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Topic: Prognosis: Stage or Oncotype Score?

Forum: Stage I Breast Cancer — Meet other members with a Stage I breast cancer diagnosis to share information and support.

Posted on: Oct 9, 2020 07:33PM

StartNew12212 wrote:

I'm struggling with my prognosis. I was diagnosed stage 1A which is an outstanding prognosis (90%+ survival/no recurrence) yet my Oncotype score was 31 which is only a 74% chance of survival/no recurrence. So which trumps which? Am I to go by the staging or the score? This is something I will discuss with my doctors, but I just don't get it and it's upsetting for me. I'm wondering if anyone knows. Thank you.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 9, 2020 09:09PM AliceBastable wrote:

The oncotype score tells you if your cancer treatment needs chemotherapy.

Endometrial cancer 2010, basal cell multiples, breast cancer 2018, kidney cancer 2018. Boring. Hope it stays that way. Dx 5/2018, ILC, Left, 2cm, Stage IA, Grade 1, 1/1 nodes, ER+/PR+, HER2- Surgery 7/11/2018 Lumpectomy: Left; Lymph node removal: Sentinel Surgery 8/8/2018 Radiation Therapy 10/29/2018 Whole-breast: Breast, Lymph nodes
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Oct 9, 2020 09:22PM moth wrote:

IMO the oncotype gives you more personalized information based on the genomic structure of your tumor. What is your oncotype recurrence score if you do chemo & hormone treatment? It should give you 2 scores - untreated and treated.

I take weekends off

Initial dx at 50. Seriously?? “Sometimes the future changes quickly and completely and we’re left with only the choice of what to do next." blog: Never Tell Me the Odds

Dx 12/2017, IDC, Left, 1cm, Stage IA, Grade 3, 0/5 nodes, ER-/PR-, HER2- (IHC) Surgery 12/12/2017 Lumpectomy: Left; Lymph node removal: Sentinel Chemotherapy 2/14/2018 AC + T (Taxol) Radiation Therapy 8/13/2018 Whole-breast: Breast Dx 2/2020, IDC, Stage IV, metastasized to liver/lungs, Grade 3, ER-/PR-, HER2- Chemotherapy 3/18/2020 Taxol (paclitaxel) Immunotherapy 3/19/2020 Tecentriq (atezolizumab) Chemotherapy 11/26/2020 Abraxane (albumin-bound or nab-paclitaxel) Dx 12/9/2020, IDC, Right, Stage IV, metastasized to lungs, Grade 3, ER+/PR-, HER2- (IHC) Radiation Therapy 12/9/2020 External Hormonal Therapy 12/16/2020 Femara (letrozole) Dx 1/28/2021, IDC, Left, Stage IV, metastasized to bone Radiation Therapy 3/3/2021 External: Bone
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Oct 9, 2020 09:50PM Beesie wrote:

StartNew,

You say "my Oncotype score was 31 which is only a 74% chance of survival/no recurrence." But isn't that the percent survival assuming endocrine therapy only (Tamoxifen or an AI), not incorporating the benefit of chemo? Your chance of survival will be significantly higher with chemo + endocrine therapy.

And the 74% - or alternately, a 26% risk of mets - seems high for a score of 31. Do you have a copy of your report? I found this sample report on-line, for a 32 Oncotype score. It shows a 20% risk (80% chance of survival/no metastatic recurrence) with an AI or Tamoxifen alone.



Additionally, while the massive TAILORx study from a couple of years ago didn't include an 'Endocrine therapy only' arm for scores above 25, you can see from their results graph that with chemo, a 31 Oncotype score is associated with a 9-year metastatic recurrence risk that falls right around 7.5%.



Technically I would think that the Oncotype score is more accurate because it is based on a genetic assessment of your own tumor, but Staging (particularly the new Prognostic Pathological Staging) and Oncotype scores should be pretty consistent. What's critical however is the assumption that the patient goes through with standard-of-care treatment, as you are doing (since you are having chemo and I expect will be taking endocrine therapy). Based on that, it looks to me as though your Oncotype score prognosis and your Staging are in fact quite consistent.



Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Oct 9, 2020 11:23PM StartNew12212 wrote:

Hi Everyone,

Here's my report. It's 76% (or 24% chance of recurrence). Anyone know what the 18%, 30% mean in parenthesis. Is this the range? If so, eeek. :(

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 9, 2020 11:24PM StartNew12212 wrote:

Hi Alice, Yes, and it also gives you a recurrence risk which is scaring me as it is quite different than the risk on a Stage 1 diagnosis.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 9, 2020 11:25PM StartNew12212 wrote:

Hi Moth, 24% no chemo and 15% with chemo. That is still high in my mind.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 9, 2020 11:26PM StartNew12212 wrote:

Thanks Beesie! You're amazing, as usual. My report above.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:02AM ShetlandPony wrote:

No, the 24% is labeled “distant recurrence risk with AI or TAM alone ”, but the 15% is labeled “chemotherapy benefit” (Not 15% recurrence risk). I’ll let Beesie explain...

2011 Stage I ITCs sn, premenopausal, Oncotype 16. 2014 Stage IV mets breast,liver. TaxolNEAD. Ibrance+letrozole 2yrs. Fas+afinitor nope. XelodaNEAD 2yrs. Eribulin,Doxil nope. SUMMIT FaslodexHerceptinNeratinib for Her2mut NEAD Dx 2011, ILC, 1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Dx 2014, ILC, 2cm, Stage IV, metastasized to liver/other, Grade 2, ER+/PR+, HER2- Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole-breast: Breast Surgery Lumpectomy
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Oct 10, 2020 12:12AM StartNew12212 wrote:

Thanks, Shetland. Yeah, I think I am not understanding something here....

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:18AM moth wrote:

The 15% is "The Group Average Absolute Chemotherapy Benefit is the potential reduction in distant recurrence risk across all ages within this range of Recurrence Score results when chemotherapy is added." So it's not an absolute risk. It's a percentage risk reduction.

So the thing is.... women as a whole have about a 10% chance of getting breast cancer in their lives. Once you've had cancer once, you're at even higher risk - either of a recurrence or of a new primary. Sucks, but there it is. About 20-30% of early stage breast cancer come back as metastatic. This is the depressing bit of pinktober that doesn't really get enough attention :(

Your risk as a hormone positive stage 1 is on the lower end so you do all you can and hope that you'll be on the lucky side of the draw.

I take weekends off

Initial dx at 50. Seriously?? “Sometimes the future changes quickly and completely and we’re left with only the choice of what to do next." blog: Never Tell Me the Odds

Dx 12/2017, IDC, Left, 1cm, Stage IA, Grade 3, 0/5 nodes, ER-/PR-, HER2- (IHC) Surgery 12/12/2017 Lumpectomy: Left; Lymph node removal: Sentinel Chemotherapy 2/14/2018 AC + T (Taxol) Radiation Therapy 8/13/2018 Whole-breast: Breast Dx 2/2020, IDC, Stage IV, metastasized to liver/lungs, Grade 3, ER-/PR-, HER2- Chemotherapy 3/18/2020 Taxol (paclitaxel) Immunotherapy 3/19/2020 Tecentriq (atezolizumab) Chemotherapy 11/26/2020 Abraxane (albumin-bound or nab-paclitaxel) Dx 12/9/2020, IDC, Right, Stage IV, metastasized to lungs, Grade 3, ER+/PR-, HER2- (IHC) Radiation Therapy 12/9/2020 External Hormonal Therapy 12/16/2020 Femara (letrozole) Dx 1/28/2021, IDC, Left, Stage IV, metastasized to bone Radiation Therapy 3/3/2021 External: Bone
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Oct 10, 2020 12:19AM Beesie wrote:

The "95% CI (18%, 30%)" represents the range of the results. 24% is the average, with 95% confidence that the results will fall in a range of 18% to 30%.

