Adjuvant Therapy

[RC Runner]

I had a double masectomy this month b/c a benign fibroadenoma was removed with a 2 cm tumor of infiltrative lobular carcinom.  I am T1c, NO, MX, Nottingham combined hist. grade (mod. fav), G2, ER+ and PR -,HER-2 neg, score of 0.  No other cancer found in either breast.  I am 48 and still menstruating.  Surgery done in  luteal phase of cycle.  CA 125 was 13.6.  Chest xray clear.
Went through surgery very well--discharged in 36 hours, drains out a few days later, back at work within 5 days of surgery.
My oncologist recommends BOTH hor.and chem. therapies. There seems to be a 9% increase if I do both in preventing recurrence (81% w/o, 89% w/both).  I question this, since I had the db. mas. and my cancer was caught in such an early stage (it did not show up on mammograms nor on ultrasound.)
I also want to know if my cancer would respond well to hor. therapy, as it is ER + but PR -.  My oncologist says it may not.
I am in good health, on no medications, don't smoke, not overweight, exercise (run an average of 30 miles a week, have good blood pressure.  I need my brain for my work, and have a family history of heart disease, so am concerned about subjecting myself to chemo.  
Thanks so much--
RC Runner

[CCF-RN,MSN-JS]

Dear RC Runner, It is accepted practice to offer adjuvant chemotherapy to most women with primary breast cancers of 1cm in diameter or greater (both node-negative and node-positive).  These are the general criteria, unfortunately, very limited information is available as to which women it is reasonable to avoid adjuvant chemotherapy.  Regarding hormone therapy, adjuvant hormonal therapy is recommended to women whose breast tumors contain hormone receptor protein, regardless of age, menopausal status, involvement of axillary lymph nodes or tumor size.  While the likelihood of benefit correlates with the amount of hormone receptor protein in tumor cells, persons with any extent of hormone receptor in their tumor cells may still benefit from hormone therapy.  The above information is from the National Institute of Health Consensus Statement on Adjuvant Therapy for Breast Cancer, December 2000.

[ritavv]

I would get a second opinion about the chemo.  It's absolutely true that the standard is to have chemo if your tumor is greater than 1cm.  However, some oncologists do not use this as the only determining factor.  My tumor was 1.6cm, T1C N0, Er/Pr+, clean margins.  My mitotic rate ( S-factor ) was very low.  I got two opinions: the first recommended chemo, the second did not.  The second one felt that I would get little benefit from the chemo because it attacks fast growing cells which my cancer was not.  In addition since my cancer was highly Er and Pr positive, he felt I would respond well to the Tamoxifen.  I was 50 when diagnosed and premenopausal.  I opted not to have the chemo.   As it turns out, the Tamoxifen increased my estrogen levels (opposite of what most experience) and so I am now on Lupron for ovarian ablation (others use Zoladex).  Since you are 48, I would ask if ovarian ablation might be something that would be appropriate for you.  To read more about it go to: http://www.cochrane.org/cochrane/revabstr/ab000485.htm
However, if your cancer has a high mitotic rate it should respond well to chemo.
I just passed my 2 year survivor anniversary.  I'm doing really well.  If you want to read more about my decision, you can go to:
http://www.bcsaf.com/stories/rita.html .  You can also contact me through that site if you have any questions.  The only addition to this story is that while I originally was on the Lupron for only 6 months, I have gone back on it now and will be taking it for another full year.

[surgeon]

the problem with statistics is that they deal with populations and not individuals. Since there's not 100% certainty, some women are going to fall on each side of the statistical probabilities; in other words, there's no way to predict for a single individual. However, your risk of recurrance is very low; and lobular ca is probably less likely to spread than is ductal. You are in a category where you chance of cure as things stand now is very high. Chemo might make it higher. But the odds are that it's not necessary (only a small minority of women would benefit in your situation). It's a tough call to make without being able to see the future for an individual.

[RC Runner]

Thank you, ritavv and surgeon especially.  Your responses are the first I've received that address the fact that we are none of us merely statistics.  I am not asking for guarantees, nor for someone else to make a decision that is mine, ultimately, and mine alone.  I am looking for more than just the recommended standards, which I have and which I question in my case for reasons stated.  Again, I appreciate your time and real concern for me, a stranger, and want you to know that I appreciate your responses beyond what I can express.

[susan m k]

I am confused by "surgeon's" comments that lobular ca is "less likely to spread than ductal".  I was under the impression that ductal cancer was contained (within the duct) and that lobular by it's very nature, would move.  Could someone explain this?  Thanks, Susan K

[surgeon]

there are two main types (and some others) of breast cancer: ductal, and lobular. The former is most common, and begins in the ducts. The latter is less common, and begins in the glands. Ductal cancer, like other forms, can be invasive or non-invasive. It gets confusing; but when it begins in the ducts and remains there at the time of discovery, it is called ductal carcinoma in-situ (meaning it's not yet "invasive"), and is nearly 100% curable. When it has crossed the walls of the ducts into the surrounding tissue, it is called ductal invasive cancer, and has the potential for spread. Likewise, there are in-situ and invasive forms of lobular cancer.  80% or so of breast cancers are ductal invasive type.