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Topic: calling all t1A (> 1 mm but < 6 mm) sisters who are HER2+

Forum: HER2+ (Positive) Breast Cancer —

Testing, treatment, side effects, and more.

Posted on: Jan 31, 2012 08:59AM - edited Apr 24, 2014 05:29AM by dancetrancer

dancetrancer wrote:

I decided to start this thread to help others who may end up in this "grey" area and are struggling to make a decision about chemo/Herceptin or not.  Current national guidelines do not recommend treatment for our stage.  Treatment is only considered for 6 mm and up HER2+ sisters.  HOWEVER, some docs do still treat t1A sisters, which makes for a very confusing and stressful decision making process for t1A gals.  I thought we could run an ongoing list of sisters, sharing our decision making process, recommendations, etc.  I will be keeping an informal poll and will update it as we go along.  So far, here is what I found:

  • 6 had no treatment (no Herceptin; some had chemo without Herceptin) and recurred with METS (one dx 2004, one 2007, one 2009, two 2010; one 2012)
  • 7 had no treatment with dx ranging from 2007 to 2012.  One has had a local recurrence 3 years after diagnosis. All others have had no recurrence yet. 
  • 29 have had treatment or are currently undergoing tx; 1 had a local recurrence after tx (ranging 2008 to 2012) 

This is completely unscientific, I know, as there likely is bias b/c women who are more aggressive about treatment may be more likely to frequent these boards, but, I still find the data helpful.  

Of the treated group:
12 had taxol plus Herceptin
12 had TCH
1 refused chemo but doc agreed to Herceptin only

1 had chemo only recommended, no Herceptin

2 had AC-TH

1 had  FECX4 with Herceptin 

 If you reply, please share the size of your IDC, year you were diagnosed, your age (if you are ok with that), Grade of IDC, ER/PR status, recommendations you received from MD's, decision you made, and treatment (if tx'd) you had.  Also note if you have had a recurrence or not. Oh and also if you don't mind sharing, tell us if you are in the USA or another country.  I am interested in seeing if there is a trend for treatment or no treatment based upon country.  

Thank you, I will update the numbers as we move along.   

P.S.  Edited to add an important point made by Beesie in this thread, so that newbies don't freak out when they see whatever numbers happen to be above:   "those who have problems tend to stay on the board longer or return to the board or search out the board when they do have problems. For example, judging by the women here, one would think that the recurrence rate and rate of mets (generally, not just HER2+) is much higher than it actually is. There are thousands of women who've popped in here for a short while, completed their treatment and then, because they don't have a recurrence, are never seen again. It's generally only the women who have a recurrence who return. It makes sense, but it means that the numbers will be skewed to those who have a recurrence vs. those who've happily moved on with their lives and have no further problems." 

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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Mar 3, 2012 03:03PM dancetrancer wrote:

Thanks kwajkid - I've added you to the list.  Sorry to hear about the pancreatitis...that does not sound fun.  Very glad to hear about the 3 years without recurrence...I hear that is the sweet spot.  Someone posted on another thread that most Her2+'s recur within the first 2 years, a few more by 3 years, and minimal after that (of course if you are ER+ you still have the longer term risk of recurrence with that, but it's not usually as high a risk as the Her2+).  

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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Mar 5, 2012 09:01PM Hindsfeet wrote:

The findings, presented today at the CRTC-AACR San Antonio Breast Cancer Symposium, is the first large study to analyze this cohort and represents a shift in the way women with early-stage HER2 positive breast cancer should be assessed for risk of recurrence and considered for treatment, said the study's senior author, Ana M. Gonzalez-Angulo, M.D, assistant professor in M. D. Anderson's Department of Breast Medical Oncology and Systems Biology.

Herceptin, also known as trastuzumab, was approved for use in 1998 for women whose advanced breast cancer expresses Human Epidermal growth factor Receptor 2, or HER2. Approximately 15-20 percent of breast cancer cells produce an excess amount of the HER2 growth protein on their surface, which makes the cancer more aggressive. Herceptin is a monoclonal antibody that latches on to these proteins and inhibits tumor growth.

"This study represents a current debate within clinical practice - the risk of recurrence for early-stage breast cancer patients with HER2 positive tumors one centimeter or smaller," said Gonzalez-Angulo. "Our findings show that women with early stage HER2 positive breast cancer have a 23 percent chance of recurrence. In contrast, the five-year survival rate of all women with such early-stage breast cancer is more than 90 percent.

"The findings indicate that physicians need to consider offering these women Herceptin-based therapy in the post-operative, or adjuvant setting," Gonzalez-Angulo continued.

Current guidelines call for no additional therapy after surgery and radiation if tumors are less than five millimeters and Herceptin-based adjuvant therapy should be discussed with patients if the tumors are from six to 10 millimeters, Gonzalez-Angulo explained.

