Neoadjuvant TCHP - Post Results Here
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The TCHP protocol was dveloped by the oncology team at UCLA. The first MO you consulted with doesn't seem very aware. Two women I know of who were ER+ as well as HER2+ both were pathologically negative post TCHP.
My MO felt that the other protocol with adriamycin was too risky for young women's hearts which is why he recommended TCHP. It is a rough protocol, i didnt feel like doing much for a good 10-12 days after each infusion, but it seems to have done the job well
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Is the TCHP protocol still in clinical trials and not approved generally yet by the FDA???? That's the only thing I can think of to explain the MO's claim that it is only approved for use with adriamycin /anthorcycline).
But even I can quickly check the internet to see that it's docetoxel that is approved with Perjeta---
The U. S. Food and Drug Administration on Sept. 30 granted accelerated approval to pertuzumab injection (PERJETA®, Genentech, Inc.) for use in combination with trastuzumab and docetaxel for the neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer.
It doesn't mention Carboplatinum... as in the Taxotere Carboplatinum and Herceptin he's recommending for me.. Is Carboplatinum as part of the mix NOT part of the approved protocol?
I'm going to get a 2nd opinion from an mo who is up at St. John's in Los Angeles, which as lots of UCLA doctors at both... I'll see what he says, I guess!
Thanks, agness, for your information!
Oh, agness-- I noticed that you got your SNB during surgery, AFTER chemo. I keep hearing that it's best to have the SNB before chemo. What did your doctors say about that? I'm just curious. Thanks!
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TCHP is what I've been getting and it is an approved protocol as far as I know. There's a TCH thread on here somewhere, so that's been going on for a while now, and Perjeta came into the mix for earlier stages of BC about a year or so ago, I think.
After TCHP, I'll be doing surgery. The H is Herceptin, and I'll continue that every three weeks through next August, for a full year of it. That is also a standard protocol for HER2+. I'll also be talking to my doctor about Tamoxifen, since I'm ER+ and PR+.
I didn't not have any SNB or anything else prior to chemo. So we don't have a true staging for my disease, other than what they could try to surmise from various imaging that was done. We know there are two breast lesions in my left breast and one node involved, but the PET/CT scan didn't show any other node involvement, and both breast lesions that were biopsied were the same essentially in their pathology. I'm going to be asking my surgeon tomorrow about how much he'll be doing as far as looking at/removing nodes when I go in next month for my MX.
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CassieCat -- my mo is pretty much offering what I want save for the Perjeta, which he insists is only given with Adriamycin as the FDA protocol! That he is so emphatic about it (I asked him several times!), I'm now wondering if he still thinks TCHP is too untested or only in trial or what!??? Might have to get a new mo!
If you don't mind me asking-- are you going to do a unilateral mx? and why mx and not lx? That is a decision I'm also working on, but it's not quite as imperative as getting some Herceptin into me!
Thank you SO much for your helpful posts!
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There are several chemotherapeutic approaches to treating Her2+ disease, their use varies based on physician preference, geographic location, and a number of other factors. Generally for tumors larger than 1cm, prior to the approval of Perjeta, there was the combination of AC-TH, and TCH. For tumors smaller than 1cm there is Taxol and Herceptin.
1. AC-TH - These drugs are Adriamycin, Cytoxan - given together for usually four doses, then the combination of Taxol and Herceptin, for a varied number of doses together based on preference (dose dense or weekly), then Herceptin for the balance of the year. Adriamycin and Herceptin are separated - and not given simultaneously - due to the cardiotoxic potential of both drugs.
2. TCH - is Taxotere, Carboplatin usually, or Cytoxan, and Herceptin - these are given together for either 4 or 6 doses, then Herceptin is continued for the balance of the year. Many docs favor this combo (including Dr. Dennis Slamon of UCLA, the doc whose research brought Herceptin to the market) as it does NOT include Adriamycin, the cardiotoxic agent.
