Views on ER+ PR+ HER-ve treatment on 34 year old

Welcome to BCO. We are very sorry about your diagnosis and the concerns that have brought you here, but we are glad you found us. This is the best place on the internet for information, understanding, and support about breast cancer concerns.

Yes, the diagnosis delivery is devastating, and there is much to consider and decide in (fairly) short order.

Neoadjuvant Chemotherapy can substantially reduce a malignant tumor in the breast. One very advantageous thing about it -- with most breast cancer types, it tends to readily show (by observable results) whether the treatment is on the right track -- whether the Chemo drug (or drug combination) being used is working well in targeting the malignancy.

There are other reasons Neoadjuvant Chemotherapy might be chosen to start treatment in a particular case, besides to reduce tumor size so as possibly to permit more conservative surgery. As an example, sometimes it is chosen because of a tumor's location (or positioning) at or very near the chest wall. As another example, some especially aggressive breast cancers are ordinarily treated first with Neoadjuvant Chemotherapy.

Besides cancer type and IHC characteristics, some other factors that could weigh in a recommendation for Chemo include tumor size, tumor cell grade, lymphovascular invasion, lymph node involvement, and the patient's age. Your young age at diagnosis tends to indicate that yours might be fairly aggressive. From reference to a Breast Cancer Stage chart, I gather that tumor cells were found in one or more of your lymph nodes.

Radiation Treatment is local treatment, but Chemotherapy is systemic treatment, calculated to reach the malignant cells wherever they may be in one's body. These treatments can help to reduce the probability of recurrence.

It will help other members in making their responses if you will go to your My Diagnoses tab at your My Profile page and there fill in as much information as you have about your diagnosis, and then set the information as public in your Settings.

You always have a say in your treatment. It is fine to express your concerns and seek other opinions.

Hi BCFighter2017:

While you may decide mastectomy is right for you for a variety of reasons, please keep in mind that mastectomy is not a substitute for systemic drug treatment(s) when the risk of distant (metastatic) recurrence is considered to warrant systemic therapy.

Lumpectomy plus radiation OR mastectomy (plus post-mastectomy radiation, when indicated) provide loco-regional control.

However, for those diagnosed with invasive breast cancer (e.g., IDC, ILC), there is an additional risk of distant (metastatic) recurrence. (The estimated size of this present risk in the individual case depends on certain clinical and pathologic factors. In some cases, the results of a prognostic test (e.g., OncotypeDX, EndoPredict, Mammaprint/Blueprint, Prosigna) may be used to inform understanding of risk and decision-making.)

With invasive breast cancer, it is possible that some cells escaped the breast before treatment. Tumor cells may have travelled to distant sites through the blood stream or the lymphatic system. Surgery is not an effective treatment for cells that have already moved to distant sites. The risk of this is greater in those determined to be node-positive. However, it may occur even in patients determined to be node-negative.

Unfortunately, the presence of a few rogue cells or clusters of cells at a distant site(s) is NOT detectable by conventional tumor staging procedures (lymph node biopsy) or whole-body scans. To address the risk that such cells may persist and grow, leading to recurrent metastatic disease, systemic treatments like chemotherapy; HER2-targeted therapy (for HER2-positive disease); and/or endocrine therapy (for hormone receptor-positive disease) are recommended in the appropriate case. One or more of these may be given neoadjuvantly (pre-surgery) and/or adjuvantly (post-surgery).

Given the initial recommendation you received for neoadjuvant chemotherapy, your current team seems likely to recommend chemotherapy (neoadjuvant or adjuvant) to you regardless of choice of surgery. Please confirm it with your team, or if other factors might be considered in their recommendations for adjuvant chemotherapy.

For example, with a surgery-first treatment plan, certain patients with negative nodes or up to three positive nodes and hormone receptor-positive, HER2-negative disease may be "eligible" to receive a prognostic test, such as the OncotypeDX test. However, this type of testing is more common in those with node-negative (N0) disease or pN1mi disease, than in those with node-positive disease, in part because of the position of clinical guidelines from NCCN or ASCO regarding use of the test. The results are used to inform the question of whether to add chemotherapy to endocrine therapy. Unfortunately, these types of tests do not always provide a clear result. In the node-positive setting, the results may be given less weight in the ultimate chemotherapy recommendation.

In any case, regardless of surgery choice, with clinical Stage IIB, ER+PR+ IDC, you are quite likely to receive an additional recommendation for at least five years of endocrine therapy (e.g., if premenopausal, either Tamoxifen OR an Ovarian Suppression drug plus Tamoxifen or an Aromatase Inhibitor).

One of the best ways to probe medical advice and learn more about treatment options is to seek a second opinion. You may wish to inquire with your team regarding the recommended time-frame for starting neoadjuvant chemotherapy, or for a surgery-first treatment plan in your case, and then arrange for a timely second opinion at an independent institution. For this purpose, many look for an NCI-designated cancer center when feasible (confirm in-network):

https://www.cancer.gov/research/nci-role/cancer-centers/find

A second opinion may include a review of all imaging, pathology (actual slides are sent overnight), related test results and written reports, as well as consultation with a Breast Surgeon, Medical Oncologist and Radiation Oncologist. You may choose to pursue treatment with your current team or second opinion team.

Best,

BarredOwl

Are you choosing lumpectomy over mastectomy, or is that what the doctors are suggesting? I was 38 at diagnosis and felt strongly that I wanted a bilateral mastectomy. I had a small tumor, so lumpectomy was an option, but my doctors were ultimately ok with my choice, even though at first they tried to steer me in the direction of lumpectomy.