Should I have chemo and/or radiation? Onco score a 5.

Hi Lurline, I had a 2.5 cm tumor, micromets in one sentinel node, and an Oncotype score of 12. My oncologist said no chemo, and I got 3 different opinions on radiation and all 3 said that it wasn't worth the risk. My cancer was on the left side so I am not sure if that contributed to those recommendations. I also had a mastectomy. I didn't really feel like I was fighting the chance of recurrence until I started taking the antihormonals, but since I was 100% ER + hopefully they carry enough of a punch. I am 2 years out and doing well, but everyone has to do what they think is the best choice at the time. Don't hesitate to get a 2nd opinion. Keep usposted!

lurline...what is your menopausal status? If you are premenopausal you might want to discuss the results of the SOFT and TEXT trials. There is much research regarding ovarian suppression in lieu of chemo. Furthermore, an even more recent study now suggests a small benefit of doing ovarian suppression with an aromatase inhibitor rather than tamoxifen for those of high and intermediate risk

http://ascopubs.org/doi/full/10.1200/jco.2015.64.3...

I suggest you register at the NCCN's website and read about the breast cancer treatment guidelines. As you are aware, with a very low oncotypedx score, the risks of chemo outweigh the benefits AND according to the TailorX study, those patients with OncotypeDX scores below 11, have extremely favorable outcomes without aggressive treatment.

I had an Oncotype score of 3 and micromets of .3mm and .7mm in the first sentinel node only. The other 7 were clear. My oncologist recommended rads to the breast and nodes including supraclavicular. I am also on Armiidex for at least 5 years. I had no problems with the radiation (at least so far) and the Arimidex has been a easy with no side effects. My Oncotype report gave me a lower 10 year survival if I had done chemo. Since I was grade 1 with a 3.3% Ki67 the chemo would have had little if any effect.

barred...not to split hairs....But the origional poster qualified for the OncotypeDX test and scored a 5. We don't know if the OP's team considered her node negative when they requested the test. However,, I am assuming that the OP was not participating in the RXPonder trial because a patient would need to have cancer in 1-3 nodes, so that leads me to assume that her team and the Genomics folks consider her node negative. That said, there is debate whether micromets are clinically "node positive." Also making the water even more murky is Sparano's lack of mentioning which side of the debate micromets fall into. Not all node negatives are alike...so I don't think it is clear that we can conclude that TailorX's preliminary data isn't relevent. IMHO, i think she and her team need to discuss its findings

lurline...i am confused. So, according to the reports, you are node negative, but because of the micromets, your doctor considers you node positive? Regardless, you have opinions from leading hospitals and they all seem to agree despite the discordent results. In sum, for most of us, there is little black and white when making treatment decisions. We all do what each of us is comfortable doing

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC43812...

Page 13 gives an interesting point about the debate if micromets should be considered node negative or positive...and this retrospective study tries to flesh out if there is importance. Very interesting, Lurline, that the Difference was small and still the risks of chemo outweighed the benefits in both cases

Re: "Also making the water even more murky is Sparano's lack of mentioning which side of the debate micromets fall into."

TAILORx Study Population is "Node-negative":

My layperson understanding regarding the types of patients included in TAILORx (i.e., "node-negative" or "N0") was also based on my consultation of the clinical trial protocol published by NEJM. The inclusion criteria for TAILORx provide:

Elsewhere it states: "Patients with operable histologically confirmed adenocarcinoma of the female breast who have completed primary surgical treatment and meet the following criteria . . "

In contrast to the various "N0" nodal statuses listed in the protocol, axillary micromets are considered "pN1mi" disease and do not appear to meet the listed inclusion criteria for TAILORx.

Five-year results for those with Recurrence Scores of 0 to 10 assigned to receive endocrine therapy alone have been published. Patients should consult with a medical oncologist regarding this publication to ensure accurate understanding of the findings and to confirm applicability to their specific case.

RxPONDER Study Population - Protocol Amendment:

Unfortunately for the pN1mi subset, per Mittendorf, writing in 2014, "A recent amendment to the protocol now requires that patients have macrometastases in their lymph nodes and excludes patients who only have pN1mi disease." See also, the current clinical trial entry:

RxPONDER: https://clinicaltrials.gov/ct2/show/record/NCT01272037

• "Patients will have undergone axillary staging by sentinel node biopsy or axillary lymph nodes dissection (ALND); patients must have at least one, but no more than three known positive lymph nodes (pN1a, pN1b or pN1c); patients with micrometastases as the only nodal involvement (pN1mi) are not eligible; patients with positive sentinel node are not required to undergo full axillary lymph node dissection; this is at the discretion of the treating physician; axillary node evaluation is to be performed per the standard of care at each institution"

(Those who might be interested in joining this trial should confirm the above with their team.)

It is hoped that a significant number of pN1mi patients were accrued in RxPONDER before the protocol amendment.

As with node-negative disease, pN1mi disease (which is formally classified as "node-positive" disease by pathologists) may not be monolithic with respect to risk profile or the potential benefit of chemotherapy. However, the question of whether the Oncotype Recurrence Score can reliably identify Stage IB (pT1 N1mi M0) patients with more favorable prognoses ("prognostic" ability) or reliably identify those who may or may not benefit from added chemotherapy ("predictive" ability) turns on the scope and strength of clinical validation of the test in relevant patient populations. Therefore, I said, "There are other relevant studies which included pN1mi patients (ask your team)." Perhaps my suggested follow-up question was phrased too narrowly, but one would hope that in response, an MO would direct the person to the most important studies applicable to their particular situation.

Patients should always confirm any outside information with their team to ensure applicability and receipt of accurate, current, case-specific expert professional medical advice.

BarredOwl

Lurline...i have a rare cancer that "usually" affects post menopausal women. Whatever research there is, is not strongly validated for pre or post menopausal women...so, like your situation, you really need to depend on a team that you trust. What I have learned from my journey...nothing is straight forward. Looking thru a rear view lens, there is nothing I would have done differently. I found with cancer, there just is so many variables and no one size fits all. At the end of the day, you can crunch all of the literature and only hope you made the best choice with whatever evidence there is. That said, with an OncotypeDX score of 5, you should plan on doing very, very well!