Topic: How large does Tumor gets chemo and herceptin

Forum: HER2+ (Positive) Breast Cancer — Testing, treatment, side effects, and more.

Posted on: Jan 21, 2012 02:05PM

Posted on: Jan 21, 2012 02:05PM

ccjj wrote:

Curious... my step mom had BMX due to high grade DCIS in left and suspicious area of concern in right.  After surgery, pathology came back with invasive ILC Her2+ in right breast. Very small, less than 1/2 cm. Sentinel nodes were clear.  Surgeon thought no chemo would be needed.  I thought all Her2+ invasive tumors were treated with chemo and herceptin.  What size warrants chemo and herceptin?

Dx 7/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/9 nodes, ER+/PR+, HER2+
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Jan 23, 2012 06:06PM voraciousreader wrote:

Trastuzumab Benefit Seen Even in Small HER2-Positive Tumors

Roxanne Nelson

December 1, 2010 - The addition of trastuzumab (Herceptin) to chemotherapy is now the standard of care for many patients with early HER2-positive breast cancer, but not all; those will very small tumors are often not treated.

Women with small T1a (≤0.5 cm) and T1b (from 0.5 to 1 cm) node-negative (N0) cancers usually have an excellent prognosis and are not believed to derive a benefit from adjuvant therapy.

However, a review paper published in the December issue of the Lancet Oncology points out that there is "strong circumstantial evidence to justify some form of trastuzumab-based adjuvant therapy in most women with T1b, N0, HER2-positive breast cancers."

According to retrospective data, note authors Susana Banerjee, PhD, and Ian E. Smith, MD, from the Royal Marsden Hospital, London, United Kingdom, some small HER2-positive cancers might have a worse clinical outcome than others.

"Retrospective studies of . . . T1a,bN0 breast cancer, treated with local therapy and usually without adjuvant therapy, have consistently reported a 10-year relapse-free survival of more than 90%," the authors write. "However, many of these studies have limitations, including small sample size, short follow-up, and some patients receiving adjuvant systemic therapy."

The risk of recurrence in this subgroup of breast cancer patients and the true benefit of any adjuvant treatment remain unclear, they note. In addition, HER2-positive breast cancer, which accounts for approximately 15% to 20% of cases, is a distinct biologic subgroup and is associated with an aggressive clinical course.

Not Considered Low Risk

Drs. Smith and Banerjee note that retrospective data from several studies suggest that HER2 is a marker of poor prognosis in patients with small node-negative cancers. In fact, they point out, these tumors have a substantially increased risk for recurrence and should not be considered low risk.

As previously reported by Medscape Medical News, some researchers believe that all low-grade HER2-positive tumors should be treated with adjuvant systemic therapy, no matter what their size. Two studies that were presented at the 2008 San Antonio Breast Cancer Symposium (SABCS) found that patients with this tumor subtype have a poorer prognosis and a higher risk for recurrence.

"The biology of the tumor, and not the size or grade, matters most in these patients," Sian Tovey, MD, from the Glasgow Royal Infirmary, Scotland, who presented the results from one of the studies at the SABCS, told Medscape Medical News at the time. "Any patient who is HER2 positive should be categorized as high risk and should receive adjuvant trastuzumab therapy."

In their review, Drs. Smith and Banerjee point out that the number of women being diagnosed with T1a,bN0 primary tumors is rising because of improved breast cancer awareness and screening programs. Thus, there is a need for clarification of the optimal treatment.

Benefit Suggested, Inconsistent Guidelines

The pivotal adjuvant trastuzumab trials, which involved more than 14,000 patients, excluded women with tumors smaller than 1 cm. But there is indirect evidence that trastuzumab might benefit patients with these smaller tumors, they write. For example, a subset analysis of the Herceptin Adjuvant (HERA) trial showed that those with tumors 1 to 2 cm in size derived at least as much clinical benefit from 1 year of adjuvant trastuzumab as did the overall cohort (Lancet. 2007;369:29-36).

In another subanalysis from the Breast Cancer International Research Group 006 trial, results suggested that node-negative patients gained at least as much benefit from trastuzumab as did the overall group, both for disease-free and overall survival (SABCS 2006. Abstract 52). These results supported those from the HERA study, the authors note.

