calling all t1A (> 1 mm but < 6 mm) sisters who are HER2+
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Yay choco!!!!
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great news choco!!!
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Thanks everyone. Just read that the NCCN guidelines (p. 40) do not rec. chemo or Herceptin for NO, MO, <5mm, triple+ tumors either.
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Hi Chocomousse:
I'm glad you've come to a decision!!
BarredOwl
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Hi:
For readers of this thread who may be facing a similar decision, I note that the NCCN guidelines for patients (Stages I and II) have not been updated since 2014 (see bottom: Version 1, 2014, page 40), and are out of date as compared to the professional version regarding this question.
The NCCN professional guidelines were updated in 2015 and do include the option of chemotherapy plus trastuzumab. They can be accessed at no cost by registering.
Specifically, the NCCN guidelines for professionals (Version 3_2015) provide for ductal carcinoma (IDC) node negative (N0) tumors ≤0.5 cm that are hormone receptor-positive and HER2 positive (emphasis added by me):
"Consider adjuvant endocrine therapy ± adjuvant chemotherapy with trastuzumab (category 2B)"
"Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate."
With these smaller tumors, the word "consider" is included, so adjuvant endocrine therapy (e.g., tamoxifen) is an option.
The "category 2B" designation applies to "adjuvant chemotherapy with trastuzumab". (The highest level of consensus is category 1.) In addition, the ± symbol reflects that chemo and trastuzumab are optional and are not always recommended.
The above intervention for smaller HER2+ tumors is based ion the results of Tolaney et al. or the "Dana-Farber study" (Tolaney SM et al., Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer, N Engl J Med 2015;372:134-141):
http://www.nejm.org/doi/full/10.1056/NEJMoa1406281...
In the discussion, Tolaney et al. state: "However, the study does not provide data to support the use of trastuzumab-based chemotherapy in all patients with small HER2-positive tumors, and there will be many patients with T1a disease and some with T1b disease who will decide with their physicians to avoid the toxic effects of a trastuzumab-based regimen."
As with many treatment decisions, the risk/benefit analysis is an individualized one and is not easy.
Best of luck to all!
BarredOwl
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BarredOwl, thanks for linking that study. I hadn't read that one. I find it interesting, looking at the disease free survival graphs, that the tumors that were less than 1 cm had a higher rate of recurrence. It's not statistically significant, but just interesting! But the take home from that study is a great survival rate for small tumors that receive chemo/herceptin.
Kendra
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BarredOwl, you rock. Thank you - I haven't looked at the professional NCCN guidelines for t1a's since 2011/2012 (when I was diagnosed and in active treatment). I really appreciate your contribution to this thread - love the scientific and detailed reference. Just my style! I just don't have the energy to delve into it like I did back then, so thank you for helping keep us up to date!!!
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dance....I read the annual professional version (red logo) of the NCCN breast cancer guidelines. It is important to look for trends....also important to look for the words "consider" vs "recommend." The footnotes and discussion sections are a must read. There is where you find results of various studies. Again, I find the trend of the annual guidelines to be of utmost interest.
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I agree VR. You are much more dedicated than me! I was really "voracious" for a couple years, but you have certainly earned your name! ha ha ha Great to hear from you. You were so helpful to me!
BTW, I think back in 2011/2012 they did not even say consider chemo + Herceptin for t1a's that are HER2+. (correct me if I am wrong. Can you believe I can't recall for sure? Can I claim chemo brain? lol) If that is correct, then there is indeed a trend in effect for the t1a class of patients. It takes a lot for them to change those guidelines.
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Hi Dancetrancer:
As recently as Version 3.2014, for ductal carcinoma (IDC) node negative (N0) tumors ≤0.5 cm that are hormone receptor-positive and HER2 positive, the guidelines only indicated: "Consider adjuvant endocrine therapy"
Thus, the addition of "± adjuvant chemotherapy with trastuzumab (category 2B)" is quite a recent change, and the discussion section specifically cites the Tolaney et al. paper published in 2015 as support.
BarredOwl
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BarredOwl - thanks so much!!!!!!!! You guys are great; I so appreciate the help in keeping this thread current with the literature and guidelines.
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dance...actually, I became really interested in HER-2 + once my maternal cousin was diagnosed. Sooo....I had to back and forward in time and brush up.....keeping my fingers crossed that she and the rest of our HER -2 + sisters do well!😘
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btw....like me, population based screening mammography missed both our tumors. Sonogram picked up mine via diagnostic imaging. Thankfully for her, while a screening sono also missed her tumor, luckily a screening MRI picked up hers! And let me tell you! She had one nasty tumor! Like many of you, her active treatment was very difficult. She's a year out from active treatment and looking to enjoying manymany, many good years ahead....
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VR, you are a really good cousin! And friend!
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Sara Tolaney is the physician at Dana Farber doing the ATEMPT trial for stage 1 Her2 pos. tumors. I am in the Tdm1 arm of that trial. The other arm is Taxol and herceptin.
