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 04:05PM

Posted on: Jan 21, 2012 04:05PM

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 24, 2012 12:07PM - edited Jan 24, 2012 12:10PM by Hindsfeet

VR...maybe the oncologist should explain to their patients that the stage is only one factor of the treatment plan. I was told, and so many here at bco seem to be saying that staging has a lot to do with treatment plan. And, my oncologist said you are stage 1a and this is your treatment plan...chemo/herceptin. I'm scratching my head thinking last March I was 1a and now I'm 1a so staging for early cancer treatment is not all the same. And, I' don't think I'm the only one who is confused about this...for early stage staging.

I suppose I am fuming over the fact the doctors with a smile say, you are lucky, you are only stage 1a, and you are cancer free BUT....you have to go through chemo and etc. If I chose to go through all that they asked me to do with all the possible side effects am I so lucky? Plus, they said your final path report was 1.8C ... my biopsy was 2C ... so 1.8C they said my tumor was small which is why I am stage 1a. I know the her2 positive is why I was encouraged to do further treatment... If I did not have the her2+++ factor, and I was grade 3, with the final path report size 1.8 C I probably wouldn't have needed more than a mx...right?

Dx 6/13/2014, IDC, 1cm, Stage IV, Grade 3, mets, ER+/PR+, HER2+
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Jan 24, 2012 12:20PM dancetrancer wrote:

Evebarry, I think they would have run an oncotype on you if that had been the case. 

I read the NCCN guidelines, and it says that the oncotype dx is:

"an option when evaluating patients with primary tumors characterized as .6 to 1 cm in size with unfavorable features or > 1 cm, and node negative, hormone receptor positive and HER2 negative." 

Sooooo, I am thinking if you had been HER2 negative, with nodes negative and your IDC being > 1 cm, they would most likely have run an oncotype on you to determine if you needed chemo.  (In my case, if my HER2 comes back negative, they most likely will not run the oncotype and tell me no chemo, since my IDC is only 3 mm.)   

P.S.  I'm confused...you are T1a?  I read that this for < 5 mm tumors.  

Cold caps work! coldcapphotos.shutterfly.com/p... TCH: 4/10 - 6/13/12; 33 rads; BMX w/fat grafting; DX: 7/29/11 @ age 43: Stage 1A on L (3 mm IDC w/ 6 cm DCIS, Gr 2 ER/PR+, HER2+) 0/3 nodes; Stage 0 on R (2 mm DCIS); see bio.
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Jan 24, 2012 02:00PM - edited Jan 24, 2012 02:01PM by bluedasher

Evebarry, T1a is less than 0.5 cm and Stage Ia is that plus node negative. T1b is 0.5 cm to 1 cm. If your tumor was 1.8 cm, then it would fall in T1c and since your nodes were negative, your stage would be Ic. Chemo and Herceptin is recommended in the NCCN guidelines for T1c HER2+ regardless of ER/PR status. It's tumors that are below 1 cm that are in a gray area for chemo and Herceptin. The copy of NCCN guidelines that I have (from 2009) says no chemo below 0.5 cm and consider it depending on tumor features between 0.5 and 1 cm. Research such as the MD Anderson retrospective study make some consider chemo for tumors below 0.5 cm.

The size that you are given at biopsy is an estimate based on the external scans (e.g. mammogram and ultrasound). They can'talways tell from those what part of the lump is invasive or even cancerous. My estimate at that point was about 3 cm. My surgeon explained that it was only an estimate and that the size from the pathology after surgery might be higher or lower than that.

After surgery is when they can really examine the lump and give a more accurate number. It turned out that part of my lump was a non-cancerous cyst and part was DCIS so the size of my invasive tumor after surgery was 0.9 cm. Even that is an estimate. For example, my bipopsy was vacuum assisted which removes more than a needle biposy so it's possible that my tumor was slightly over 1 cm rather than slightly under. I was making the chemo decision before the MD Anderson study results were released and concern that the tumor might have been bigger than 1 cm helped me decide.

If your tumor was HER2-, they might have used oncotype to help decide whether to do chemo. NCCN suggests that greater than 1 cm should have chemo if oncotype isn't done or if it is done and the score is over 18. It also suggests that if it is between 0.5 and 1 cm and has bad features.

