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Forum Name: Breast Cancer

Question: Node negative ER positive breast cancer-should I take chemo?


 hopeful51 - Fri Mar 28, 2008 11:27 am

I recently had surgery for breast cancer, it was a stage 2 invasive ductal carcinoma tumor measuring 3.5 cm., 4 lymph nodes were removed and found to negative as were the the margins of the tumor. When seeing my oncologist he recommended chemo, radiation, and homone therapy( Arimidex) for 5 years. Since last week when I seen him he has changed his recommendation. A bone scan was done plus blood work all came back clear, good news. Now he feels because I am estrogen possitive Her2 that I don't necessaryily need chemo the choice is mine the odds he gave me where l in 10 with outout chemo in 10 years to 1 in 12 with chemo. I don't know what to do I am really fear the thought to taking chemo if this drug really works. How affective is it in people like myself and weighing out the pros and cons what would you recommend, I have to tell them by Monday of this week and I am not sure how to pursue this. If you could help me at all I would really appreciate it. Lynda
 Dr. Tamer Fouad - Fri Mar 28, 2008 4:42 pm

User avatar Hello,

It must be a very difficult time for you I understand. You are basically required to make a decision about something that is very important and that you do not know enough about. The truth of the matter is, this is a very controversial issue.

Patients with node negative breast cancer have traditionally always received adjuvant chemotherapy if their tumor sizes are more than 1cm (NCCN guidelines in the US) or in Europe when more than 2cm in size. Your tumor was larger in size than both. Only recently was the question raised that a very good subcategory of patients (apparently) like yourself may not need chemotherapy. Especially post-menopausal women seem to benefit even less from chemotherapy.

Various methods of assessment have been used - from a web based tool - Adjuvant Online! to gene mapping using Oncotype Dx. All of which are primarily concerned with this particular subgroup.

Most doctors will not advise chemotherapy if they think absolute benefit from chemotherapy in 10 years is less than 3% in terms of survival.

At this stage let me try to help you by suggesting that you address your concern very directly to your doctor. Tell him that you do not feel qualified enough to make such an important decision and that you would like him to help you make it.

A few points that will help if you clarify them - you mentioned 4 lymph nodes were removed - was a sentinel lymph node biopsy performed, because generally level I and level II lymph nodes are removed which amount to about 10 lymph nodes. You can ask him about this.

Ask him about the type of chemotherapy regimen he would suggest and the toxicity both short term and long term. It may be that you are ready to suffer a few months for the sake of every extra percent of survival benefit. But by also knowing the long term effects and how frequently they occur you can weigh the risks vs the benefits. For example you may decide that extra percentage is not worth it if there is a 2% chance that you could live with heart disease for example. Fifty six is not old you have many more years to live and enjoy and you should be looking forward to that.

In order to be able to weigh the odds you should know the odds. Have a frank discussion with your doctor and ask him to help you through this.

Please keep us updated!
 hopeful51 - Fri Mar 28, 2008 8:53 pm

Thanks for answering me so soon. To begin with my my estrogen and progesterone recepters were positive and my Her2 was negitive (all 3 antibodies with a straining intensity =+1. The lymph nodes that were removed were sentinal nodes and as I said they were clear. The test you are speaking of is not available in Canada that I know of, should I check with my doctor to find out if I can have this test done. I am very confused as to what to do. I seem to get everything colds, flu and I worry about having chemo and having know immune system to fight it. My doctor seems to think that my odds are good without it but if I want it the choise is mine. The chemo is recommended for a 12 week period every 3 weeks for four sessions the drug that he is suggesting is Docetaxel and Cyclophosphamide by intravenous. When he first suggested chemo he told me there was a 16% chance without chemo and a 12% chance in 10 years He is now saying 10% chance without it and a 8.5 % with it in 10 years. I really don't know what to do. I know your not really supposed to recommend, but is it possible for you to tell me what you would recommend, I know the final decision will have to be mine. Is it standard for that many lymph nodes to be removed if the senital nodes are clear? If you could answer as soon as possible I would appreciate it.
Lynda
 hopeful51 - Fri Mar 28, 2008 9:49 pm

Hi it's Lynda again I forgot to mention to you that besides the chem he is suggesting or was suggesting 26 consecutive radiation treatments are prescibed. Even if I don't have the chem the hormonal therapy Arimidex and radiation treatment I will still take. I hope this information helps,so you might be able to help me. Thank-you
Lynda
 Dr. Tamer Fouad - Sat Mar 29, 2008 1:09 pm

User avatar Hello Lynda,

Thanks for the update. Sentinel lymph node biopsy is great - that's an appropriate number of lymph nodes.