According to Gonzalez-Angulo, the number of patients with HER2 positive tumors smaller than one centimeter continues to increase as breast cancer surveillance and early detection become increasingly sophisticated.

"Before now, there's been no data regarding how to treat these women because they were excluded from all the definitive trials confirming Herceptin's benefit. This data strongly suggests that we need to rethink how we treat early-stage breast cancer patients with HER2 positive tumors and likely offer anti-HER2 therapy in the adjuvant setting."

Dx 6/13/2014, IDC, 1cm, Stage IV, Grade 3, mets, ER+/PR+, HER2+
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Mar 5, 2012 09:15PM dancetrancer wrote:

Thanks evebarry.   That study was done by MD Anderson I believe in 2008.   I am very familiar with Dr. Gonzalez's work, and it is why I am considering tx for my tumor (3 mm).  This and other studies have established pretty strongly that chemo/Herceptin is usually indicated for tumors > = 6 mm.  Even though tumors < 6mm were included in this study, many MD's still do not agree that chemo/Herceptin is recommended for this subgroup.  They say the number of patients in this study was too small to draw firm conclusions from, that it is retrospective data, and that b/c t1a's and t1b's were grouped together, you cannot distinguish if t1a's have the same amount of risk for recurrence as t1b's.  Despite all these criticisms of the study, it still has strong enough data for me to give it merit and make me be concerned about my recurrence risk. 

Hence, the controversy for t1a's.   No one REALLY knows for sure what our recurrence risk is, b/c the studies are few and small.  

I feel that MD Anderson treats these small tumors most aggressively compared to other facilities.  I am going to have a consult with them to see if they indeed feel my particular case warrants chemo/Herceptin or Herceptin alone.  I'm hoping I will have peace of mind with my decision, either way, then.  I will update what I learn after my consult.   

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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Mar 5, 2012 09:59PM whippetlover wrote:

Just a reminder that the 23% recurrence rate mentioned in the MD Anderson study is made up of both local recurrences and distant recurrences. I don't have the figures at hand but it is important to note this.

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Mar 5, 2012 10:06PM Beesie wrote:

Yes, that is an important point.  The 22.9% recurrence rate over five years is made up of 13.6% distant recurrence and 9.3% local recurrence.

http://www.medscape.com/viewarticle/585328 

“No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke
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Mar 6, 2012 07:37AM dancetrancer wrote:

Yes, it's the distant recurrence rate (aka risk of metastasis) that is most concerning to me.  

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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Mar 6, 2012 08:46AM dancetrancer wrote:

Not sure if I posted this article before by Dr. Winer from Dana Farber.  It gives a good overview of the controversy surrounding treatment for subcentimeter HER2+ tumors, and he makes a specific comment regarding tumors < 5 mm.   He makes a good point that trials will likely never be done specifically for t1a's b/c of the small number of patients that fall into this subgroup and the difficulty that would be incurred trying to recruit large enough numbers for the study.   So most likely we will never have the "gold standard" type of randomized research trials to help us make decisions. 

I've noticed from this and other articles that it seems Dr. Winer falls on the do not treat side for t1a's, vs. MD Anderson that leans toward consider treatment side.   

Current Challenges in HER2-positive Breast Cancer 

In summary, small, node-negative HER2-positive tumors have better outcomes than do larger HER2-positive tumors, and as such, consideration of potential toxicities should strongly influence any recommendations on adjuvant therapy. Within the realm of subcentimeter HER2-positive tumors, there is a relative lack of data with T1a ( 0.5 cm) tumors and microinvasive tumors. The optimal chemotherapy regimen in this subgroup is debatable, and it is unlikely that there would be a definite answer derived from prospective phase III trials as a result of its low prevalence and event rates that would necessitate a large cohort. Overall, our threshold for treatment mirrors that put forth by the NCCN, that consideration of trastuzumab and chemotherapy should be limited to tumors 0.5 cm in size and larger. The toxicity trade-off in smaller tumors may not be justifiable with current adjuvant regimens used in larger or node-positive HER2-positive 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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Mar 6, 2012 11:58AM - edited Mar 6, 2012 12:06PM by AlaskaAngel

Both sources (MD Anderson and Winer's) have been ones I respect, and I often suggest to others that they seek info to make their decision from them, as to me they seem not only to be way out in front in leadership toward a more current and future approach toward dealing with bc, but also don't put blinders on when it comes to the truth about SE's, etc. and actually also put some effort into doing work to try to address them.