Your signature line indicates node negative but your Oncotype results assume you to be node positive. That's why your results were based on the TransATAC study whereas node negative reports are based on NSABP B-14 (as shown in the sample report in my previous post). To my understanding, TransATAC included post-menopausal women only and did not include a chemo arm; all participants took endocrine therapy only. I guess that's why the SWOG 8814 study is referenced for the chemo benefit.


Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Oct 10, 2020 12:25AM StartNew12212 wrote:

Moth, You wrote "About 20-30% of early stage breast cancer come back as metastatic" then what are these percentages in the mid-even high 90s-of cancer free survival for early stage breast cancer?

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:30AM StartNew12212 wrote:

Interesting, Beesie. I had micromets in the one node they took. I don't know if you recall, but my surgeon could not find my sentinel node so the node that was taken out may or may not be the sentinel node. I feel like I do not have a good idea about node involvement at this point-so frustrating. Maybe this is why my oncologist ordered the test with the assumption I was node positive. I will have to ask him. So does this mean, if I was indeed node negative, that I would have a totally different score? Does the oncotype consider micromets to be positive for the purpose of their test? Thank you!

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:33AM Beesie wrote:

The 15% is "The Group Average Absolute Chemotherapy Benefit" so it is an absolute risk reduction. But it's an average benefit for everyone with scores between 31 and 100. The range of absolute risk reduction benefit from chemo is 3% to 28%.

If you achieved the average 15 point benefit, your risk with chemo would come down to 9% (24%-15%). But that seems like more benefit than chemo usually provides. And since your score is at the bottom of the 31-100 range, your benefit is likely to be less than the 15% average.

Under the 15% box, it indicates that the estimated chemo benefit for individual scores is on page 2. So what does it say on page 2?


Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Oct 10, 2020 12:34AM - edited Oct 10, 2020 12:38AM by ShetlandPony

That 20-30% averages everybody — stage I, II, III; various Oncotype scores, treatment choices, etc. Some of these people have a low risk, some have a moderate risk, some have a high risk. The statistic tells us that if you take the whole group of early stage (not metastatic/stage iv) bc patients, that around 20-30% will recur. Statistics are useful for defining the problem, for research, etc. but they do not say what will happen to YOU as an individual.

2011 Stage I ITCs sn, premenopausal, Oncotype 16. 2014 Stage IV mets breast,liver. TaxolNEAD. Ibrance+letrozole 2yrs. Fas+afinitor nope. XelodaNEAD 2yrs. Eribulin,Doxil nope. SUMMIT FaslodexHerceptinNeratinib for Her2mut NEAD Dx 2011, ILC, 1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Dx 2014, ILC, 2cm, Stage IV, metastasized to liver/other, Grade 2, ER+/PR+, HER2- Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole-breast: Breast Surgery Lumpectomy
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Oct 10, 2020 12:36AM StartNew12212 wrote:

True, Shetland.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:41AM Beesie wrote:

Yes, your recurrence risk would be lower with a 31 score on the node negative scale, as per my example with the 32 score.

I remember now your situation with the SNB and micromet. I don't know how Oncotype handle micromets. Their node positive report covers patients with up to 3 fully positive nodes, so one would think that would be quite different than a micromet.

Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Oct 10, 2020 12:43AM StartNew12212 wrote:

Thank you, Beesie!

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 12:59AM ShetlandPony wrote:

That discussion about the node is here, and it seems that the node they did get had isolated tumor cells, not a micrometastasis. ITCs mean less cancer than a micromet and are considered node negative. Of course, as discussed, we do not know what the sentinel node would have shown, so that’s why we are looking at the node-positive score.

https://community.breastcancer.org/forum/91/topics/877359?page=1#post_5581166


2011 Stage I ITCs sn, premenopausal, Oncotype 16. 2014 Stage IV mets breast,liver. TaxolNEAD. Ibrance+letrozole 2yrs. Fas+afinitor nope. XelodaNEAD 2yrs. Eribulin,Doxil nope. SUMMIT FaslodexHerceptinNeratinib for Her2mut NEAD Dx 2011, ILC, 1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Dx 2014, ILC, 2cm, Stage IV, metastasized to liver/other, Grade 2, ER+/PR+, HER2- Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy Whole-breast: Breast Surgery Lumpectomy
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Oct 10, 2020 01:12AM StartNew12212 wrote:

