doi/pdf/10.1200/JCO.2013.53.3935

Different ASCO guidelines apply to radiation in the mastectomy setting and the DCIS setting.

When first diagnosed, I confess that I spent a good deal of time reading publications and material that I later came to appreciate were not applicable to my particular situation. Guidelines address what is done in the general case, but there may be appropriate exceptions to what is provided. In addition, guidelines represent snapshots in time, and there may be additional and/or more recent and/or conflicting studies available that should be considered. It is difficult to absorb large amounts of information, and easy to misunderstand highly technical documents, including whether and how the findings should be applied in the individual case. Therefore, if a document influences your thinking in any way, it is essential to confirm your understanding, as well as currency and proper application to her case, with her RO and MO.

When in doubt about a recommended treatment plan, perhaps the best way to probe medical advice (assuming there is time) is to seek a second opinion at an independent institution. This may include a review of all imaging, pathology results, and related testing to date (with physical slides sent overnight); and consultation with a medical oncologist and radiation oncologist.

BarredOwl