In this particular difference of opinion, this is what comes to mind for me:

When it comes to the numbers game, what I marvel at is that best guestimates of our individual risk are so completely blind to the full range of the basis for cancers. What do I mean by that? I mean, that even though as intelligent people we already know that various human practices do matter in increasing the likelihood of getting cancer. Smoking. Obesity. Poor diet.  Lack of regular exercise. Etc. So my common sense tells me that if I tend to practice more of those negative practices, I stand more of a chance of increasing my odds of recurrence, and if I tend not to, my chance of recurrence is lower. In other words, when considering the statistics as they apply to me, I know that the worst end of the statistical estimates is most likely to be composed of those with poor practices, and the best end of the statistical estimates is most likely to be composed of those with healthy practices. So even though the range for tiny cancers does include people who end up with recurrence if they only do "x" and not more treatment, I know where I personally am most likely to be within that range. I don't see doctors ever considering or talking about that when trying to guide those with smaller evidence of cancer. It gets back to what I consider to be a dangerous philosophy that is so pervasive in making recommendations for bc. What seems like the most humane approach, i.e., overkill for many in favor of saving a few, is actually less humane because of the failure to include genuine consideration of the very real factors of human behavior so that fewer humans are subjected to the full range of the negative effects of treatment that is not benign.

I could understand, for example, a doctor telling a patient with a miniscule amount of cancer that if she practices more of those factors then she might want to lean toward additional treatment. But that is not what the NCCN guidelines take into account, and that is not what is discussed in the physician-patient session advising treatment.

I don't believe in leaving common sense out of the objective evaluation.

To this, were I the doctor advising a patient, I would tell them to take into consideration their ability to tolerate risk. If they are a person who is very highly anxious about any risk, they should lean toward doing the treatment to provide them with more peace of mind. If they are not, then it they may wish to take a different approach in dealing with the general recommendation for treatment.

A.A.

Dx 12/3/2001, DCIS/IDC, Left, 1cm, Stage IA, Grade 3, 0/1 nodes, ER+/PR+, HER2+ (IHC) 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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Mar 13, 2012 05:48PM dancetrancer wrote:

Hi all.  I'm just re-reading some articles I found in preparation for my onc consult next week to make a final decision.  Not sure if I've shared this one before, but it's worth re-sharing if I haven't.  My take away is that I'll be asking what my ki67 is and also will be still strongly considering (and discussing with the onc) herceptin monotherapy (well, with Tamoxifen, but no chemo).  

Small HER2-positive, node-negative breast cancer: who should receive systemic adjuvant treatment?

summary and conclusions

Approximately 6%-10% of small node-negative tumors are HER2 positive, and there is fair evidence for an increased risk of relapse and decreased survival in these patients (Table 1). However, there are no data directly supporting the use of adjuvant treatment including trastuzumab in this patient population. Subgroup analyses from adjuvant trastuzumab trials show that patients with node-negative pT1c tumors derive the same benefit from adjuvant chemotherapy and trastuzumab as compared with patients with higher risk tumors. Furthermore, two retrospective investigations suggest that patients with small node-negative HER2-positive disease may derive clinically relevant benefit from adjuvant trastuzumab-based therapy. As the risk of relapse may be substantial even in small node-negative tumors, and assumed that the relative risk reduction is similar to larger tumors, the absolute benefit should be large enough to consider adjuvant treatment in these patients. However, it is still unclear how to individualize adjuvant treatment, and which type of adjuvant treatment best fits specified patient subgroups. NCCN and AGO guidelines recommend to consider treatment in HER2-positive pT1bpN0 tumors [23, 25]. Available data do not clearly show a substantial difference in the risk of relapse between pT1a and pT1b HER2-positive tumors. Current data rather suggest tumor biology (proliferation and grade) than shear tumor size to be a more relevant predictor for the risk assessment in these small HER2-positive tumors. The authors suggest that these factors should be included in addition to tumor size in decision making and that adjuvant treatment may also be considered in patients with HER2-positive tumors <6 mm when factors such as increased Ki-67 and/or poor nuclear grade suggest aggressive tumor biology. The value of the hormone receptor status is still controversial and not very helpful since in most of the studies the hormone receptor status was without any influence on the risk of relapse in small HER2-positive tumors. Individual adjuvant treatment must weigh the benefits and risks of the treatment with the risk of relapse and death from breast cancer. The less reliable data we have, the more difficult is the choice of individual treatment. In addition to decide who should be treated, the optimal adjuvant treatment in small HER2-positive tumors is still an open question. Short-term treatment with chemotherapy and trastuzumab has been shown to be effective in reducing the risk of recurrence in HER2-positive breast cancer in the FinHER trial. These less intensive regimens with less toxicity (including little cardiac toxicity) and good tolerability might prove to be adequate for patients with small HER2-positive, node-negative tumors. Furthermore, the addition of trastuzumab to adjuvant endocrine treatment without chemotherapy in small HER2-positive, estrogen receptor-positive tumors is equally controversial as is the addition of chemotherapy to endocrine therapy plus trastuzumab. Data from the metastatic setting suggest endocrine treatment in combination with anti-HER2 targeted treatment to be superior to endocrine therapy alone [28-30]. However, data in the adjuvant setting are lacking. Still for about half of the panelists at the St. Gallen Consensus Conference 2009, this combination was a reasonable option for patients with HER2 and hormone receptor-positive node-negative tumors [31]. Although the proportion of HER2 positivity is lower in small tumors, the absolute increase of lower stage tumors by widespread screening urges for further evaluation in these patients. Future studies with prospective biomarker analysis or gene profiling may better define which patients are at increased risk of relapse and which groups of patients benefit the most from adjuvant systemic treatment. However, the conduct of a randomized clinical trial in this niche population is extremely challenging and might not be realized.

