Mar 3, 2012 04:03PM 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+).  

Mar 5, 2012 10:15PM 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.   

Mar 5, 2012 11:06PM beesie.is.out-of-office 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 

Mar 6, 2012 09:46AM 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.  

Mar 13, 2012 06:48PM 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.