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They just announced the new protocol for our size tumor and triple positive. Kind of new it was coming, not sure if I am glad I went thru chemo after all. But then there is the wondering factor? At least I was diligent in that aspect.
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Jersey girl - who is "they"? Do you have a link to what you are talking about?
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Jersey,
Are you talking about the taxol/ herceptin protocol
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Hi:
I note that while Jerseygirl is Stage 1A, her profile indicates a tumor size of 1cm - 1.9cm. Thus, she is not actually a t1a (referring to tumor size, not stage), which encompasses only tumors > 1 mm but ≤ 5 mm in greatest dimension.
Jerseygirl would appear to be in the t1c subgroup of Stage 1A: t1c Tumor > 10 mm but ≤ 20 mm in greatest dimension.
Perhaps Jerseygirl will respond, but for now, the only recent thing I have seen pertinent to t1c is this retrospective meta-analysis:
Summary:
http://www.onclive.com/web-exclusives/adjuvant-tra...
Journal Article:
http://jco.ascopubs.org/content/early/2015/06/22/J...
"In summary, patients with HER2-positive tumors ≤ 2 cm derive significant benefit from the addition of trastuzumab to their treatment regimens, although the majority of patients included in our analyses had T1c, node-positive disease and were thus a selected group."
The discussion section is worth reading, though the focus is mostly on what the study does not say about T1a-b N0M0 tumors, and the challenges of trial design in this setting.
BarredOwl
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Thanks Barred Owl, you are absolutely correct. JerseyGirl, it is very clear that chemo is indicated for your size tumor. This thread is for those with much, much smaller tumors. (not that you aren't welcome! It just doesn't apply to you, and I don't want you to get confused about your treatment choices!)
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dancer, sizing does have me confused, I took my stats off of lab report of biopsy originally, so possibly I am wrong about my stats, I will recheck the tumor stats, to be sure. I did have two tumors in same breast when surgery was done so I will recheck size for each. The tv reporter stated that good news coming out about breast cancer findings and smaller scale size to ours, with no margin issues was changing the protical. We have 5 major breast cancer research hospital in the Philadelphia area, but can't recall the name of the?
Sorry will look for more reports on line. It was action news in Philadelphia WPVI .
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Bared owl- Wouldn't Jerseygirl be t1b?T1c would indicate positive nodes.
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Hi Wabals:
There is some uncertainty as to the actual size for Jerseygirl, although if the size was exactly 1 cm, it would be a t1b size.
Like "t1a" and "t1b", the designation "t1c" is a size classification only, not a stage, and does not indicate nodal status. Here is a partial breakdown of T sizes (T1s only), which are only part of the "TNM" staging determination:
T1 Tumor ≤ 20 mm in greatest dimension, includes:
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
For a good explanation of staging using all three T, N and M criteria, see here:
https://cancerstaging.org/references-tools/quickre...
As you can see from the grid (bottom, center of page 1), any T1 size tumor (including t1c) that is also node negative (N0) and M0 (T1, N0, M0), would be Stage IA.
BarredOwl
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ok girls here is the exact reading on the pathology report
Skin lesion measuring 0.7cm x 0.8cm in diamatur ; also a white firm modular tissue measuring 0.8 x 0.7 x 0.5 cm. the lobular carcinoma, moderately differentiated, at least 1.3 cm involving 50% of the biopsy core. Also it says ILC of 1.7 cm Nottingham score. And Ducral carcinoma 0.6 cm. ok
So now you have to tell me what this means. All margins clear. And they noted overall grade 3. ?
They also noted strong ER positive 98% PR positive 81%. And Her2. 3+. What is KI67. 49%
Sorry it took awhile hurricane Joaquin was heading this was but turned, still plenty of winds and rain from Norse' ester also.
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Jersey Girl did you get herceptin with your chemo? You would need that with her2 pos.
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Hi Jerseygirl:
I looked around at other threads, and it looks like you did receive trastuzmab (HERCEPTIN), right?
The above description is a little confusing to me about how many tumors (two or three) and the sizes of each. There is a reference above to a "biopsy core", but it looks like you also had bilateral mastectomy, so there would be a separate surgical pathology report. Perhaps you are listing the combined pathology findings from both a (surgical) biopsy and mastectomy surgery.
Invasive Ductal Carcinoma (IDC): A ductal carcinoma of 0.6 cm would be size T1b:
T1b: Tumor > 5 mm but ≤ 10 mm in greatest dimension.
(Because no node status is provided about the IDC, I cannot guess at stage.)
Lobular Carcinoma (ILC): The ILC in the opposite breast (?) would have a separate size determination, but I don't know what it is. For "lobular" and "ILC" there seem to be two measurements above (1.3 cm and 1.7 cm). I can't tell if there are one or two ILC tumors. If there is just one ILC tumor, I do not know how the biopsy and surgery measurements would be read together.