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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Mar 13, 2012 08:30PM - edited Mar 13, 2012 08:31PM by whippetlover

Hi dancetrainer. None of the research relating to t1a tumors is absolutely definitive. The article that you post above is of interest though, as it states that randomized clinical trials will probably never happen in this population. So many of the studies which investigate t1a/t1b tumors are flawed as the numbers are so small or they are retrospective which can be problematic.

At the end of the day it will be your decision and one that you have to feel most comfortable with. You have certainly armed yourself well by doing as much research as is possible and you have helped inform many of us as well. Finding out your KI 67 score will give you the final piece of the equation that you need to make this very big decision.

I, and others, will be watching for your post once you have been to see the onc next week. I think that AA is right when she says that it is really all about our individual ability to tolerate risk.

Very best wishes to you. 

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Mar 13, 2012 08:42PM dancetrancer wrote:

Thanks whippetlover!  

I have a low risk tolerance.  However, that means I'm afraid of recurrence but also afraid of long term side effects of chemo.  LOL.  Just have to laugh at myself.  I would make a horrible president or general...I don't make decisions from my gut well at all, obviously!  

Truly, though, I've come to terms with all of the gray in this situation, as best I can.  I am ready to make a decision after this last consult.  

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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Mar 13, 2012 09:02PM suzieq60 wrote:

dancetrancer - great article!! Good luck with your decision, I know you'll make the right one.

Sue

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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Mar 13, 2012 09:07PM KCD wrote:

Coming back to say that I chose  to go with 12 weekly taxol / herceptins followed by every herceptin every three weeks for a year.    I just compeleted treatment 4 of 12 today.

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Mar 13, 2012 10:19PM dancetrancer wrote:

KCD - thank you for the update!  I hope your treatments are going smoothly! 

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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Mar 21, 2012 03:35PM dancetrancer wrote:

Hi all!  Well, I finally made a decision after meeting with an onc at MD Anderson (one of the authors of the 2008 study and subsequent articles).  She strongly recommended chemo/Herceptin, especially since I am "young"/premenopausal.  Please feel free to check out my thread where I detail all of what she said to me (I took notes after listening to my taped appt).  If you are trying to make a decision, you may find it very helpful.  I think I started posting the summary around page 8 or 9.   I grilled her like I always do all of my docs, and she wasn't phased in the least.  She knows all the small HER2+ research forwards, backwards, and sideways and had an answer for everything.   I totally trust her recommendation.  Will be starting TCHX6 sometime within the next two weeks. 

< 5 mm HER2+ IDC...why NOT chemo??? 

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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Mar 21, 2012 04:03PM dancetrancer wrote:

FYI, just happened upon this article discussing local recurrence rates for t1ab's.  

Estrogen/progesterone receptor negativity and HER2 positivity predict locoregional recurrence in patients with T1a,bN0 breast cancer. 

Abstract
PURPOSE:

Data have suggested that the molecular features of breast cancer are important determinants of outcome; however, few studies have correlated these features with locoregional recurrence (LRR). In the present study, we evaluated estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) as predictors of LRR in patients with lymph node-negative disease and tumors < or = 1cm, because these patients often do not receive adjuvant chemotherapy or trastuzumab.

METHODS AND MATERIALS:
The data from 911 patients with stage T1a,bN0 breast cancer who had received definitive treatment at our institution between 1997 and 2002 were retrospectively reviewed. We prospectively analyzed ER/PR/HER2 expression from the archival tissue blocks of 756 patients. These 756 patients represented the cohort for the present study.

RESULTS:
With a median follow-up of 6.0 years, the 5- and 8-year Kaplan-Meier LRR rate was 1.6% and 5.9%, respectively, with no difference noted in those who underwent breast conservation therapy vs. mastectomy (p=.347). The 8-year LRR rates were greater in the patients with ER-negative (10.6% vs. 4.2%, p=.016), PR-negative (9.0% vs. 4.2%, p=.009), or HER2-positive (17.5% vs. 3.9%, p=0.009) tumors. On multivariate analysis, ER-negative and PR-negative disease (hazard ratio, 2.37; p=.046) and HER2-positive disease (hazard ratio, 3.13, p=.016) independently predicted for LRR.

