Treatment plan questions

[Franciscus]

My wife is 51 yrs. old. She was diagnosed on May 23, 2005 as having invasive ductal carcinoma of the right breast. Combined Bloom-Richardson Grade of I-II. Estrogen and progesterone negative. HER-2-NEU positive. MRI showed size of tumor as least 3.4 cm. Tumor within 1 cm of prepectoral fascia. Blood work normal. Bone scan shows no sign of spread. CT PET scan to be done this week. One of which staged this as Stage IIa; the other would not offer an opinion on that yet. Two oncologists have suggested neoadjuvant chemo: one doctor suggested this for breast conservation; the other for treatment value (allows one to see if chemo is working etc.).  
Questions:

1. What other tests should we do at this time?
2. Is not doing chemo an option?  
3. What recurrence or survival benefit does she get by having chemo for her cancer?
4. Can a mastectomy be safely done given the 1 cm distance from the prepectoral fascia?  
5. Are carboplatin and taxol choices for neoadjuvant?
6. Will the CT and PET tell us if sentinel lymphnodes or axillary nodes are affected? Is this determination made before neoadjuvant chemo begins?axillar

[CCF-RN,MSN-JS]

Dear Franciscus, The reason for doing neoadjuvant or preoperative chemotherapy is to shrink tumors so they can be surgically removed.  In some situations it allows women who would need a mastectomy because of large tumors to have breast-conserving treatment if they want it.  Another reason for neoadjuvant chemotherapy may be for locally-advanced tumors (i.e. tumors growing into the skin or chest wall or have enlarged lymph nodes that are matted together but no evidence of spread elsewhere in  the body).  The treatment in this case is to shrink tumors enough to be able to be surgically removed.    

The information from the CT scan and PET scan may give information regarding if there is suspicion or evidence of disease outside of the breast, or evidence of an enlarged lymph node but not whether or not lymph nodes are affected by cancer.   Checking the lymph nodes requires biopsy and if pre-operative chemotherapy is done, whether or not the lymph nodes are biopsied would depend on the whether lymph nodes are enlarged, or sometimes sentinel node procedure may be recommended.   In locally advanced disease checking the lymph nodes would occur with surgery later if the tumor shrinks.  
Decisions regarding types of chemotherapy, the risks and benefits of pre-operative chemotherapy are based on all information such as tumor characteristics, size of tumor, location, results of scans etc. These risks and benefits are best discussed with a medical oncologist who can base such recommendations on all of the patient’s information.

Given the complexity of your wife’s case and questions, we would recommend that you have a detailed discussion with your oncologist about these issues.

[Franciscus]

Any feeedback would be helpful. Thanks.

Francisc

[Franciscus]

Thanks very much for your helpful observations. My wife's case is difficult because she is not clearly in nor out of categories that plainly require chemo, so its very much a judgment call.

I am not convinced that chemo is worth the risk, but not sure either if she should take a gamble and fo watchful waiting after a mastectomy. I guess many others have been in this situation.

[surgeon]

As long as the margin per se is not involved, mastectomy is an option: in her case, it seems it is. If she were to have mastectomy, then neoadjuvant therapy isn't really an issue. However, it's been pretty well shown that for a tumor her size, adjuvant chemo improves survival. As I expect you know, there's no way currently to determine in a specific case when it's useful or not; in other words, given a 3 cm tumor, in a thousand women there will be more survivors among those who take it than those who don't. Within each group, there are some for whom chemo will be of no benefit: some who would have been cured without it, and some who won't be cured with it. Unfortunately, you just have learn what the data are, and make a decision. It's a sophisticated game of odds-playing.

[Franciscus]

Thank you for your reply. It is a tough decision that has to be made. The statistics are not easy to decipher. Assuming no node involvement, the Mayo clinic website gives my wife's case a 70% 10-year survival with no chemo, and a 78% rate with ACT. Hard to know what that really means.