Voraciousreader, The study you just posted had results that contradict the MD Anderson study regarding hormone negative and hormone positive effect on HER2+ tumors under 1 cm. In the MD Anderson study, recurrence was about the same for HER2+ hormone negative and HER2+ hormone positive. In the Cancello, et al. study, if I'm reading it correctly, hormone positve HER2+ was less likely to recur than HER2+ hormone negative but more likely than HER2- hormone positive. I wonder what the difference was, maybe just statistical variation since most Stage Ia and Ib tumors are HER2- so the sample size isn't very large?  Or perhaps there was a difference in treatment - the second study doesn't say that they excluded women who had chemo.

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 24, 2012 02:02PM suzieq60 wrote:

Eve - the stage is totally blown out of the water when HER2 comes in to it - that's the difference. I did look up 1A and it aplies to tumours up to 2cm with negative nodes.

Stage IA: T1, N0, M0: The tumor is 2 cm (about 3/4 of an inch) or less across (T1) and has not spread to lymph nodes (N0) or distant sites (M0).

2nd diagnosis October 2010 - IDC 5.8mm node negative - missed on mammogram in October 2009 Dx 10/13/2009, ILC, 1cm, Stage I, Grade 3, 0/5 nodes, ER+/PR+, HER2+
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Jan 24, 2012 02:28PM AlaskaAngel wrote:

The problem here is that we are literally not all on the same page.  Take a look.  The guidelines on page 26 of the patient's NCCN guidelines do not list a T1c anymore. This is very recent.

http://www.nccn.com/files/cancer-guidelines/breast/index.html#/26/

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 02:34PM - edited Jan 24, 2012 02:35PM by AlaskaAngel

Is it merely a printing error? Or are they suddenly throwing those at least risk in with those at higher risk (due to greater size), since there are so few in the former T1a's that are HER2 positive.... ? This would, of couse, sway the influence for choice of therapy for the smallest tumors (by using the added much greater number count for T1c's) toward the use of chemotherapy for a new definition of "T1a's".

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 02:43PM AlaskaAngel wrote:

Frankly, given that the question of risk for HER2 positives who have a high AIB1 level (about 1/3 of those who are HER2 positive, as I understand it) remains open, that could actually account for the incidence of recurrence for the HER2 positive tumors that are less than 0.5 cm and have not received other systemic treatment, since that group usually received just tamoxifen.

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 03:36PM voraciousreader wrote:

Eve....I am going to try to make this as simple as possible.  I am sorry that your doctor told you that you are cancer free and have a small tumor and also said that you were Stage 1A.  That is INCORRECT...My tumor was 1.8cm and I was Stage 1B.  (Bluedasher...the NCCN guidelines have been updated since 2009 and now there are just TWO Stage 1 catagories.. Stage 1A and 1B.)

Now, Eve... please follow me with this one concerning ME...Despite being Stage 1B and having the same size tumor as you, 1.8 cm, and having a Grade 1 tumor AND having a "favorable" histology (mucinous), my doctor STILL recommended the Oncotype DX test to examine the genetic characteristics of my tumor to determine if Chemotherapy would benefit me.  So now you ask me if YOU would have needed more than a MX, had it NOT been HER2+, but based on a tumor of the same size as mine but one that was a Grade 3...which is the most aggressive.  And the answer to that question is....YOUR DOCTOR WOULD HAVE HAD THE ONCOTYPE DX TEST DONE ON YOUR TUMOR TO DETERMINE IF CHEMOTHERAPY WOULD HAVE BEEN OF BENEFIT TO YOU.  More often than not, many women with Grade 3, ER+ Stage 1 and Stage 2 tumors have high OncotypeDX scores and ultimately do chemotherapy.  From time to time, Grade 3  tumors do come back with low OncotypeDX scores or intermediate OncotypeDX scores and that's where the decision is always the hardest to make.  So with a Grade 3 tumor chemo would have probably been recommended. 

But your tumor, despite being "early stage" and despite being Stage 1..... is a VERY AGGRESSIVE TUMOR because it is GRADE 3 AND because it is HER2+.  And although there is NO EVIDENCE that it has left your breast, THAT DOES NOT MEAN YOU ARE CANCER FREE. 