CONCLUSION:
Patients with ER/PR-negative or HER2-positive T1a,bN0 breast cancer had a greater risk of LRR. Therapeutic strategies, such as the use of chemotherapy and/or anti-HER2 therapies, should be considered for future clinical trials for these patients. 

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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Jun 4, 2012 01:16AM laprofessoressa wrote:

Thanks for this. I have a 6mm tumor (they thought it was larger but the rest ended up being DCIS....), HER 2 POS

Lumpectomy

now will begin (in 2 weeks) chemo TCH and Herceptein for the year & radiation

Dx 4/24/2012, <1cm, Stage I, ER-, HER2+ Surgery 5/10/2012 Lumpectomy: Left, Right; Lymph node removal: Right, Sentinel Surgery 5/24/2012 Lumpectomy: Right Targeted Therapy 6/19/2012 Herceptin (trastuzumab) Chemotherapy 6/19/2012 Carboplatin (Paraplatin), Taxotere (docetaxel) Radiation Therapy Breast
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Jun 4, 2012 08:27AM dancetrancer wrote:

You are so welcome laprofessoressa!  I'm glad you found it helpful.  I'm currently in the middle of TCH myself.   If you have any questions about that regimen, this thread is very helpful - lots of great ladies on it who have been through TCH still post over there:  taxotere,carboplatin and herceptin

And I don't know if you are hormone positive or not, but if you are, the triple positive thread is also a fantastic resource.  

Welcome to the boards!  

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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Jun 8, 2012 12:31PM hopeful123 wrote:

Thought this might interest this group it is an abstract at the most recent ASCO. I was excited about the last line and wanted to share- no relapse!

Author(s): Yazan Migdady, William M. Sikov, Bachir Joseph Sakr, Adam J. Olszewski; Memorial Hospital of Rhode Island, Pawtucket, RI; Warren Alpert Medical School of Brown University, Providence, RI; Program in Women's Oncology, Women and Infants Hospital of Rhode Island, Providence, RI


Abstract:

Background: T1ab triple-negative (TN) or Her-2-positive (H2+) breast cancers are reported to pose relatively high risk of relapse, but benefits of adjuvant chemotherapy are uncertain. We studied the impact of chemotherapy on recurrence-free survival in this group. Methods: Records of all consecutive cases diagnosed in Brown-affiliated centers in 2000 - 2010 were reviewed. Factors influencing chemotherapy decision were studied with logistic regression, and recurrence-free interval (RFI) with a Cox proportional hazard model and Kaplan-Meier estimator. Results: Among 1415 screened T1a/b N0 cases, 161 were eligible (57 TN; 104 HER2+), with a median age of 57 years; 66% tumors were T1b. 20% of patients underwent mastectomy, 76% received radiation and 30% hormonal therapy. Adjuvant chemotherapy was recommended in 53% of cases. Younger age (p<10-6), stage T1b (p<10-5), high grade (p=0.001), HER2+/ERPR- status (p=0.017) and diagnosis after 2006 (p=0.007) were significantly predictive of the medical oncology recommendation. There was a significant trend with decrease in anthracycline (p<0.001) and increase in taxane use (p<0.001). With a median follow up of 46 months, the 5-year rate of relapse was 6.1% (95%CI 2.7-13.9%), somewhat higher in T1b tumors (8.1%) and without detectable difference in TN/HER2+ subgroups. In a univariate analysis chemotherapy did not significantly impact the recurrence-free interval (HR=0.45; 95%CI 0.09-2.34; p=0.32), however there was a detectable benefit (p=0.02) for T1b tumors in a multivariable Cox model including age (p=0.02) and LVI (p=0.01). The histology, type of surgery and year of diagnosis were not significant. There were no relapses among ER/PR+ patients who received hormonal therapy or HER2+ patients who received trastuzumab. Conclusions: The risk of relapse in biologically aggressive T1ab breast cancers is very low with judicious use of adjuvant therapy. The benefit of chemotherapy is likely restricted to the highest-risk patients with T1b tumors, lymphovascular invasion and younger age.

