How many percent reduction in 10yrs recurrence shall do chemo?

kaaadams,

While officially the Intermediate Oncotype range may be gone, from the standpoint of chemo recommendations, it is not. The most widely used and respected treatment guidelines are the NCCN guidelines, and here's what they say for your diagnosis:

https://www.nccn.org/professionals/physician_gls/default.aspx#breast This is the Physician's version, and you need to register to access.

Note that for Oncotype scores of 26-30, the recommendation is either endocrine therapy alone or chemo + endocrine therapy. So while the Oncotype report might be more black & white about it, that's because they sell their product as being a tool to determine whether or not chemo will be beneficial and should be recommended, and it goes against their interest to suggest that there is a fuzzy middle. But when a group of breast cancer specialists take the Oncotype research results and turn them into treatment guidelines, they do separate out the Intermediate 26-30 scores with different recommendation.

One other thing about the Oncotype report. The benefit that they suggest from chemo - in your case reducing your risk from 17% to 10%, represents a 41% risk reduction. This is based on an early study that was used to validate the Oncotype test, so this 41% is based in research, but it's important to note that most other studies have not found such as large risk reduction from chemo.

I'm a big fan of PREDICT UK and also CancerMath but these are models whose results represent an average for all patients. Therefore it's unlikely that these models will be as accurate as an actual analysis of the genetic make-up of the tumor itself - which is what the Oncotype score represents. Often Oncotype results and PREDICT/CancerMath results are quite similar, but in a case like yours, where the PREDICT result is so different from the Oncotype result, I'd think that more weight should be put on the Oncotype result. That said, it is interesting that despite being PR- and having a high Ki-67, your Oncotype score is only 28. That's low compared to most PR- Oncotype scores I've seen on this site, and suggests that the genetic make-up of your tumor includes some favorable components that are balancing out the PR- and Ki-67.

Here's a link to CancerMath: http://www.lifemath.net/cancer/breastcancer/therapy/index.php

Personally I think the Oncotype result should be one factor in the chemo decision, not the only factor. And I have big questions about how Genomic Health currently present the 26-30 Intermediate scores. An 'Endocrine Therapy Only' arm was not included in the TAILORx study for any patients with scores of 26 and higher - all these patients were given chemo. As a result, the only TAILORx data available for the 26-30 scores are recurrence risk figures that assume the patient will be having chemo & endocrine therapy. Therefore to determine the difference between chemo & endocrine therapy vs. endocrine therapy only for 26-30 Oncotype score patients, Genomic Health use the 'Tamoxifen Only' results from their original validation studies. That makes sense, except for the fact that for the lower scores, TAILORx results are so different. For scores of 25 and below, TAILORx found much lower recurrence rates than the previous study for those who had endocrine therapy only. So is it valid for Genomic Health to use this (possibly outdated) older 'Tamoxifen only' study for 26 and higher scores?

Sorry, probably just added to your confusion.

Cathy, you need to clarify with your MO if he is referring only to metastatic recurrence, which is what the Oncotype score projects, or whether he is including local recurrence.

You mention a 25% risk after radiation, which suggests that your MO is referring to local recurrence, since rads does not usually impact metastatic recurrence risk. Additionally, the 50% reduction from Tamoxifen is specific to local recurrence risk; for metastatic recurrence risk, the reduction benefit from Tamoxifen is closer to 30%. So it seems that your MO might be combining local and metastatic risk, which a lot of MOs do, but in reality each is a separate risk that should be evaluated individually.

Cathy, if your MO is combining the risks to come up with the starting 25%, I have no idea how much would be distant recurrence vs. local recurrence. Local recurrence risk is influenced primarily by tumor size, tumor grade, and the size of the surgical margins.

The Oncotype 9-year recurrence is metastatic only.

Since most metastatic recurrences occur without there first being a local recurrence, no, there is no way to avoid a metastatic recurrence strictly through monitoring/close follow-up. If you are going to have a metastatic recurrence - and hopefully you never do - the seeds of that recurrence are already in place, with a few rogue breast cancer sitting somewhere in your body, those cells having moved beyond the breast prior to surgery (and probably well before you knew you had breast cancer). When it's just a few cells, it's microscopic and impossible to detect with any tests or screening. But when it's just a few cells, systemic treatments, such as chemo and endocrine therapy (AIs or Tamoxifen), can find those cells and kill them off, in effect stopping a metastatic recurrence before it ever happens. And that's why chemo is given to patients who show no sign of mets, and why endocrine therapy is recommended to every ER+ patient with invasive breast cancer.

Dear ladies,

Thanks for your responses. Racy - I did seek a second opinion after my diagnosis of IDC July this year, 2019. I haven't for adjuvant treatment though. Seeking a second opinion would cost me another delay and the Oncotype numbers make it so cut and dry, I don't think MOs will say any different, but thanks. Ideally, I would, but I feel time is of the essence for starting an AI or Taxotere. I'm a long way out now from when I first felt a lump on June 1st.

OnTarget - It's great to hear you made it thru the chemo without signs of neuropathy! I appreciate hearing from women who made it thru. I'll definitely ice my hands and feet. You are considerably younger than me though. Wish I could hear from 60-somethings more in this forum.

DorothyB- My risk of recurrence is 17% with AI alone, but my MO says you can never get risk below 10%; so 7% risk reduction with AI and CT. When she figured the RSPC for me and the result was 15, it was good news but not much different, so seems accurate. Unless she meant my new Oncotype # was 15 with RSPC? or did she mean 15% RS? I better shoot her a message to be sure. Do you know?