When you mentioned that your family and friends all agreed with you that you didn't need chemotherapy along with the Herceptin...I wondered if they understood what is evident to most of us here. Were any of them with you when the doctor discussed your treatment protocol based on your tumor's characteristics? Or perhaps did you tell them all that you were "early stage" and "cancer free" and left them, like you were led to believe, when you first spoke to your "sweet" doctor, that you had done enough to keep the beast at bay.

But Eve.... let's be realistic.  First you had DCIS.  Then you had Mucinous BC and now you have a VERY AGGRESSIVE tumor.  Do you see a pattern and trend here?  You mentioned to me that you wanted to understand WHY your body was capable of making so many cancers and find ways to mitigate that.  I think we would all love to understand why we got our breast cancers.  But more importantly, we want to find a way so that we don't revisit what we've had to endure.  I know quality of life is so important to you.  It is as important to you as it is to all of us.  It is also important to the "sweet" doctor who broached the subject of doing chemo with you.  Again, had she not thought that you were a good candidate for chemo AND Herceptin, then she would never have brought it up in the first place.  She took an oath to "First, do no harm."  She would NOT want to see you suffer.

So Eve...I am going to say this once again, loud and clear.  Be angry at your doctor for telling you that you are "cancer free" and offering false hope to you ESPECIALLY after what you've gone through in the past few years.  But understand that with an early stage tumor, despite being aggressive, with Standard of Care treatment, according to the NCCN 2011 guidelines, you have the chance to live a long, healthy life.  Not doing the Standard of Care, in your situation is brave.  Again, I'm not as brave as you are.   

I know someone will come along and dismiss EVERYTHING I have said to you. That's okay. But even if I can't change your mind, at least I hope I have enlightened YOU and others who might happen to come upon this thread. The only way to make an informed decision is with enlightening information.  At least with all of this information, I hope you can comprehend it and accept the wise counsel of your "sweet" oncologist. I also hope that you get other opinions from other MO's and truly listen and understand what they tell you. 

And step back for a moment and look at THIS thread!  Here we are discussing a tumor way, way smaller than yours and debating the need for aggressive treatment.  Your tumor is 4 times GREATER!  That should give you pause to reconsider......

Regardless, we'll be here for you, no matter what you decide to do.

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 03:44PM voraciousreader wrote:

bluedasher...you raise a good question.

" I wonder what the difference was, maybe just statistical variation since most Stage Ia and Ib tumors are HER2- so the sample size isn't very large?  Or perhaps there was a difference in treatment - the second study doesn't say that they excluded women who had chemo."

  Why not email the lead authors?  From time to time, I email researchers and they are kind enough to answer my questions....I try not to read between the lines.  Why not give it a shot and let us know the answer.  Believe me, researchers LOVE hearing from people!!

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 03:46PM bluedasher wrote:

Okay, apparently either the staging has changed or, more likely, I was wrong about how tumor size relates to Stage I substages. Everything I look at now says that Stage Ia includes all tumor sizes up to 2 cm - it doesn't matter if the tumor size is T1a, T1b or T1c.

However, if you look at pages 74 and 76 of the NCCN guidelines that AlaskaAngel linked, you will see that the treatment recommendations for HER2+ are still based on whether the tumor was less than 0.5 cm (T1a), between 0.5 and 1 cm (T1b) or greater than 1 cm (T1c and larger). They don't use the terms T1a, T1b and T1c but they are differentiating treatment based on those sizes. I don't think it is an error - the NCCN older NCCN guidelines just use size without using the terms T1a, T1b and T1c too even though in the staging part of the document they mentioned them.  

There is one strange anomaly in the treatment tables that I don't understand. The older doctor's NCCN guidelines that I have say consider chemotherapy and Herceptin for HER2+ hormone negative tumors between 0.5 and 1 cm and either consider endocrine therapy or chemotherapy, Herceptin and endocrine depending on tumor features for HER2+ hormone positive between 0.5 and 1 cm.

This new patient guideline (they only had the doctor's one when I was treated) says the same as that for HER2+ hormone negative, but for HER2+ hormone positive it says Herceptin, hormone and chemo for anything above 0.5 cm. They removed the differentiation between T1b and T1c treatment for hormone positive but still have a lesser recommendation for T1b hormone negative HER2+. That makes no sense to me. Perhaps it is a mistake?

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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