Older Women Treated With Hormone Therapy May Not Need Radiation
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Roche, side-effects vary tremendously from one woman to another; please don't read all the negatives and expect that they will necessarily apply to you.
I have read some research that indicates that women over age 65 may be able to forego radiation - I'll see if I can find the link for you. That may be part of why your MO thinks you could pass on radiation. That being said, at this time standard of care following lumpectomy is radiation, with AIs or tamoxifen for ER+ women. If you don't do radiation I hope you'll give AIs a fair chance. A low chance of recurrence doesn't mean NO chance of recurrence, after all.
Is there any chance that your MO and RO could do a conference call with you in the room with your MO to explore ALL of the issues you've discussed with each of them? That might help you feel more comfortable with whatever decision you come to. Good luck with it.
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Roche, I had a lumpectomy, radiation and hormone therapy... no regrets, it all went faster and better then I expected,
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I am 61 and I think my plan is radiation . My nodes were clear and tumor was 3mm . With clean margins. I hope this is the end of it. Any thoughts or advice?
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Elem:
Do you know the HER2 status of the IDC? There should also be a grade for the IDC. Also, have you met with a medical oncologist?
BarredOwl
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d
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hi ,
No all I know is that initially the BS said something about a pill but that was when I just had DcIS . Then it was removed and had some invasive component . So an SNB was done . He said nodes clear caught as early as possible and I will need radiation to prevent recurrence. I have not seen an MO although tomorrow I will see an RO referred to by BS . I have an appt . With MO down the road because of second surgery , they rescheduled so I would be healed up from both lumpectomy and SN
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Hello
What would happen if hormone pills were stopped and lost window of opportunity for rads? This is the question I am agonizing over and I have to decide on rads this week. The MO (2) answers are
to just stop the pills. Also another factor is the skipping of rads over 70. I don't understand this study as age is a number and decision should be based on health status not age alone.
Any other healthy women over 70 told about hormones over rads
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Hi Elem:
With hormone receptor-positive disease (ER+ and/or PR+), when you meet with the medical oncologist, you will probably discuss "endocrine therapy" (e.g., tamoxifen or an aromatase inhibitor ("AI")). These drugs are in "pill" form.
Be sure to ask the medical oncologist about the HER2 status. HER2-positive disease is treated quite differently from HER2-negative disease, so this result is critical information with respect to chemotherapy and HER2-targeted therapy.
If you have not already done so, be sure to obtain copies of the pathology reports from all biopsies and surgeries, along with any addenda or supplements with ER, PR and HER2 test results for your review and records. It is best practice to confirm the information you receive with the underlying documents (with your name and actual results).
As far as radiation and the original post in this thread, I think that this is the related news feature (dated May 18, 2015). The Moderators should have included a link to it in their post.
Feature: http://www.breastcancer.org/research-news/some-treated-w-hormonal-tx-may-not-need-rads
Liu (2015) Study Publication: http://ascopubs.org/doi/full/10.1200/JCO.2014.57.7999
Bellon (2015) comment: http://ascopubs.org/doi/full/10.1200/JCO.2015.61.2069
The title of the feature is rather misleading, and the study had significant limitations. As a result, this study was not seen as a practice changing study. Further research to substantiate or validate the findings is needed before it is implemented in the clinic, as noted by the authors:
"However, omitting RT and using intrinsic subtyping and clinical factors is a substantial change in care. The breast cancer community would likely require additional prospective evidence before this becomes standard of practice. To validate this observation, a prospective, single-arm clinical trial open to women age 55 years or older with pT1N0 grade 1 to 2 luminal A breast cancer has begun in Canada. . .
. . .Further studies may validate the exploratory finding of a low-risk group of postmenopausal women with early-stage luminal A breast cancer group who may be spared the inconvenience and adverse effects of breast RT."
Other clinical trials regarding the omission of radiation therapy in older patients have used higher age cut-offs (e.g., PRIME II, age 65 or older; CALGB 9343, ≥ 70 years).
As of this date, the National Comprehensive Cancer Network (NCCN) guidelines (Version 2.2016) provide that breast radiation therapy may be omitted in select patients ≥70 y of age with estrogen-receptor positive, clinically node-negative, T1 tumors who receive adjuvant endocrine therapy (category 1). Patients should seek case-specific, expert professional advice from a Radiation Oncologist to understand whether this is a reasonable option for them.
In any event, when you meet with the Radiation Oncologist, do not hesitate to request a personalized risk benefit analysis. Inquire what clinical and pathologic factors weigh in favor of radiation therapy in your specific case. Ask about your estimated risk of local recurrence, and the estimated absolute risk reduction benefit you would receive from any particular course, which must be weighed against the risks. With some lower risk disease, shorter courses may be an option.
