Should I really get both radiation and chemo?

[catiacc]

Hello and thanks in advance for help. I have undergone simple mastectomy to left breast for IDC. Pathology report showed multicentric disease, 2cm and 1.8 cm, MBRS 7/9, grade 2, ER/PR+, Her-2neu - by immunostain, no lymphovascular invasion, clear posterior margins, + several DCIS intermediate nuclear grade no necrosis, several non extensive foci. Additional breast tissue showed one more focus of DCIS, less than 0.3 cm. present to within 1 mm. margin (inferior posterior). SNL (5 nodes removed prior to mastectomy) negative. Pathological stage: T1c, N0 (snl), Mx. ki67 10%. Reexcision to get wider margins in DCIS excluded by surgeon bc of location of tumor. Radiation oncologist and medical oncologist in US suggest both chemo and radiation followed by Tamoxifen. European oncologists I consulted suggest Tamoxifen and LHRH analog, but no radiation, no chemo. I am waiting for second opinion, but am in a conundrum...is this really so debatable/controversial?

[CCF-RN,MSN-JS]

Dear catiacc:  Decisions regarding adjuvant therapy (treatment given after surgery to try to prevent or minimize the growth of microscopic deposits of tumor cells that might grow into a recurrent tumor) are based on a number of factors.  These include size of tumor, features of tumor (how it looks under the microscope, hormone receptor status, HER-2 neu levels), lymph node status etc.  When a tumor is larger than 1cm, tamoxifen and chemotherapy are often recommended (in postmenopusal women whose tumors contain hormone receptors, an aromatase inhibitor may be recommended instead of tamoxifen).  Because the absolute benefit to chemotherapy in this situation is relatively small, many women must be treated to benefit a few.  You might discuss with your oncologist whether a test such as the Oncotype DX assay may be helpful in making the decision about chemotherapy. This is a test done on the tumor that looks at the expression of certain genes in your cancer that helps to predict prognosis. The result can help estimate your prognosis if treated with tamoxifen alone. Patient's whose tumors fall into a low-risk category do not appear to have much benefit from chemotherapy while those whose tumors fall into a high-risk category have significant benefit from the addition of chemotherapy to hormonal therapy. In regards to radiation therapy, again practices may vary but common indications following mastectomy include tumors larger than 5 cm, those with multiple lymph nodes involved or those with positive surgical margins. You may benefit from consultation with a radiation oncologist to further discuss the risks and benefits for your individual situation.

[lizziecee]

I have just re-read your post and wonder if you are postmenopausal - if you are, Arimidex has shown that it is better than tamoxifen in preventing recurrences. It does not protect the bones from osteoporosis, as much as tamoxifen, but my Oncologist switched me from tamoxifen after 2 months to Arimidex. You might like to google Arimidex and discuss this with your Oncologist.

I also had the same ER+ ,HER2- status (pr status not done),which my Onc said is a good prognostic factor - great to know there is some light at the end of the tunnel.
Take care.

[catiacc]

Thanks Lizziecee. I do think that node negativity makes a difference, from what I read, but so might multicentric disease. I don't find a lot of info on that. I am premenopausal, and my DCIS had actually cribriform pattern and no comedonecrosis. I was thinking of asking for Oncotype DX, but my oncologist said it wouldn't change his recommendation anyway.

[lizziecee]

Hi - until the doc responds, I thought I would share my situation as it is very similar to yours, with the exception of the lymph node status - I had 2 nodes positive on WLE surgery, and 2 more were found positive on total axillary removal. I had a 2 cm idc tumour, with intermediate grade DCIS, both comedo and cribriform. Not quite sure what the DCIS nomenclature means.
The protocol at the centre of breast excellence I attend in England is for both chemo and radiotherapthy, if a tumour is 2 cm or above. This is decided at a team meeting, with the attending bc surgeon, oncologist and radiologist present.

It could be that the spread to the lymph nodes predicated chemo (I was told before both surgeries I would only have radiotherapy, so chemo came as a big shock), but in all cases, a tumour of 2cm+ they advise chemo. I had 6 x FEC, which was 4 years ago, and it could be that they are using taxanes now, or dose dense chemo. My chemo was every 3 weeks. I believe radiotherapy starts about 3-4 weeks after finishing chemo, but mine was delayed for 6 weeks whilst I had urgent treatment for Crohn's, which was exacerbated by the chemo and having to stop my usual chemo, methotrexate. I am back on the mtx and doing fine, as I hope you will do also.

[lizziecee]

Hi there - glad the nurse responded to your queries and hope this helps somewhat in the decision whether to have chemo or not. Guess as I had lymph node involvement, the decision was really clear cut. Your situation is a little different.

If you want other opinions, I have found the Johns Hopkins bc internet helpline very helpful - a very knowledgeable bc nurse  there also answers queries and she may have some input on your multifocal situation.

Otherwise you may like to try posting to the breastcancercare.co.uk site - a very interactive site in England with many very intelligent and articulate women. I am sure someone there will have experienced your same dx and can offer some insight. The USA breastcancer.org site is also very helpful.

It is a very difficult and intensely personal decision whether to go for chemo and/or radiotherapy. I knew zilch when I was dx with bc, but even with the knowledge I have now, I would still have made the same decision to have both. My attitude was very optimistic, and still is - to have whatever treatment my doctors felt in my best interests.

Hope it all turns out okay for you.
Liz.