The lack of supportive evidence, however, places clinicians in a dilemma when they are trying to select appropriate therapy for this group of breast cancer patients. "Present guidelines for the systemic treatment of small, HER2-positive breast cancers are uncertain and inconsistent," Drs. Smith and Banerjee write.

Future Directions

Ideally, prospective randomized trials of trastuzumab-based treatment are needed for this population, but they are not likely to ever be conducted for a number of reasons, the authors write. Because of the low incidence of small HER2-positive breast cancers and the relatively low event rate, a large number of patients would be needed, which would be expensive. The design of trials has already proven difficult to agree upon, and successful recruitment to a randomized trial with a no-treatment group would be challenging. Finally, the choice of treatment for the investigational group is controversial.

Taking this into consideration, they suggest that the "next best approach would be a nonrandomized prospective study." Additional supportive evidence could be garnered from ongoing trials that include patients with small HER2-positive tumors.

The authors offer 2 more recommendations. One is to create prospective databases on the management of patients with HER2-positive cancers, which would provide retrospective analyses of outcomes associated with different treatments. The second is to incorporate molecular markers and multigene assays into clinical datasets, which might help identify and stratify relative risk within this subgroup.

"As in other areas of breast cancer management, this type of approach will eventually lead to a much more accurate prediction of which systemic therapies, if any, will most benefit each individual patient with these difficult, small, HER2-positive cancers," they conclude.

Dr. Smith reports receiving occasional honoraria for lecturing from Roche. Dr. Banerjee has disclosed no relevant financial relationships.

Lancet Oncol. 2010;11:1193-1199.

Doctor told me regarding my prognosis that I WASN'T on the Titanic! Hmmm...Really?....Okay! 02/2010 Pure Mucinous Breast Cancer, Oncotype DX 15, Stage 1, Grade 1, 1.8 cm, 0/2 nodes, ER+ 90% /PR+ 70% HER2- (+1)
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Jan 23, 2012 06:20PM melly1462 wrote:

First, many thanks to you ladies providing all this info!  I know it takes an insane amount of time to do the research.

@evebarry:  I couldn't agree more.  I stay confused.  After finally coming to grips with the need for chemo, the RO casually mentions the MO waiting on my Oncotype score before seeing me.  Really??!!   According to John Hopkins and the NCCN my HER+ status trumps the Oncotype.  Furthermore, the test should NOT even be done on HER+ women. 

Appt with MO tomorrow.  We'll see.  Thank you again, these boards have been a source of comfort.

Lumpectomy 1/13/12. 5 day radiation with SAVI. TCH x6, Herceptin til Feb. 2013. Considering declining Tamoxifen, looking for alternatives. Dx 11/29/2011, IDC, 2cm, Stage IIA, Grade 3, 0/1 nodes, ER+/PR-, HER2+ Surgery 9/17/2012 Prophylactic ovary removal
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Jan 23, 2012 06:29PM voraciousreader wrote:

Eve... When making treatment decisions there are two parts to the equation. One is Stage and the second part is based on the characteristics of the tumor. That is why the treatments are all over the place. I don't understand why you keep emphasizing that you are Stage 1A or emphasizing you are "only" Stage 1A? Your stage is only one piece of the equation. In fact, when you go to the cancermath website to look up mortality figures they do not ask for your Stage. They ask for the size of your tumor, hormonal status, histology of tumor, Grade and how many nodes. All of that information guides treatment recommendations.

Doctor told me regarding my prognosis that I WASN'T on the Titanic! Hmmm...Really?....Okay! 02/2010 Pure Mucinous Breast Cancer, Oncotype DX 15, Stage 1, Grade 1, 1.8 cm, 0/2 nodes, ER+ 90% /PR+ 70% HER2- (+1)
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Jan 23, 2012 06:39PM voraciousreader wrote:

Eve... I want to clarify for others that based on the characteristics of your tumor, your doctor recommended chemo and Herceptin which was considered Standard of Care, based on the NCCN guidelines. The discussion we are having HERE is regarding a smaller tumor than yours which the present Standard of Care based on the current NCCN guidelines does NOT recommend chemo and Herception.