Dx 1/2012, IDC, Stage IA, Grade 3, ER+/PR-, HER2+
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Jun 8, 2012 12:33PM - edited Jun 8, 2012 12:35PM by hopeful123

Background: T1ab triple-negative (TN) or Her-2-positive (H2+) breast cancers are reported to pose relatively high risk of relapse, but benefits of adjuvant chemotherapy are uncertain. We studied the impact of chemotherapy on recurrence-free survival in this group. Methods: Records of all consecutive cases diagnosed in Brown-affiliated centers in 2000 - 2010 were reviewed. Factors influencing chemotherapy decision were studied with logistic regression, and recurrence-free interval (RFI) with a Cox proportional hazard model and Kaplan-Meier estimator. Results: Among 1415 screened T1a/b N0 cases, 161 were eligible (57 TN; 104 HER2+), with a median age of 57 years; 66% tumors were T1b. 20% of patients underwent mastectomy, 76% received radiation and 30% hormonal therapy. Adjuvant chemotherapy was recommended in 53% of cases. Younger age, stage T1b, high grade, HER2+/ERPR- status and diagnosis after 2006 were significantly predictive of the medical oncology recommendation. There was a significant trend with decrease in anthracycline and increase in taxane use. With a median follow up of 46 months, the 5-year rate of relapse was 6.1%, somewhat higher in T1b tumors (8.1%) and without detectable difference in TN/HER2+ subgroups. The histology, type of surgery and year of diagnosis were not significant. There were no relapses among ER/PR+ patients who received hormonal therapy or HER2+ patients who received trastuzumab. Conclusions: The risk of relapse in biologically aggressive T1ab breast cancers is very low with judicious use of adjuvant therapy. The benefit of chemotherapy is likely restricted to the highest-risk patients with T1b tumors, lymphovascular invasion and younger age.

Sorry looks like the previous message got chopped.

Dx 1/2012, IDC, Stage IA, Grade 3, ER+/PR-, HER2+
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Jun 8, 2012 02:00PM dancetrancer wrote:

hopeful123, thanks for posting the study!  I look forward to when it is fully published, and I can read the details.  It's a small number of patients, but still very encouraging.  It makes me feel even more comfortable stopping at 4 tx vs 6 (TCH for me), considering I am ER/PR+.  Yay for no recurrence!!! 
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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Jun 8, 2012 02:15PM chachamom wrote:

Thanks hopeful!

Jill. Age 59. "Life is a shipwreck, but we must not forget to sing in the lifeboats." - Voltaire. No chemo/herceptin and no radiation because the largest of multi focal tumors was 3mm Dx 3/12/2012, IDC, <1cm, Stage IA, Grade 2, 0/5 nodes, ER+/PR+, HER2+ Hormonal Therapy 5/29/2012
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Jun 8, 2012 02:18PM dancetrancer wrote:

I found this additional abstract from the ASCO 2012 meeting:

Impact of adjuvant trastuzumab-based chemotherapy in T1ab node-negative HER2 overexpressing breast carcinomas.

Author(s):
Jean-Sebastien Frenel, Manuel Jorge Rodrigues, Julien Peron, Vano Yann-Alexandre, Johanna Wassermann, Marc Debled, Francois Picaud, Laurence Albiges, Anne Vincent-Salomon, Paul H. Cottu; Institut de Cancerologie de l'Ouest/Site Rene Gauducheau, Saint-Herblain, France; Institut Curie, Paris, France; Centre Léon Bérard, Lyon, France; Centre Antoine Lassagne, Nice, France; Centre Rene Huguenin/Institut Curie, Paris, France; Institut Bergonié, South-West Comprehensive Cancer Center, Bordeaux, France; Institut Claudius Regaud, Toulouse, France; Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France

Abstract:

Background: HER2 overexpression has been recognized as a pejorative prognostic factor in node negative T1ab (T1abN0) breast tumors. Randomized clinical trials have shown benefit of adjuvant trastuzumab-based chemotherapy (ATBC) for node-positive and/or greater than 1 cm (T1c or more) HER2+ breast carcinomas. There are no prospective efficacy data of ATBC in T1abN0 HER2+ tumors. Methods: We retrospectively evaluated 276 cases of T1ab node-negative HER2+ breast tumors in 8 French Comprehensive Cancer Centers. We assessed clinical, therapeutic features and outcome. We estimated the probability of disease-free survival (DFS), analyzed associations of ATBC, patient and tumor characteristics with DFS and prognosis factors using the log-rank test, multivariate analysis with logistic regression and Cox's proportional hazards model. Results: Out of the 276 T1abN0 cases, 129 (47%) received ATBC (ATBC+) and 123 (45%) were not treated by either trastuzumab or chemotherapy (ATBC-). Of these 252 ATBC+ or ATBC- patients, decision of ATBC was associated with date of diagnosis (before or after ASCO 2005 Annual Meeting when interim results from three trastuzumab adjuvant trials were reported) and with poor prognosis features: negative hormone receptors (HR-) status, Elston-Ellis high grade, tumor size > 5 mm and age. With a median follow-up of 44 months 16 recurrences were observed (13 in the ATBC- group, 2 in the ATBC+ and 1 with adjuvant chemotherapy alone). Nine recurrences were distant metastases. A survival benefit in ATBC+ was observed with a 99% 40-months DFS versus 93% for ATBC- (logrank p-test = 0.018). In an exploratory analysis, two factors were significantly associated with worst prognosis for ATBC- that were not observed for ATBC+ : HR- status (98% 40-months DFS for ATBC+ patients versus 84% for ATBC- patients; logrank p-test = 0.0003) and presence of lymphovascular invasion (100% 40-months DFS for ATBC+ versus 73% in ATBC- cases; logrank p-test = 0.003). Conclusions: In our series ATBC is associated with a significant reduction of risk of recurrence of T1abN0 HER2+ tumors. A clear DFS benefit of ATBC was observed in HR- tumors and/or in presence of lymphovascular invasion.