3. Taxol and Herceptin - usually twelve weekly doses, continuing Herceptin for the remainder of the year, generally given to those with smaller tumors, is showing excellent response for that demographic. Occasionally people are overly sensitive to Taxotere and Taxol is substituted in the TCH regimen.
Where I think there may be confusion for you in looking at the FDA approved protocol is with the addition of Carboplatin in the TCH regimen not appearing on the info on Perjeta's website. Many docs are simply adding Perjeta for the six neoadjuvent doses of TCH. Adjuvent treatment with Perjeta is not FDA approved currently for early stage breast cancer, although you will see some docs doing it if insurance will pay for it.
On your question regarding SNB - some people have it prior to chemo (during their port placement) and others wait until their surgery after chemo. It depends on how important accurate staging is to you and your physicians - you will see both scenarios - this is a personal choice made in concert with your medical team.
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SpecialK-- So the MO I have is probably thinking only of the Adriamycin + Perjeta protocol.... maybe? Could it be that he just doesn't trust the other protocols? Or maybe KP, insurance, doesn't like other protocols? It just seems weird that his recommendation is SO close but not Perjeta!
MO is definitely not into the SNB before chemo. I just needed to know if I should push for it. Or get another MO.
I'm going for an outside 2nd op with MO now... So we'll see!
THANKS!!!!!
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I will be talking some more about the MX tomorrow and can tell you more after that as to why it's being suggested vs. just a lumpectomy. I'm not totally 100% sure why, but my sense before was that a) the extent of my tumors made MX more likely and b) to help prevent recurrence. I will get more clear on this myself tomorrow.
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april - to clarify - there is no early stage FDA approved neoadjuvent protocol for Perjeta with Adriamycin. Anyone who is receiving Adriamycin and Perjeta is having a protocol that their docs have put together for them specifically - they are simply adding Perjeta to an AC-TH regimen, that is why you see much more of the TCHP regimen for early stage.
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Thanks, SpecialK. Then that MO was totally, totally wrong! That's kind of scary!
----'-deleted frantic rant about dealing with relatives during a stressful time---''
----I got a 2nd op. First MO finally agreed to it. Decided to change MO and insurance during open enrollment.
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I have a PET/CT scan tomorrow and we'll see just how effective the neoadjuvant TCHP was for me. Fingers crossed!
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CassieCat - I hope you have great results! !!!
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I started TCHP Dec. 17.
Unfortunately my side effects landed me in the hospital for dehydration, low kidney function and low potassium. I'm on my second day of IVS and kidney function is back up but need a bit more potassium. .. and super strong anti-diarrhea meds that will work. Or maybe a change in the chemo cycles. Gah.
The TCHP just did a job on my GI tract. I was surprised because I have never had stomach problems. Ah well.
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The side effects of TCHP are awful, but that combo destroyed my tumor. Hang in there and know that no matter how awful you feel, TCHP works.
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Skoolgirljen- thanks for the encouragement! I'm definitely hoping I'll be able to stand it and that it will work for me.
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Hi All,
This is my first post here. I am receiving neoadjuvant TCHP. I have finished 4/6 treatments. I go for my 5th tomorrow. I do receive neulasta shots the day after treatment also. So far, my blood counts have been ok except for being anemic. I will see how my tests are tomorrow as I also got the flu this cycle and was knocked on my butt. The first 6-10 days are the worst. I am given steroids, benedryl, ativan, and pepcid pre-chemo (possibly other drugs too, but don't know for sure). I also have ativan, lomotil, zofran, and prilosec at home to take as needed. I take claritin pre and post neulasta shot and the bone pain is not as bad.
Here are some of the symptoms I have had and how I have coped with this regimen.
Mouth sores/heartburn.