Doctor told me regarding my prognosis that I WASN'T on the Titanic! Hmmm...Really?....Okay! 02/2010 Pure Mucinous Breast Cancer, Oncotype DX 15, Stage 1, Grade 1, 1.8 cm, 0/2 nodes, ER+ 90% /PR+ 70% HER2- (+1)
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Jan 23, 2012 07:00PM bluedasher wrote:

Iago, in that study they didn't break out results for HER2+ hormone- vs HER2+ hormone+. Since only 10% of the group were HER2+, perhaps it was too small to break into hormone positive and hormone negative. There were 38 hormone- in the 98 HER2+ cases. From the poster tables, it is possible to calculate how many hormone+ and hormone- events there were amongst the HER2+ group because they give the total events for Hormone receptor postive and negative and they give the numbers in HR-positive HER2- and TN subgroups. When I do that calculations, I get numbers that are very close for hormone+ HER2+ vs hormone- HER2-.
The whole world is a narrow bridge and the main thing is to not fear. Dx 9/2008, IDC, <1cm, Stage IB, Grade 2, 0/5 nodes, ER-/PR-, HER2+ Targeted Therapy Herceptin (trastuzumab) Surgery Lumpectomy: Left Radiation Therapy Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel)
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Jan 23, 2012 08:09PM AlaskaAngel wrote:

The answer is, no one knows whether the chemotherapy is necessary or not.

A.A.

Dx 12/3/2001, DCIS/IDC, Left, 1cm, Stage IA, Grade 3, 0/1 nodes, ER+/PR+, HER2+, Surgery 1/3/2002 Lumpectomy: Left; Lymph node removal: Left, Sentinel Chemotherapy 3/12/2002 Adriamycin (doxorubicin), Cytoxan (cyclophosphamide), Fluorouracil (5-fluorouracil, 5-FU, Adrucil) Radiation Therapy 9/10/2002 Breast Hormonal Therapy 11/15/2002 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jan 24, 2012 04:22AM Rubyluby wrote:

Its a question of doing a cost benefit analysis or weighing up the trade offs associated with treatment and with not having treatment. Herceptin and chemo do have side effects. The case for having chemo and Herceptin was absolutely clear in my own situation (1 cm tumor, grade 3, hormone negative), however this treatment put me into instant chemical menopause and I gained 30 pounds which I am still struggling to lose, 3 years after diagnosis (having been a healthy weight all my adult life).  As a result, my cholesterol levels have sky rocketed and I have to take a hefty statin now. My treatment may have reduced my chances of recurrence from about 23% to about 8%, but what has the cost been my health in terms of heart disease? By what percent has my risk of heart disease gone up?  

These are difficult decisions, I realise, and I wish you the best of luck.

Lucy 

Dx 1/13/2009, IDC, Right, 1cm, Stage IA, Grade 3, 0/5 nodes, ER-/PR-, HER2+
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Jan 24, 2012 06:10AM sassa wrote:

When I was talking about a 25% chance of the HER2+ cancer spreading through the blood without lymph node involvement, I was talking about the initial presentation, not recurrence chances.

So when first undergoing staging, there is a 25% chance that BC will be found outside the breast with no involved lymph nodes.  This is true of tumors that would be considered stage one because of size.  I am not sure of the chances for larger tumors.

I found this out in my reading, unfortunately I don't remember where I came across it.  I did confirm this with my oncologist and she said it was true.

For my next set of figures, I am talking about after mastectomy and chemo.  Herceptin was the first year after chemo so when I say two years, that is two years after finishing my AC, one year after finishing my herceptin.

As far as recurrence went, the chances she told me was 50-75% in the first year after my mastectomy with no chemo.  Mastectomy and chemo dropped the chance down to 30% during the first year.  Finishing the year of herceptin dropped the chance down to 17% in the second year after chemo.

Because I am hormone negative, my chances of recurrence started decreasing after year 2, dropped even more after year 3, and now as I approach my 5 year post chemo check up, if I am still NED, my chances will be down around 1%.  After 10 years NED, I can consider myself "cured" because mu chance of recurrence will be about 0%.