I would recommend that you take a copy of the reports with you to your next meeting with the MO and just ask her to explain it to you, so you are sure you understand the diagnosis. You can write down questions before, such as:
(a) How many ILC and IDC tumors were in each breast?
(b) How large was each tumor in greatest dimension (the largest dimension for each)?
(c) Was each tumor separately tested for: Grade, ER, PR, HER2 and ki-67, and what were the results for each tumor?
(d) What is the lymph node status on each side?
(e) In view of the sizes in largest dimension for each tumor, and node status on each side, what is the stage on left and stage on right?
Have a piece of paper ready at the meeting, with a column for the left breast and a column for the right breast. Write down the size and Grade, ER, PR, HER2 and ki-67 for each tumor separately in the appropriate column, so you don't forget. Note the relevant nodal status on each side (left and right) (your profile gives 0/5 and 0/1, but both for ILC and none for the IDC). Note the stage determination on each side. At the end, have the MO review your list to confirm that your understanding of the sizes and characteristics of each tumor, nodal status, and stage on each side is correct.
Ki-67 is a marker of proliferation, but you can ask the MO about what it means.
BarredOwl
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thanks barred owl , I am on my 9th dose of trauzamataub her+ 2 antibody, for a total of 18. No tumor in right breast all clear. 2 separate tumors in left breast . One was IDC and other ILC. No nodes involved and all margins clear. Does that clear anything up?
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Hi Jerseygirl:
Half way through! Super. With negative nodes, ductal (one) and lobular (one) tumors 6 mm or greater, at least one of which is ER+, PR+, HER2+, your treatment decision makes sense, and would be within the guidelines.
Glad it is unilateral. Sorry, I was confused by two numbers for nodes (0/5 and 0/1) in your profile, which also refers to right lymph node removal, and left sentinel node biopsy.
I think for the same reason that you aren't sure about size from the info above, I am not sure either! Also, it looks like the ER, PR, HER2, and Ki-67 is for one of the tumors only. (I would think there would be some difference in the percent values for ER, PR and Ki-67 between the ILC and IDC.) Anyway, I would not want to provide you with incorrect information!
To be certain, the best thing would be to ask your MO or the pathologist to review it with you. You can say you are continuing to learn about breast cancer and are reading various things about t1a, t1b and t1c tumors and recurrence rates, and would to confirm your understanding of your pathology.
For the ILC ask:
What is the "size of the ILC in greatest dimension"?
What is the Grade, ER status, PR status, HER2 status and ki-67?
For the IDC ask:
What is the "size of the IDC in greatest dimension"?
What is the Grade, ER status, PR status, HER2 status and ki-67?
Ask: Am I correct in understanding that the overall stage is Stage IA?
Ask: How should I think about my risk of recurrence with two different tumors having the specific features above?
With definitive information about the "size in greatest dimension", you can see where each tumor fits in among T1 tumor types:
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
Hope that helps!
BarredOwl
P.S., I have no reason to question the Stage IA. I included the question, because it is good to confirm since you are asking other things.
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I was referencing the NCCN patient guidelines. Here's a link to the page and treatment recommendation chart: http://www.nccn.org/patients/guidelines/stage_i_ii...
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Hi:
I am aware that you are referencing the Patient version. The Patient version is not updated as frequently as the Professional version. I checked the page you cited on September 25, and I have checked again today. The "screen shot" you provide has cut off the bottom of the page, where the date information is located. Please look on-line to access the bottom left corner of the page that you have posted which indicates: Stages I and II Breast Cancer, Version 1.2014. The Patient version has not been updated since 2014. The Professional Version, which requires registration for access, has been updated in 2015, and reflects the most current NCCN position. The Patient version is out of date, and should not be relied on as reflective of the current NCCN position.
The Professional Version (3_2015), which I logged into to see today again, remains as I stated above on Sep 25, 2015 09:21AM , edited Sep 25, 2015 09:27AM.
As I stated above, the "category 2B" designation applies to "adjuvant chemotherapy with trastuzumab". The highest level of consensus is category 1, so category 2B reflects a lower level of consensus. In addition, the ± symbol reflects that chemo and trastuzumab may or may not be selected. Thus, patients will work with their doctors to decide what to do in their particular case, which may within the current Professional guidelines applicable to the subgroup in question either include or not include adjuvant chemotherapy with trastuzumab.
BarredOwl
[Edited to Add: By "subgroup in question, I mean: "ductal carcinoma (IDC) node negative (N0) tumors ≤0.5 cm that are hormone receptor-positive and HER2 positive"
Please see my documentation in the chart "BINV-5" (page 16 of the pdf document, top line, right), and related discussion of invasive breast cancer commencing at "MS-11" (page 85 of the .pdf document) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), Breast Cancer, Version 3.2015 available at no charge at http://www.nccn.org/professionals/physician_gls/f_... ]
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