My doctor has me use a baking soda/salt water solution (1 t. baking soda+1t. salt in a quart of water) to help with mouth sores. I also use a baking soda based tooth powder instead of toothpaste the first week after treatment as it helps reduce the mouth/throat sores and heartburn. I also do take the prilosec as needed and usually do not need it to build up in my system to get a helpful response. I also found (for me) avoiding bread and crackers, oily or greasy foods, acidic foods, and peppery foods helped limit my hearburn.I typically eat a lot of bananas, peaches, sweet potatoes, cantaloupe, and hard boiled eggs immediately after treatment. Sometimes I also add in cottage cheese or greek yogurt too.
Constipation/Diarrhea
I get sever constipation followed by diarrhea and then it normalizes by the 3rd week. At first I didn't do anything to see if my body would correct itself. Now I start taking stool softeners right away and then see how the diarrhea is. I don't always take the lomotil. I have crohns disease too so I don't know if my digestive se's are worse than other peoples.
Peripheral neuropathy.
I get tingling in my finger tips and have also had tingling in my lips, chin, tip of nose, eye twitches(this sucks). I cut myself dicing vegetables after the 2nd treatment and didn't know it until I saw it, but didn't mention it to my MO. Pre 4th treatment I mentioned cutting myself and that my fingers were still tingling at the end of my 3rd treatment so they reduced the taxotere for the 4th treatment. neuropathy has been better this cycle.
Nail issues
My finger nail beds are turning red/purple and my fingers tips are getting very sensitive to touching things. My husband has started helping with dishes as scrubbing pots hurts. He has been helping our 3 yo change her earrings as it hurts to do small things with my fingers. I had been ok with the other side effects. This side effect has affected my quality of life more than the others. My mo said my nails will most likely start to separate from the nail beds too. If anybody has any suggestions or treatments that helped lessen this, I'm all ears.
Other issues
My eyes water a lot too. I do use a lubricating liqui-gel drop, but my skin seems to be allergic to it. If anybody has any drops that work for them, please let me know. I had really bad restless legs this cycle, but assumed it was because I got the flu too and wasn't eating anything for about a week (assumed my potassium and/or magnesium levels were low). I had an asthma attack during the 30 minute wait period after the perjeta last cycle. I will see if they change the perjeta this next cycle. The fatigue is not too bad for me. The first week sucks, but then I start to feel better. Maybe it helps having 2 kids (3 and 10) that I have to take care of. I haven't recovered my energy this cycle like the others but I blame getting the flu 2 days after chemo.
I also found that I crave a lot of orange fruits and vegetables, eggs, and lean protein after chemo. My potassium and other nutrient levels have not been low and I assume it's because of this and I take a multivitamin everyday also. Don't know if anybody else has had cravings or foods that repulsed them. The only thing I couldn't stand is the smell of spearmint as my mom and mother-in-law both chew spearmint gum.
I meet with the bs and the ps on January 15th. I also have another bMRI that day too. We will find out how small the tumor is at that point. The 4.5cm tumor couldn't be felt after the 2nd cycle. I'm er/pr- and her2+++ and it sounds like that dx responds well to this treatment. I also had 4 satellite tumors in the same area. MRI and PET did not show direct lymph node involvement, but won't know for certain until surgery. Also, I will most likely get radiation even with complete response. My MO mentioned that if I don't have a complete response he will likely recommend a few more rounds of adjuvant chemo (besides the 1 year of herceptin). Has anybody else had their MO recommend this or heard of this? I go to the Cleveland Clinic and trust all of my Doctors. I just wanted to know if anybody else has heard of this or is or will be doing additional chemo and if the Doctors gave any reasoning.
Sorry this is so long. I am sorry to see so many people going through the same thing. I hope everything goes well for others.
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indyaskye -- Thanks so much for all the detail! I am just so curious about how others are experiencing this course of treatment, so this is wonderful.
The infusion center nurse who talked to me during my first round of chemo suggested taking B-6 vitamins for neuropathy. I think SpecialK, on this forum, said she also took L-glutamine.
I've got Type 2 diabetes and neuropathy is a risk for that, too, so I want to try and head it off as much as I can! I'm taking the B-complex vitamins for sure!