Thanks ladies! We're all in this together and life is good! Thank you for any and all experiences you share with us all!

cathy, the Canadians in BC subforum is here https://community.breastcancer.org/forum/55/topics/779734?page=91#idx_2725

m

cathy, how people manage on AC+T seems really hard to predict. I had pretty easy pregnancies, just nausea and fatigue the first trimester. I loved being pregnant so I can't compare. For me this was worse but that doesn't mean it will be like that for you.

I was otherwise very healthy and fit and on paper was an excellent candidate for dose dense. I know there are lots of people who worked right through chemo with only minor adjustments to their schedules. I could not have done that. It made me very tired, esp the AC. I was also extremely neutropenic and did not respond to the colony stimulating shots that are supposed to make your bone marrow increase production. I was hospitalized twice and needed IV antibiotics because I developed fevers while having essentially 0 white blood cells.

My MO had to do many adjustments to my dosages and schedules & the dose dense was essentially dropped & I went on a personalized schedule. Because I was so neutropenic we had to be very careful about my exposure to infectious agents. My family cleaned and disinfected everything, I avoided going anywhere that there were people but I spent a lot of time in the forests and parks with my dogs... and then I napped with the dogs I exercised at home, did yoga, watched netflix, puttered around the house. It seemed that about 2-3 days after the treatment I was really tired and limp and then I'd perk back up and be close to back to normal. Taxol was easier as whole & we went camping the day after I finished taxol. I recovered quickly and I went back to school while still doing daily radiation last September.

fwiw, I would not hesitate to do chemo again if I had to. The biggest thing I had been worried about was nausea and vomiting but that was well controlled with the medications they give you.

The thing with cancer treatment in BC is that every cancer patient is a patient of the BC Cancer Agency and every MO works under the BC Cancer Agency. They all follow the same guidelines; the breast cancer management guidelines are here btw if you haven't seen them yet http://www.bccancer.bc.ca/health-professionals/cli...

Cases which are unusual can be brought to group committee for consultation. My case got tossed around a fair bit because there was considerable discussion whether to treat me as ER+ or triple negative. So even though I personally didn't seek a 2nd opinion, I know that several MOs considered my case and gave their opinions which ultimately went into what my MO recommended.

Generally speaking I think the idea of second opinions in our system doesn't really make a lot of sense because 2nd, 3rd etc opinions are kind of built into the system. The entire program is very closely tied to the research arm through UBC, and they're all involved in collaborative care in developing the evidence based guidelines and supporting clinicians in case management. I think maybe for surgical options & reconstruction, there is more variation but I'm not sure if there's really that much variation for chemo protocol recommendations? (eta: but maybe ask this on the British Columbia forum because you'd get more responses from local peeps.)

I did hear that some places in the US will do a chart review. I think maybe MD Anderson? Someone else would have to chime in with info but I remember reading you could send in your surgical, pathology, oncotype etc reports and get their recommendation.


Oh and I found Taxol was considerably easier than AC. The dose dense taxol is every 2 weeks but I switched protocols & did the 12 doses of weekly taxol instead

here's the dose dense (DD) AC+T protocol from the BCCA http://www.bccancer.bc.ca/chemotherapy-protocols-site/Documents/Breast/BRAJACTG_Protocol.pdf

all the other chemo protocols are here: http://www.bccancer.bc.ca/health-professionals/clinical-resources/chemotherapy-protocols/breast

kaaadams: I'm 60 with an oncotype score of 45. Because I was also node positive, I knew I'd have to do chemo even before the test came back. I did neoadjuvant to shrink the lump before surgery. Chemo is not fun but I have to say that AC was easier for me than the taxanes (started out with taxotere and changed to taxol). With AC, I had numerous side effects that didn't always last long and weren't too troubling except the cumulative fatigue and mouth sores. The taxanes were rougher for me. I did ice my hands and feet and still got neuropathy. I also got hand/foot syndrome and severe bone/muscle pain. My MO likes dose dense and that might be why my reactions were so extreme. I opted out of the last dose as I'd had about 85% and decided to move on to radiation.

I hope that you are in the typical group that handles the taxanes well.

cathy67: I never had nausea. I think the pre-chemo drug cocktails are good and it prevented me from having that problem. Still, I would take a anti nausea tablet on the night after infusion--just to help me sleep.

I was a young nurse in labor and delivery before epidurals. I saw all the women suffering so I decided never to get pregnant--that's why I don't have children now.

I think we are lucky in this day and time that so many people where wigs or have hair extensions. Few people notice. I think we pay more attention to ourselves than others do.

cathy67: This is the place to be when you want to 'talk' and ask questions. Someone always seems to respond to help us make those difficult decisions.

I suppose 'tolerable' lies in the eyes of the beholder. Everybody will react differently. Some side effects just don't effect everyone. Other people have higher thresholds for pain and discomfort. I think I amazed myself with what I could handle. I still went to work everyday during chemo. I didn't always stay the entire day but I got there and back.

I'm sure you will discuss the benefits versus risks of chemo with your MO. I'm not sure if you said you had the oncotype done or not. My MO was recommending chemo just because I had lymph node involvement and grade 3 but when the oncotype came back at 45, it was almost a certainty that I would be doing chemo.