 

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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Jun 8, 2012 03:00PM hopeful123 wrote:

Dance- I saw that too. They all look promising. If you do see the publication PM me please.
I am moving on to Weekly Taxol/herceptin. Hope this isn't as bad. You need to have a big celebration once you are done.

Dx 1/2012, IDC, Stage IA, Grade 3, ER+/PR-, HER2+
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Jun 8, 2012 03:12PM dancetrancer wrote:

Thanks hopeful!!!  You too!!!  I've heard the taxol is not as bad as the AC, just gotta really watch for neuropathy (supplements and ice nails, etc.).   I just have one more next week.  That will be my 4th TCH.  I've decided the risks of tx # 5 and 6 for my size tumor are not worth the benefit...hope I'm right.  So many tough decisions along this path! 

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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Jun 10, 2012 07:06AM dancetrancer wrote:

Thought this article may be of interest to my t1A sisters.  It examines the practice patterns in Italy and was recently published April 2012.

 Adjuvant chemotherapy of pT1a and pT1b breast carcinoma: results from the NEMESI study.

ABSTRACT:

BACKGROUND:
The prognosis of pT1a-pT1b breast cancer (BC) used to be considered very good, with a 10-y RFS of 90%. However, some retrospective studies reported a 10-y RFS of 81%-86% and suggested benefit from adjuvant systemic therapy.
METHODS:
To evaluate the variables that determined the choice of adjuvant chemotherapy and the type of chemotherapy delivered in pT1a-pT1b BC, we analysed the small tumours enrolled in the NEMESI study.

RESULTS:
Out of 1,894 patients with pathological stage I-II BC enrolled in NEMESI, 402 (21.2%) were pT1a-pT1b. Adjuvant chemotherapy was delivered in 127/402 (31.59%). Younger age, grading G3, high proliferative index, ER-negative and HER2-positive status were significantly associated with the decision to administer adjuvant chemotherapy. An anthracycline without taxane regimen was administered in 59.1% of patients, anthracycline with taxane in 24.4%, a CMF-like regimen in 14.2% and taxane in 2.4%. Adjuvant chemotherapy was administered in 88.4% triple-negative and 73.46% HER2-positive pT1a-pT1b BC. Adjuvant trastuzumab was delivered in 30/49 HER2-positive BC (61.2%).

CONCLUSIONS:
Adjuvant chemotherapy was delivered in 31.59% T1a-pT1b BC treated at 63 Italian oncological centres from January 2008 to June 2008. The choice to deliver chemotherapy was based on biological prognostic factors. Anthracycline-based chemotherapy was administered in 83.5% patients. 

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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Jun 10, 2012 08:13PM vjm wrote:

Hi Dance - what day is your last tx? I go on Friday if all lab work favourable. Just when you start feeling like yourself again......!!!! Finally able to drink water without it tasting like chemicals and get out and about. Thanks for posting this research - it really helps remind me why I am going through all this with such a small tumor. I continue to experience SOBOE with palpitations, emotional waves, and weepiness when I try to go out walking or with Qigong. Haven't tried yoga since #3. Pisses me off. Hopefully it will dissipate once #4 is over and not be r/t the Herceptin. You are very busy supporting so many others on this chat - I don't seem to have the energy to sit at the computer very long - and want you to know how much you are appreciated.Smile With extreme and sincere gratitude, vjm xoxo

Dx 10/28/2011, IDC, <1cm, Stage IA, Grade 3, 0/2 nodes, ER+/PR+, HER2+ Surgery 11/29/2011 Lumpectomy: Right Surgery 12/28/2011 Lumpectomy: Right; Lymph node removal: Right, Sentinel Radiation Therapy 3/12/2012 Breast Targeted Therapy 4/13/2012 Herceptin (trastuzumab) Chemotherapy 4/13/2012 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy
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Jun 11, 2012 07:14AM dancetrancer wrote:

Hi vjm! Thank you so much for your very kind words. It meant a lot to me. I have so much gratitude to the women who walked this path ahead of me and helped me make a decision; I try to pay it forward when I can.