Thanks, Shetland! I didn't realize ITC was less than a micromet-I thought they were synonymous. That's interesting. So, once again, the question mark looms due to the sentinel node failure. So frustrating! I feel like I do not have a good feel regarding prognosis, stage, and now even the accuracy of the oncotpye score. I feel like my surgeon failed-big time-in not at least taking out a couple extra nodes to get a better picture of what is really going on with my lymphatic system.

But I digress...

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes
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Oct 10, 2020 11:11AM Beesie wrote:

Ah, ITC and not micromets. Yes, there is a difference, since ITC is considered node negative. So it's very interesting that your doctor had your Oncotype score done based on you being node positive. I guess that was his way of compensating for the failed SNB and not knowing for sure if there might be any more nodal involvement.

But it's interesting that your MO made a different assumption with your staging. Your Prognostic Pathological Stage is Stage IA, as you indicate, based on your diagnosis being T2, N0 (i.e. assuming node negative based on ITC), M0, Grade 2, ER+/PR+/HER2-. But if your MO had assumed you to be node positive (changing the N from N0 to N1), your Prognostic Pathological Stage would be Stage IB. And just to confuse things further, your Anatomical Stage, which is the traditional method of staging and the only way staging was done until late 2018, is Stage IIA, based on T2, N0, M0.

As for your Oncotype score, just to clarify, whether you are node negative or node positive, your Oncotype score would be the same. The test is the same; 21 genes within the tumor are analysed and scored, resulting in the Oncotype score. So your score would be a 31 whether node negative or node positive. But the recurrence risk and chemo benefit associated with the score is different depending on the nodal status. The node positive results for a 31 score are the results you received. The node negative results for a 31 score are the chart and graph I posted previously (well, the chart shows a 32 score, but obviously a 31 score would be very close to that).

One of the big problems with Oncotype recurrence risk results is that Genomic Health (the Oncotype people) use several different research studies. Even in your report, your recurrence risk with endocrine therapy only is based on one study (TransATAC) while the benefit from chemo is based on another study (SWOG 8814). So this means that there are different risk figures out there for the same score, depending on which study is referenced.

Look at this graph that I found on-line. It shows recurrence risk and chemo benefit (at 5 years, however, not 9 years) based on SWOG 8814; I have added in lines to highlight a 31 Score and the corresponding recurrence risks with and without chemo. This graph also answers the question about how Oncotype handle micromets - you can see that at the top of the chart, it states "Micromets & Node Positive (1-3)".


All this probably just confuses things more. The big problem, of course, is that your diagnosis is not definitive, since the SNB failed. Adding to the confusion is the fact that your MO has made one assumption (node positive) for your Oncotype results and another assumption (node negative) for your Staging. The difference in risk is significant, as the various graphs show. If you truly only had ITC and therefore are Node Negative, you are Stage IA and with your Oncotype 31 score, your recurrence risk after chemo is approx. 7.5% (as per the TAILORx chart I posted yesterday). But if you are in fact node positive, then your stage is higher (although likely just Stage IB), and your prognosis may be more in line with the information from your node positive Oncotype report and the graph that I included in this post. All that to say that your original question about your prognosis - whether it should be based on your staging or your Oncotype results - is something you need to talk to your MO about.

Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Oct 10, 2020 12:52PM - edited Oct 10, 2020 12:52PM by StartNew12212

Wow, Beesie! Thank you for all of that excellent information. I definitely need a meeting with my oncologist.

Dx 6/2020, IDC, Left, 4cm, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 8/12/2020 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 9/29/2020 AC + T (Taxol) Radiation Therapy Breast, Lymph nodes

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