BarredOwl
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Hi BarredOwl ,
I did see the RO today and that information was all readily available . It was estrogen+Progesterone+ and HER2-
Also he said TI no grade . My invasive tumor was very small 3mm in size . Margins clear and sentinal lymph nodes were clean .
So with whole breast radiation for 4 weeks everyday my recurrence would be approx . 6%
Doing nothing approx. 15% and with combination hormone and radiation 1-2%
So I am going to digest this information , read more about it and decide which dorection I should go. I am 61 and relatively healthy. I do have a stent in my main heart artery LAD. But I am otherwise in good condition.
Thank you for your response and input . It is so helpful . I am glad this forum is here.
Thanks again 💐.
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Hi roche:
You asked: "I don't understand this study as age is a number and decision should be based on health status not age alone."
I provided information on "this study" in my post to Elem (see above).
As far as clinical consensus guidelines, their recommendations are based on the results of different trials, such as PRIME II and CALGB 9343, and the observed behavior of tumors in older patients, that are consistent with underlying biological differences. Here is a feature regarding the PRIME II trial:
ASCO Post (Moran, 2015): http://www.ascopost.com/issues/april-25-2015/prime-ii-and-the-omission-of-radiation-therapy-in-low-risk-elderly-patients-undergoing-breast-conservation-the-time-has-come/
The author notes:
"Breast cancers in older patients are more often associated with indolent features and with overall better outcomes than those in younger patients."
As far as the effects of not completing endocrine therapy, studies show that the benefit received varies with the length of treatment. Ask your radiation and medical oncologists what your baseline risks of local, contralateral, and distant recurrence are (without both endocrine therapy and radiation therapy). That will give you an idea of these recurrence risks without either treatment or with only a few months of endocrine therapy alone.
The article from the ASCO Post discusses various studies in the area and provides one view regarding the results, along with citations to various clinical trials and studies.
There may be other relevant studies in this area that affect understanding. Please be sure to confirm any information and statistics from the article against the underlying study publications. If any publication affects your thinking, be sure to discuss it with your team to ensure accurate understanding, applicability to your case and receipt of case-specific expert advice.
BarredOwl
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Thanks Stellamaris,
I've thought about that scenario also and time is running out for my decision.0 -
Thank You. It's a tough decision . I don't like the idea of a pill for a lengthy time frame . The radiation lowers my risk to approx 6% from 15% if doing niether. With both tx's I am told approx . Risk is 1-2%! Iwill need to make a decision soon
Thank You
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I was diagnosed in November, surgery in January and now am facing the same decision as you ladies. I turned 70 in December so technically my course of treatment would be no radiation, only hormone therapy. After much thought, worry, stress, etc. I've decided to go for the radiation. I have a difficult time with so many meds and I'm not sure if I want to deal with the side effects of "the pill"! I'll make that decision later but in case I decide not to do hormone therapy or try it and can't tolerate it, at least I have the protection of the radiation.. I'm being treat at a major cancer center and have total confidence in my team. I hope you make a decision that feels right for you.
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Radiation is not a substitute for hormone therapy & vice versa. They do two different things: radiation is local and will do nothing to prevent any undetected micromets that might have escaped the breast from growing and spreading. All it does is kill tumor cells that might have been left behind in the breast. Hormonal therapy is systemic—it is designed to kill those micromets by starving them of the estrogen they need to divide, grow and take hold elsewhere in the body.
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Well, I met with my RO today and she supports my decision to skip radiation and go straight to hormonal therapy. I'm not posting this to go pro or con -- , but to share my decision process with others who may be on the fence. I based my decision primarily on the national cancer guidelines as they apply to my cancer and age.
NCCN guideline 2.2017 (category 2A): In patients 70 years or older, omission of radiation therapy can be considered for patients with stage 1 estrogen-receptor positive breast cancer who undergo a lumpectomy with negative margins and are likely to complete 5 years of endocrine therapy. Omission of radiation therapy has been associated with a modest increased risk of local recurrence (4% vs. 1% at 5 years; 10% vs. 2% at 10 years). However, there has been no difference in OS or distant metastatic disease.
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My 81 year old mother maybe doing the chemo thing Taxol etc.. for every week for 12 weeks then every 3 weeks how are you doing on the chemo. She originally told them no but thinking about it. She was diagnosed with Invasive ductal carcinoma .
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I am a 71 yr old and was diagnosed with DCIS in Feb.2017. It was stage 0, non invasive and the tumor was "The size of a grain of rice." I was told I was a good candidate for extolling the wisdom of yearly mammograms. I had a lumpectomy which was very successful and turned out to be practically painless. It was followed with 20 radiation treatments, At the 2 week point, I began to feel the fatigue , although it wasn't debilitating. I waited 6 weeks to begin the AI ( anastrozole) so that I could get some energy back.I had very little discomfort from the radiation. A little peeling underneath the breast and a tender nipple area , both of which healed quickly. I have now been on the anastrozole almost 5 months and wish I could trade it for something - anything. MO is of the opinion that if I stay on it, I will get through the " discomfort" and be just fine.I only see him once every 6 months and he asks how I am. If I mention any problems, he always seems to have a glib answer. 4 days in a row before my last visit I could hardly walk due to the pain in my back, shoulders and knees. He said " Oh, that;s arthritis ." I haven't ever had that problem before. I'm thinking I need a new MO who I can talk to, or does it just seem to be me??