Heartburn was the first thing I felt after my first chemo-- a kind of burning in my stomach. It wasn't terrible, but I could tell the chemo was just hitting my GI tract hard! After a week it felt like my taste-buds were burnt off! I haven't had mouth sores yet, but it did get very tender in my mouth for a while. Now I'm in my 3rd week and feel like I'm coming out of all that a bit--but I'm still having major diarrhea problems (and because of that--hydration problems)-- to the point of having to have another IV drip yesterday! gah!
It was really weird what kinds of foods I could stand to eat. My stomach felt so tender and unsettled that I didn't want anything dry or rough-- no pure protein or carbs or anything hard or crunchy. The protein shakes were OK. And dairy products that weren't too sour (yogurt was a bit rough)-- so milk and cream and soft cheeses. I liked cottage cheese if it wasn't too dry and if it had stuff in it--either fruit or some kind of flavoring.
I only threw up once, about 3 days after my first chemo... so nausea hasn't been a big problem.
Nails, I've only had one chemo, so not a problem yet. There are people who say to ice them-- hands and feet--while getting chemo. Someone also suggested taking biotin supplements. Having sensitive or lifting nails sounds like a problem. I hope you can find something to help, indyaskye.
I think I might try and look into what I can do about that, too, before it becomes a problem for me. I'm not sure there's much one can do, since people say that the icing may not help at all...! I do wish you the best with that.
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I can't imagine doing more chemo after surgery after 6 rounds of TCHP my body was really in lousy shape. I could barely go up the stairs for 5 weeks post chemo. It was likely compounded by the Zoladex shot I got before round 5.
Make sure to take a good probiotic supplement during treatment, start a few days after each infusion and stop when the drugs are most active in your system. The chemo drugs are toxic to your gut flora and you need that to help your body assimilate nutrients.
Definitely ice hands and feet as some other gals in my chemo group had some terrible issues with their nails.
Someone I know was hospitalized on TCHP due to diarrhea/electrolyte issues twice. Her team switched out weekly Taxol for the every three weeks Taxotere and that seemed to be enough adjustment.
I am 6 months PFC tomorrow. My ears still ring, my energy is low (radiation slowed me way down), my period came back a few weeks ago but it was really heavy and my anemia has returned after it had gone away a couple months ago -- rads probably contributed some in this regard. My hair regrowth is about 2.5-3" long and my eyebrows are still filling in -- it takes a while for eyebrow shed to not be all at once so they get thinning in waves and then come back more. My Achilles' tendons are still tight, this started a couple months post chemo and I've read it can happen due to low potassium levels -- exactly what Taxols due, push potassium out of your body.
I'm looking forward to being done with Herceptin in just over two months.
Best wishes to everyone. You can do this!
-A
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Yikes... I hope I don't have to be hospitalized again! But I wouldn't be surprised... I mean, this was just my first round of chemo and I still can't stop the diarrhea, and that wipes out potassium, too!
I was thinking of a pro-biotic. One of the doctors recommended it... but there were all kinds of warnings on the box about not taking it if someone is immuno-suppressed...
I really don't know what to do... I'm hoping my MO can fix things somehow, but I'm worried.
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I saw a naturopathic oncologist thoughout treatment who was wonderful at helping me know how to support my body through treatment. You might consider trying to find someone in integrative oncology or naturopathic oncology to add to your team.
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agness -- I hadn't even thought of that... Sounds like a great idea. I wonder if my MO is supportive of that kind of thing, and if he maybe knows someone? I'll have to ask...
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I had this TCHP for 6 cycles and then had surgery on 12/17. My tumor did shrink as it was mm from my chest wall and thought to be 8+ cm. Pathology report following surgery was 6.5 cm for tumor with clear margins of 2.3 cm. I did not get the complete pathological response I was hoping for, but my histology report at time of surgery stated I had a Mucinous Adenocarcinoma which I have read is not as responsive to chemo.0 -
Everything has regressed quite a bit, according to my PET/CT scan. Whether or not there is still any active cancer or not we'll find out after the MX and pathology can be done on the tissue. I go in for surgery Friday. My surgeon was really pleased with how well chemo worked for me.