It's not that I don't want to make a recommendation, I really would love to help you and I understand your dilemma. However, it's technically impossible to make a recommendation without evaluating everything first hand. Many things are taken into consideration including your general health, the outcome of your physical examination etc.

After reviewing your information and the update, it seems quite clear to me that your doctor really cares for you. He has offered you the best treatment currently available. His assessment of your odds is quite precise and I would not view his change of opinion in a negative view. Rather, it is a delicate situation and one where treatment has to be individualized. I think your doctor is honest to review his opinion and to change it for what he thinks is better.

I would stick with his recommendations if I were you - but I still think that this really should not be your decision alone. You cannot take responsibility for a decision you are not equipped to make. I would convey this to your doctor quite frankly if I were you and just like you asked me to make a recommendation ask him to guide you.

Again, in an attempt to make things a little easier for you - after reviewing all available data I think you should go with what your doctor recommended. Docetaxel and cyclophosphamide is given to reduce the risk of heart toxicity that is associated with standard forms of adjuvant therapy. All the same this can be a tough regimen for some people and docetaxel can cause muscle aches, reduced immunity, body fluid retention, neuropathy (such as numbness in the finger tips). Cyclophosphamide can cause nausea, vomiting, skin and nail changes. Most of these are temporary and may not be an issue but their not worth it for a difference of benefit of 1.5% at 10 years.

That said, you should not feel like you have to make a decision until you feel absolutely confident you are doing what you want for yourself.

Good luck and keep me posted!
 hopeful51 - Sun Mar 30, 2008 10:59 am

Hi thank-you for the advice so far. I do have a question for you that maybe you can answer for me before I see my doctor on Monday. I never got a CT scan to determine if there are any tumors in my organs,should I have gotten one or should I ask for one? Is it because all my tests so far were normal so they don't feel its necessary? I am considering asking him for a CT wether he will give me one I don't know. Also is your blood monitored during radiation?
This will help with my decision.
Thanks so much Lynda
 Dr. Tamer Fouad - Mon Mar 31, 2008 3:42 pm

User avatar Hello again Lynda,

I apologize for not seeing your post earlier. I hope your meeting with your doctor has made you feel better and that you were able to make an informed decision.

To answer your question, CT scans are not done routinely in the staging working for early breast cancer as long as your labs are fine and you don't have any symptoms or signs that may suggest anything abnormal. A chest x-ray and labs are enough. Other tests are not useful and the added exposure to irradiation from these scans is not justified.

Please keep me updated!
 hopeful51 - Mon Mar 31, 2008 7:12 pm

My meeting with my doctor did not go well today, I went in with a possitive decision that I was not going to take chemo. I asked him once again to confirm the percentages as he had told me, just to be sure and to my shock he came back with not 1.5- 2 % but a 5 % difference between taking chemo and not. He did say it was still a small margin but it was still my decision wether I wanted it or not but consider it was a rather large tumor. I feel sick to my stomach I don't know anymore I quess I should have the chemo... all he could say was I I'm sorry I made a mistake. Can you please give me some advice?

Thanks Lynda
 Dr. Tamer Fouad - Tue Apr 01, 2008 3:29 pm

User avatar Hello Lynda,

I am sorry to hear about your meeting. All this confusion doesn't help at all.

In a situation like this I would advise you to be on the cautious side of things. Breast cancer is a treatable disease once it's caught early. The reason for adjuvant chemotherapy is to prevent distant metastasis to the bone, liver, lung or brain. If that should happen all bets are off you would need chemotherapy and the outcome would not be so rosy.

To put it this way - if I had to choose between side effects that may cause a temporary reduction in your quality of life compared to risk of metastatic disease, I would go for the chemotherapy.

Some people tolerate chemotherapy very well. Just put yourself in that state of mind to hang in there for next 5 months. After that things should return to normal. With appropriate supportive care, careful monitoring of your immunity (blood count) you shouldn't have to go through any serious infections.

Yes, I agree with the decision to take chemotherapy. We are only allowed to drop it if we are sure we know what the risks of doing so are. With all the confusion, we can't be sure enough. We definitely, don't want to find out the hard way.

Ask your doctor for some literature about your chemotherapy regimen, that should help make you feel more in control of what's to come.

Keep a positive attitude and go for it.

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