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Roche, I am not exactly in your situation, being 59, but have read a lot about this issue. The short version is that radiation is to prevent any recurrence in the same breast, while tamoxifen is to prevent mestasis to the other breast and the rest of your body. Since you are 70, the standard is to skip radiation and do hormone therapy only, and this would be especially true for you if your ER and PR scores are high. There is even a clinical trial at Johns Hopkins where women in their 50s and 60s in your situation skip radiation, which I explored and sadly am not eligible for. Speaking only for myself, since my RO recommends only 3 weeks of radiation, not 7, I decided to go ahead and do that. Side effects are much less than the standard 7 weeks of radiation, and I feel like it is an insurance policy of sorts in case I don't tolerate the hormone therapy. So perhaps a good step for you is to talk to your RO about this shorter protocol (called the Canadian method), as well as partial breast radiation rather than whole breast. There is also a "one and done" treatment called IORT. I truly don't mean to confuse the issue for you but just adding information on intermediate options. In my case, the surgeon, RO and MO all agreed so that made it a bit easier.
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Roosterlady, your MO should be more helpful. There are other AIs, plus good old tamoxifen to consider since you are post-menopausal and experiencing joint pain. I'd suggest you get a second opinion.
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On another site I read a couple of diaries of breast cancer survivors.. I saw my oncologist for my first appointment on April 25. He didn't do a blood test at that time
( probably because I wasn't done radiation yet) . My next appointment was on May 23 and he did do a blood test then. I told him that we summer in New York which is 1000 miles from where we live. We usually stay for 5 months but were planning on 3 to 4 depending what the oncologist said. i did tell him if he felt it was necessary we were only 20 minutes from a hospital with a good cancer center. He said that would not be needed. He then gave me a prescription for anastrozole and made an appointment for me for Nov. 7 which was a 6 weeks after we would be home. he also said, when I asked about dealing with side effects that he prefers his patients to stick with it and quite often the se's lessen or go away completely. I went to see him on the 7th and told him I'm having problems Is every 6 months the norm for visits with the oncologist ? I thought it was odd that he didn't seem to think monitoring was necessary when I first started the meds but I'm wondering if the next visit ( which is in May ) he'll tell me to come back in a year?
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I have not met with an MO to discuss hormone therapy yet; that is in two weeks. But yes, I understand six-month check-ups are the norm. My concern for you is just that he's blowing off your concern about side effects so glibly. Perhaps while you are in New York you could get a second opinion?
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Thank you Georgia, Hearing others say I should get a second opinion is helpful. I can't imagine 5 years with an MO who thinks " suck it up " is valid medical advice. I may get in touch with my nurse navigator or my RO . Both have said to contact them if I feel I need help. I did pick up on the fact that the RO said that every time I mentioned the MO.
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roosterlady, I was 65 at dx. Ended up with mx. Long story short, I had a 4.5 cm tumour, multi focal, multi centric, onco score 27. No rads, no chemo. I am 2 years in on the AI, and side effects are diminishing, although I never had joint pain. Thinning hair and sleep disturbance due to hot flashes. I see my MO every 6 months. He did do a bone scan and put me on Prolia due to osteoporosis. I am glad I dodged the rads and chemo. Best wishes
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TY Stellamaris I was doing a little more research and hit on a board at Mayo Clinic. Got a little more info there. And doesn't God work in mysterious ways ? I got up this morning wondering what kind of day it would be. It has turned out really well. My nurse navigator called just to check because we hadn't talked in quite some time ( I spent the summer in the Adirondacks ). She did tell me to try taking the meds at night and I waited until this evening to take them. I can't believe how well I'm feeling. No fatigue or joint pains. I do have a few ulcers in my mouth but I got some meds from the dentist for that. The change is so huge that my DH said he can't believe how much better I am. I don't feel quite so stressed knowing that I can change Drs. if it comes to that and possibly end up changing meds or taking a break.
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So glad to hear!
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Roosterlady - My dx was at age 70 (I got breast cancer for my 70th birthday - woohoo!) and I had a bilateral mastectomy May 3, 2017 and opted for no reconstruction.I have been on Arimidex since end of June this year and I haven't really had many problems at all. I already had back issues and really bad osteoarthritis in one thumb, and I have had those issues for a few years, so I know the Arimidex isn't causing them. The few hot flashes and night sweats I was having seem to have subsided a lot.