Dx 11/6/2006, IDC, 1cm, Stage IA, Grade 3, 0/9 nodes, ER-/PR-, HER2+
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Jan 24, 2012 06:54AM voraciousreader wrote:






Prognosis in women with small (T1mic,T1a,T1b) node-negative operable breast
cancer by immunohistochemically selected subtypes.

Print Print this page






Sub-category:ER+



Category:Breast Cancer - HER2/ER



Meeting:2011
ASCO Annual Meeting



Session Type and Session Title:General Poster
Session, Breast Cancer - HER2/ER



Abstract No:546



Citation:J Clin Oncol 29: 2011 (suppl; abstr 546)



Author(s):G. Cancello, P. Maisonneuve, N. Rotmensz,
G. Viale, M. G. Mastropasqua, G. Pruneri, E. Montagna, S. Dellapasqua, M.
Iorfida, A. Cardillo, P. Veronesi, A. Luini, M. Intra, O. D. Gentilini, E.
Scarano, D. Pastrello, A. Goldhirsch, M. Colleoni; European Institute of
Oncology, Milan, Italy; Division of Pathology, European Institute of Oncology,
Milan, Italy


Abstract Disclosures



Abstract:


Background: Knowledge is limited about prognostic significance of
breast cancer subtypes among women with small invasive node-negative breast
tumors. Methods: We explored patterns of recurrence in 1,715 patients
with pT1mic/T1a/T1b, node-negative operable breast cancer according to four
immunohistochemically defined tumour subtypes: (i) Luminal A (ER-positive,
PgR-positive, HER2-negative and Ki-67<14%); (ii) Luminal B (ER-positive
and/or PgR-positive, HER2-positive and/or Ki-67≥14%); (iii) HER2-positive, both
endocrine receptors absent; and (iv) triple negative. Results: At
multivariate analysis, patients with the triple-negative subtype showed an
increased risk of loco-regional relapse (HR 3.37; 95%CI: 1.31-8.70) and breast
cancer related events (HR 2.17; 95%CI: 1.04-4.53). Overall, Luminal B was not
associated with a significant higher risk of recurrence compared with Luminal A,
while the subgroup of Lumimal B with HER2-positive has a 2-fold risk of reduced
breast cancer survival compared with Luminal A subtype. HER2 was the only
subtype with a statistically significant increased risk of loco-regional relapse
(HR, 4.77; 95%CI: 1.65-13.8), distant metastases, and reduced breast cancer
related event-free survival and overall survival (HR, 2.95; 95%CI: 1.07-8.10) if
compared with the Luminal A subtype, at multivariate analysis.
Conclusions: Patients with small size, node-negative breast cancer are at
higher risk of relapse if with HER2-positive endocrine receptor absent or
triple-negative disease.

Doctor told me regarding my prognosis that I WASN'T on the Titanic! Hmmm...Really?....Okay! 02/2010 Pure Mucinous Breast Cancer, Oncotype DX 15, Stage 1, Grade 1, 1.8 cm, 0/2 nodes, ER+ 90% /PR+ 70% HER2- (+1)
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Jan 24, 2012 09:35AM AlaskaAngel wrote:

Please note, the information does not mention that using standard treatment with the addition of chemotherapy (and trastuzumab) results in some patients with treatment failure anyway.

"Conclusions: Patients with small size, node-negative breast cancer are at
higher risk of relapse if with HER2-positive endocrine receptor absent or
triple-negative disease."

A.A.

Dx 12/3/2001, DCIS/IDC, Left, 1cm, Stage IA, Grade 3, 0/1 nodes, ER+/PR+, HER2+, Surgery 1/3/2002 Lumpectomy: Left; Lymph node removal: Left, Sentinel Chemotherapy 3/12/2002 Adriamycin (doxorubicin), Cytoxan (cyclophosphamide), Fluorouracil (5-fluorouracil, 5-FU, Adrucil) Radiation Therapy 9/10/2002 Breast Hormonal Therapy 11/15/2002 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)

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