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It seems like TCHP isn't working the same for the ER+ gals. If I was HER2 and ER positive I think I would press my doc to do ovarian suppression at the same time with Lupron or Zoladex. It is being studied right now to help preserve fertility post chemo.
My MO gave me Zoladex before my 5th dose and it covered my final two rounds. We think it contributed towards the increased muscular pain I had towards the end of chemo and afterwards for weeks. So not nice but if it helps to shut down the cancer cell line more then why not ?
Some premenopausal gals in my chemo group are doing ovarian suppression with arimidex, it is also supposed to be more effective than just hormonal treatment (forgetting the name of the estrogen blocking drug).
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Someone wanted to know why I had my SND after chemo. I had a number of enlarged nodes at the time if my diagnosis and the biopsied node contained cancerous cells. We already knew that I was stage 3B and doing an SND wouldn't change that. My objective was to cause the least amount of damage to my body while treating my cancer. My surgeon and team worked with me on achieving that, plus I had the advantage if a type of breast cancer that responds really well to neoadjuvant treatment. Left to the decision making by most oncology teams I would have been recommended a mastectomy and ALND with adjuvant treatment. I wanted better than standard of care and understood enough about the trade-offs.
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CassieCat. Glad to hear your surgeon thought your chemo went well. I hope you are feeling strong and ready for your surgery on Friday. I will be thinking of you and praying for your surgery and quick heal!
PMR53
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agness, what do you mean, isn't working the same? Can you clarify that? Thank you.
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Hi Cassie - Patients with ER+/HER2+ disease tend to be less likely to have a pathologically complete response (PCR) to neoadjuvant chemo. It is believed that it is because the dual "fuel" source provides the cancerous cell line an alternate way to survive chemotherapy. The highest PCR is seen with ER-/HER2+ disease. We are seeing that largely playing out here as well in those that have had treatment with TCHP.
I wonder why hormonal treatment is not done concurrently with chemo as a standard.
Ann
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Thanks for clarifying that. I am curious to see what my pathology shows after surgery. While everything has shrunk dramatically, we won't know for sure what's still lurking in there (or not) until the tissue gets examined.
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Cassie - Good luck on your surgery this Thursday. I hope your healing is swift and without complication.
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I had 6 rounds of taxotere, carboplatin, prejeta and herceptin. Just finished my one year of herceptin. My left breast was triple positive with six tumors. My right breast had one 2 cm tumor, was er and pr positive, but not her2. I did not get a complete pathology response from the TCH. That has worried me some. But I hear others say that have had surgery first that they will never know if they got a full response or not. I guess it all comes out the same as long as it is gone. I hope so anyways.
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vettegirl, I am hoping for a complete pathological response but at this point, I feel like I've done all I can do. I'll have the surgery, do the radiation if it's indicated, take Tamoxifen, keep up with the Herceptin and live my life as healthfully as possible. I'm reading Life over Cancer and Anticancer, and both books have lots of good information for trying to keep cancer at bay. It's worth a shot.
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Hello,
I had one tumor (3.4 cm), which was biopsied as triple positive and grade 2 when I was diagnosed. After neoadjuvant chemo, I did not get a complete response, however the 8mm invasive tumor left was assessed as grade 1. I haven't received the hormone and her2 receptor status on this piece that was left. While initially I felt bad that I did not receive a complete response, I realized that this was only due to the mixed nature of my tumor. Neoadjuvant chemo works best on high grade tumors, and even moreso on hormone negative and her2 positive than triple positive tumors. In that sense I realized that chemo did get me a full response on the higher grade portion of my tumor, even though it was not even grade 3. This made me feel better.
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