My 4th tx is scheduled for Wednesday, pending bloodwork as well. I had a slight drop in kidney function, so we are retesting and then have to make decisions from there. I so hope you start feeling better soon - I agree, the heart palpations are concerning. Hoping it is just fatigue related to bloodwork and has nothing to do with Herceptin. I guess we both will be due for our 3 month echo's soon and will definitely know more then!

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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Jun 21, 2012 08:13PM Lmont79 wrote:

I am a new member and I am having a difficult time figuring out what topic/group to join. I am 33yrs old was diagnosed with large DCIS stage 0 in my right breast in April 2012. Based on mamo, MRI and ultrasound my tumor seemed Iintact and I had no lymph node swelling. My core biopsy came back with the following diagnisis: nucleur grade 3, ER + 14 perc., PR-. Because of the size on the DCIS and my age I opted for a skin sparing bilateral mastectomy with SND. My left breast and 1 left side lymph node came back completely negative, no sign of cancer. On my right side I hade 5 lymph nodes removed, all negative. The DCIS was 7 cm with very small margin .5mm on both the posterior and anterior side, my O'S took the top layer of pectoral muscle to help with the small posterior margin. All margins were clear with the exception of 1 microscopic DCIS evident in one of the path slides. My pec muscle and nipple and ariola skin were all negative. I have a centrally located (within DCIS) 2 invasive components: 1.6mm plus focal micro invasion .8mm. My invasive component is Er+70%+2, PR+10%+2, HER2+(3+), Bcl-2-, Ki-67 30%, p53+ (3+). My FISH results: HER2/CEP-17: 5.83, HER2 signal count:19.53, CEP-17 signal count:3.35. I have been told by 3 radiologist to do 50 g of radiation over 5 weeks. 3 MO's have said no chemo with 5 years tamoxifen. 2 MO's have said based the aggressive component of HER2+ the size is of invasive cancer is not as significant as the biology of the invasive cancer (triple positive) and they would recommend TCH chemo with a year of herceptin. Getting 3 more MO options in the coming week. The OMs that reccomended chemo feel very strongly that there is a good chance, even with neg nodes, that the HER+ has gotten into my blood stream and a reoccurance in the next year would not be curable. The med onc that say no chemo, and I have recently had 7 from Johns Hopkins reviewed my path and say no chemo, all suggests that because this began as DCIS and then had very small invasive spot, 1.65 mm and a second microinvasive spot .8 mm they don't feel that chemo is appropriate. My hubby and I will leave in a few weeks to see a med onc at MD Anderson who specializes in her2+. We will also see Dennis Slamon next week to hear his thoughts (I live in L.A so no travel for that one). On a side not I am super healthy, mom of two small boys and breast fed both. Having a really hard time sorting out the right decision regarding chemo!

Dx 4/9/2012, IDC, <1cm, Stage I, Grade 3, 0/6 nodes, ER+/PR+, HER2+ Surgery 5/17/2012 Lymph node removal: Left, Right; Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Targeted Therapy 7/30/2012 Herceptin (trastuzumab) Chemotherapy 7/30/2012 Carboplatin (Paraplatin), Taxotere (docetaxel) Radiation Therapy 11/13/2012 Breast
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Jun 21, 2012 08:55PM dancetrancer wrote:

Lmont79, this is the right thread for you - welcome!   You may also want to review my personal thread where I went through h*ll trying to decide whether to do chemo or not:  

< 5 mm HER2+ IDC...why NOT chemo??? 

I, too, flew to MD Anderson to see a specialist in small HER2+ tumors.  Chemo was recommended for me by them (I had 4 opinions total - 1 said definitely no chemo/H, two said definitely chemo/H, one said would do Herceptin monotherapy if it would make me feel better).  

MDA said b/c of my age (and of course their HER2+ subcentimeter research) they felt my recurrence risk was high enough to warrant the chemo/Herceptin risks.  National guidelines, however, do not recommend chemo/Herceptin for < 6 mm.  There is quite a bit of controversy.  Get all of your opinions, read as much as you can, and then try to feel in your gut what you think is the right decision for you.  It is a very hard decision to make - I really feel for you!  

It came down to for me, thinking about what I'd regret more - side effects from chemo that could be long lasting, or it coming back as metastatic and then being incurable.  MDA recommended 6...I figured I'd try and see how it went and if I needed to stop I would.  So, I have had 4 TCH's and decided to stop and go to Herceptin only.  I've had a rough chemo experience and at this point feel I've done what I needed to do with the chemo and that the herceptin will really protect me from here on.  Hopefully the 4 will be enough - seems like many are only doing 4 with the tiny tumors.

Hope this helps - please check in whenever you like with questions/thoughts/what you decided, etc... 

Also, I would LOVE to hear what MDA says to you AND what Dr. Slamon says - so please do report back!!!   

BTW, I had small margins ant and post, too, and had to have rads on my L side.  I feel your pain - we have very similar situations!  

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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