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 05:05PM

Posted on: Jan 21, 2012 05:05PM

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 05:01PM - edited Jan 24, 2012 05:02PM by bluedasher

I just checked the doctor's version of the NCCN guideline and it's the same as the patient guideline.

For hormone+ HER2+, 0.5 cm and above all have the same recommendation: Herceptin, chemo and hormone therapy.

For hormone- HER2+: 0.5 to 1 cm is consider chemo and Herceptin; above 1 cm is chemo and Herceptin. 

I don't understand why they would have a stronger recommendation for chemo and Herceptin for hormone+ HER2+ than for hormone- HER2+ between 0.5 and 1 cm. I would understand changing the recommendation for 0.5 to 1 cm HER2+ to chemo and Herceptin (taking away the "consider") in light of the MD Anderson study and others, but not making a weaker recommendation for hormone negative HER2+ than hormone positive.

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 05:42PM voraciousreader wrote:

Like I said...the NCCN guidelines are a moving target and are updated as need be.  With so much controversy...you see with sisters who have the SMALLEST tumors why it is such a dilemma.....  Again, you can appreciate why it would be difficult to definitively answer the question because of the difficulty in designing a clinical trial......  Again, it is important to look at several years of NCCN guidelines to obtain a trend.  And, more and more current studies are indicating more treatment....

Interestingly, for my type of cancer, Mucinous... the trend is favoring LESS treatment.....

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 05:46PM Minnshark wrote:

Evebarry. I couldn't agree. I am a Stage1a no node but .5cm so no chemo with a BMX. For me, the choice between a lumpectomy and BMX was very easy to make.

Vora.. Thank you for this article.

Diagnosis: 11/29/2011, IDC, .4cm, Stage 1a, Grade 3, 0/2 nodes, ER-/PR-, HER2+
BMX: 12/14/2011
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Jan 24, 2012 05:48PM AlaskaAngel wrote:

The word that comes to mind is "gerrymandering".... 

When someone like evebarry sees the lack of congruence in it, and is left to try to figure it out when it doesn't make sense, while others miss seeing it entirely, I really give her a lot of credit for expressing that confusion.

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 05:55PM voraciousreader wrote:

Minnshark..for a very small tumor it really is such a tough call.  I am so glad you got several opinions and have made peace with your decision.  I truly believe that is the essense of what THIS is all about.  We arrive at a decision with the best evidence available and move on with our lives and all accept, graciously, our "new normal." 

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 06:13PM - edited Jan 24, 2012 06:24PM by Hindsfeet

VR...I hear you, but I posted on this thread because I was told my tumor was small. In regard to mucinious tumors...mine was 1 C and they did not do a oncotype on the mucinicous because in the end my bc surgeon said you don't do them for those types of cancers...although I asked for one due to past discussions we had.  

My friends know that I have early cancer, with the aggressive her2+++ component. Because most have seen friends or family suffer due to chemo they said for me not to go there. My family are very well aware of my dx and risk. They also have done research and feel that I am doing the right thing...in fact, they would be angry if I choose to do chemo.

I have made a request for my mx tissue to be sent to the original lab where I had the biopsy sent to. I do plan to have a second opinion. You are given about 5 minutes with your bc surgeon for post op telling you the good news. I had hoped my oncologist would have had the time to answer my questions, but seem a little frustrated in me asking...and again only talked about the 5 lines that were readable on the 5 page report...node 1, negative, node2, negative, node 3, negative, node 4, negative, tumor, postive, stage 1 with hormone positive, and her2+++ .... that's about it and the rest is for me to figure out for myself.

I also addressed the whole staging topic on the early cancer as I believe the whole staging topic is confusing...especially since there apparently so many opinion even amongst oncologist.

I misplaced the biopsy report...several pages, very detailed. I've requested another and hopefully it will soon all make sense. Sorry for being on the wrong thread.

Dx 6/13/2014, IDC, 1cm, Stage IV, Grade 3, mets, ER+/PR+, HER2+
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Jan 24, 2012 06:22PM voraciousreader wrote:

Eve... This past year my 86 year old mother was diagnosed with lung cancer.  She's a very active woman.  At NO point was chemotherapy ever mentioned as a treatment.  Her case was presented to a tumor board and it was decided that all she needed was radiation.  Today she is NED and enjoying her life.  Doctors do not recommend chemotherapy lightly.  If they truly believe the evidence is there that you will do well with it... then they will recommend it.  If there is no evidence that chemo will help you, then they will make that recommendation as well.....

I think you need to depend less on hearing the emotional pleas of people who have seen others suffer during and after chemotherapy.  Instead, come HERE and see how others are thriving.

Get those MO opinions and by all means, have your case presented to a tumor board, like my mother and have them help you make an INFORMED decision.

I truly wish you well.....

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 06:32PM voraciousreader wrote:

One more thing Eve,  others would be angry if you went there?  How selfish of them.  It's YOUR life.  When I was diagnosed...I never discussed with anyone what I was going to do.  Not even the DH.  He came with me to my meetings with the MOs.  The decision was entirely mine and mine alone...Furthermore, outside of my immediate family and my brother and sister, I told only a handful of people that I am a breast cancer survivor.  My mother doesn't even know that I was treated for breast cancer.