I hope your problems with it ease up. Also hope you check out a new MO. I adore mine - and I see him about every 3-4 months. He said he will be meeting with me every 4 months until I hit the 5 year mark. And I see my BC surgeon every 4 months as well.
Good luck!
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I was given the option diagnosed stage1, grade1 idc 7mm, I’m 67. The reasoning is that there was a study which showed that woman over 65 or 70 have the same long life with or without radiation. They may have another recurrence however. But my thinking is, another lumpectomy would be possible and that would be easy on my old age. Radiation can cause problems of its own too. My radiation oncologist was ok with not having it.
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I was given the option diagnosed stage1, grade1 idc 7mm, I’m 67. The reasoning is that there was a study which showed that woman over 65 or 70 have the same long life with or without radiation. They may have another recurrence however. But my thinking is, another lumpectomy would be possible and that would be easy on my old age. Radiation can cause problems of its own too. My radiation oncologist was ok with not having it.0
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Any guidance would be helpful on trying to decide to proceed with radiation or not.
I have alot of data, and some uniquely missing, but I do not feel I am getting specific treatment plan based on my particular situation by my doctors, especially given the lumpectomy has caused continued swelling and pain in my breast. (I had a radial scar removed at same surgery on the other breast but have had no swelling or pain symptoms).
I have spent the last 3 days researching online and trying to determine if radiation is really needed in my case. I learned that the Oncotype DX test could assist in decision making. I have been offered partial breast radiation (not sure which types), if I sign a waiver due to the fact no lymph nodes could be found from surgery (rare situation I am being told, but definitely does not help in an analysis).
One of the primary reasons I do not want to do radiation is that my breast has been extremely, extremely swollen and painful. My concern is that this problem will continue or worsen with radiation per what I have read about side effects i.e. seromas (note: I also have nerve inflammation issues & make alot of scar tissue from surgeries, which have both caused difficulty in recuperating from a variety of surgical interventions during my lifetime).
My situation is odd apparently due to the following: 1. surgery pathology could find no cancer and the assumption is that the biopsy surgery removed it in its entirety (the reason this could happen was that the invasive duct carcinoma was only 2 mm and found via an MRI not mammogram due to a radial scar in other breast). 2. they could not find any lymph nodes in my pathology even though they took 2 large samples, including armpit, so the radiologist stated it is not definitive that the cancer has not gone into lymph nodes (but I believe it has not as biopsy pathology report also states negative for lymphovascular invasion, at least I hope, but given the carcinoma had tubular features--not sure if that means tubular carcinoma or just tubular features--that it would be so slow growing and caught so early that it would not have traveled).
Since no carcinoma removed at surgery I am trying to find out if my older biopsy could be used for the Oncotype DX test. This test information, from what I have read, would be helpful in determine to do or not do radiation.
The biopsy pathology reports state grade 1, stage 1, ER 97%, PR 93% (have been on HRT for 17 years since complete hysterectomy mid 40s, HER2 negative, Ki-67 10%. Genetic testing negative. However, my pathology summary states invasive, yet it also states Focal DCIS (which I do not know if that means if it was just DCIS or had it evolved into being invasive). I wish my oncologist, surgeon & radiologist team would have provided me more specifics on interpretations of my pathology.
Another concern: The removal occurred 2 months ago, whereas lumpectomy only 3 weeks ago. I have read that over 8 weeks from surgery (keep in mind my real surgery/removal of cancer occurred 2 months ago at biopsy and not at lumpectomy) radiation begins to loses its efficacy (that report can be found on this website). They do not think I would be ready for radiation for another 30 - 45 days due to my breast swelling and pain. Which means it isn't really 8 - 10 weeks out, it is 13+ weeks out if I opt for radiation (note: they are stating I should have radiation and I know that is protocol, but again given the early stage, type, timing, and possible side effects I am just not sure if it will be worthwhile). I am 62. Otherwise good health. But I do not want to expose myself to more potential pain and problems if radiation is really not moderately or highly beneficial in my case.
I am looking for any advice to make an informed decision on to do radiation or not. I will begin hormone suppression therapy--arimidex after the radiation decision is made. I am guessing I won't be able to have the Oncotype DX test done from a biopsy removal.
I have read at least a dozen clinical trials, all having somewhat conflicting recurrence rates (though much less than the radiologist threw out trying to make me do radiation). So any thoughts or questions I should be asking would be helpful, especially given some missing information to know whether or not this is truly considered a low recurrence scenario for me. Thank you.
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I agree with Grian. Having done research myself, I know that one study isn't enough. But it's an interesting proposition. I was told that had I been age 70, they wouldn't do radiation. I don't know what's magic about that number. I feel blessed to benefit from all of the research that has been done to this point and I know that five years from now, more discoveries and changes will have occurred that might change everything we endured.
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