Perhaps you have too many people in the mix...

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 06:56PM bluedasher wrote:

Minnshark, whether the surgery that you received was a lumpectomy or a mastectomy doesn't enter into the decision on whether chemo is recommended or not. Surgery addresses the local breast cancer as does radiation. Having a lumpectomy or a mastectomy affects whether you should have radiation. Lumpectomy should generally be followed by radiation to clean up any stray cancer cells that didn't get removed from the breast. Mastectomy may not need radiation, though that decision is also affected by how close the tumor was to the chest wall and whether it was in the nodes.

Chemo is a systemic treatment that can kill off cancer cells that have already gone past the breast. Having a mastectomy or a lumpectomy doesn't affect those cells so the decision isn't dependent on which surgery that you had. For example, if you look at the NCCN treatment guidelines, which kind of surgery one had doesn't enter into the adjuvant chemo decision. 

The only case where it makes a difference is that some women with larger tumors may choose to have chemo before surgery to try and shrink the tumor so that they can have a lumpectomy rather than a mastectomy. After surgery, the type of surgery doesn't matter regarding whether to have 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 07:11PM - edited Jan 24, 2012 07:16PM by beesie.is.out-of-office

There are three areas of confusion that I see in the discussion that is on-going here.

1) There is confusion between tumor sizes T1a, T1b and T1c and staging.  

  • When discussing invasive cancer, the tumor size is only one element in the staging and in fact a T1 tumor (whether "a", "b", or "c") can be any stage except Stage 0.  For example a T1a tumor, which is a tumor that is 5mm or less in size, can be Stage IA up to Stage IV.  What determines the rest of the staging is the nodal status and the presence of mets.
  • About 18 months ago Stage I was divided into Stage IA and Stage IB.  The difference between Stage IA and IB is not the tumor size - any T1 tumor can be either Stage IA or Stage IB (or Stage II, etc.). The difference is that Stage IB includes micromets.  Until January 2010 (the changes were made mid-year in 2010 but were backdated to the start of 2010), micromets was considered the same as macromets and automatically moved the patient to Stage II.  However a review of research showed that the presence of micromets (a nodal involvement of >0.2 mm and/or >200 cells but none >2.0 mm) had only a 1% impact on mortality and as such, the decision was made to move those with micromets from Stage IIA into a newly created Stage IB. 

2) There is confusion about the role of staging and how it plays into treatment decisions.

  • If you look at the staging charts you will see that each stage includes a lot of different diagnoses - which therefore require different treatment. Staging also does not make any mention of the grade of the tumor, the ER/PR status of the tumor or the HER2 status of the tumor - other key factors in the treatment decision.  
  • Doctors talk to us about our stage and they talk to us about our treatment, but stage does not determine treatment.  Someone who is Stage IA with a grade 1 T1a tumor that is ER+/PR+/HER2- will not have recommended the same treatment as someone who is also Stage IA but has as T1c tumor that is grade 3 and ER-/PR-/HER2+.  On the other hand, this second Stage IA individual is likely to have the same or very similar treatment to someone who is Stage IIB or Stage IIIB who has the same tumor characteristics (grade 3, ER-/PR-/HER2+).

3) There is confusion about tumor size and whether tumor size counts either in risk, prognosis and/or treatment decisions.

  • It does.
  • For one individual and perhaps on average (an average of all women with Stage I HER2+ cancer) it may be true that there is a 25% chance that an HER2+ cancer will have already spread through the blood without lymph node involvement, upon initial presentation.  This doesn't mean that this is true for all Stage I HER2+ cancers and for all individuals who have Stage I HER2+ cancers. There is a big difference in risk level between a 2mm tumor and a 1.9mm tumor - even though both of these tumors are Stage I tumors. It's quite simple, really.  The more cancer cells, the greater the risk that one or two rogue cells (or more) might have slipped undetected into the vascular system (the bloodstream), only to show up later as mets.
  • Let's say that there are 1000 cancer cells in a millimeter.  Someone who has a 2mm tumor has 2000 cancer cells in her breast. Someone who has a 1.9cm tumor has 19,000 cancer cells in her breast. With almost 10 times as many cancer cells, it seems pretty obvious that the risk of occult mets would be quite a bit higher for the person with the 1.9cm tumor (all other things being equal). This is why the "average" risk numbers for Stage I HER2+ tumors cannot be applied to someone like Minnshark, who has a smaller than average 0.4mm HER2+ tumor.

At lot about BC is difficult to understand and in many areas of BC diagnosis and treatment, even the best doctors don't always agree. But there are some things that are facts (TMN Staging, for example) and there are other things that are logical, intuitive and simply common sense (all other things being equal, a larger tumor with more cancer cells presents a greater risk). We have enough to debate about here on the stuff where there are no clear answers - and there is a lot of that - that I find it particularly frustrating when there is so much debate and so much misinformation about the stuff that should be pretty clear.    

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