Neo-adjuvant chemo, surgery, mastectomy,

[TSund]

I pulled the message below from another thread. I am wondering how it might impact Ruth's situation. Ruth is receiving neo-adjuvant (pre-surgery) TCH chemo, and so far responding extremely well as far as tumor shrinkage. (hurrah!) Unfortunately the reason for neo-adjuvant was NOT so she can receive lumpectomy, as she had multi-quadrant tumors, so they were pretty much saying she should have mastectomy anyhow.

However, the info below has my mind reeling a bit. The onc says Ruth has a chance for Complete Response based on chemo response so far. Ruth would dearly love to save her breast. I have pretty much been of the thought that she should do anything to remove the possibility of recurrence, and thus was with the idea of mascectomy. If she does have an evident CR, should we give any thought to saving part of the breast and avoiding the more extensive surgery? I think the problem is that CR may not be proven till after surgery or may be unprovable without masectomy? Should we consider biopsies to figure out what is truly going on? She will have extensive rads post surgery either way.

2)Another PRESSING thought on my mind is whether it might be good to have part of her chemo post-surgery, after the probable mastectomy? Ruth told me she doesn't mind staying bald a while longer (she likes the shape of her head! grin) Right now the plan is just TCH x6, then surgery followed by rads. She will have 4th treatment in a week. Might a chemo treatment or two (either additional or postponed) post surgery knock out the problems that surgery might cause according to school of thought below?

THX as always for your wonderful input!!!

Terri

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<HR style="COLOR: #cc0033" SIZE=1><!-- / icon and title --><!-- message -->not trying to open up a Pandora's box, but there is a school of thought that the genes which are turned on (and turned off) in breast cancer are very like the genes turned on and off in the signature of inflammation and wound healing and that the smaller the surgery that is done the better. The thought is that a mastectomy might stir up more of these cytokines and other substances which might actually worsen the situation. Interestingly, when they looked at women who for one reason or the other (fear, lack of access to medical care, etc) had their surgery long after the lump appeared, they found that the tumors recurred with a large spike two years after surgery (not 2 years after the lump was discovered) implying that something about the surgery was responsible for starting the clock ticking and causing the mets to manifest.

This explains the trend to neoadjuvant therapy, whether herceptin plus an AI (trial, I believe) or herceptin plus chemo, in order to allow a smaller surgery to be done and the trend toward the performance of core/needle biopsies.



As Esther says, the current thinking is that mastectomy only prevents local recurrence and not distal metastases and even if you did recur locally a repeat lumpectomy could be performed without (in many papers), as I understand it, significant worsening of prognosis.

(Just throwing things at you): Has anyone discussed radiation therapy to decrease your chance of local recurrence. Also, has anyone discussed a lymph node biopsy at this stage--they do it after neoadjuvant(pre-surgical) chemo to try to see how effective the treatment has been so perhaps it would be a consideration if it would change your treatment--otherwise I have read papers of radiation therapy given to the axilla (armpit) in those where lymph nodes have not been biopsied. I am not recommending anything--just raising questions.

Could you talk any of them into ordering circulating tumor cells test. It is done by Quest's Nichols Lab and called Cell Search and since you were considered Stage IV should be paid by insurance. If you have them, they can be followed with treatment and probably a mastectomy won't really make a difference as it is more likely there are dormant cells in your bone marrow or elsewhere and your problem is not really local.

I have no qualifications to give ANY ADVICE--am just well-read and trying to be helpful.

Where are you located. as a second/third opinion might be helpful

PS has anyone restudied your liver and what have they found?

Hope some of this helps!
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[Lani]

via PET, MRI, multiple biopsies, etc, but can they be certain they have examined all the different tumors (you did not say how many are seen and by what modalities) Was an MRI and/or PET done pre-chemo?

Since you are in Texas, perhaps MD Anderson would do a surgical oncology second opinion. I know they gave up doing oncologic second opinions on bc patients several years ago (there were too many who wanted them and not enough doctors) on anyone not agreeing to be treated there. At a bc meeting I attended I met a breast surgeon from MD Anderson named Anthony Lucci--don't know if he sees consults but he presented an interesting paper on cox2, walnuts and bc and seemed thoughtful.

Anyone can give you the "company line" that mastectomy is the treatment for multifocal bc. I don't know the answer and have no expertise ...but would suggest you look the person in the eyes, decide if they have the capacity to think outside the box and ask them what the risk/benefit analysis they would tell their sister or mother of going either way.

They probably won't have good stats for you, as it is not commonly done.

Ask them not to let their personal judgement color their answer ie, whether they feel EVERYTHING must be done to decrease the chance of even local recurrence. I know there are figures for the elderly where a large number of the infirmed do not get surgical care. It is just that neoadjuvant therapy is often done on a clinical trial and then there is no freedom to give less than the standard of care--clinical trials must always give the standard of care PLUS something (vs the standard without that something) to be considered ethical and approved.

I came across an interesting paper today and will post it. Remember though that the persons who chose not to have surgery may have been so old, infirmed, demented or without family help that they also did not get the rest of the recommended care ie, remembered to take tamoxifen, get radiation therapy etc.

Will post it to follow...

[Lani]

The same patients who may have opted not to have surgery may not have had a lot of the other treatments for bc (ie, radiation therapy, may not have taken their tamoxifen, etc)

ABSTRACT: The incidence, indications and outcome for the non-operative management of breast cancer [Journal of Surgical Oncology]
Background and Objectives: This study aimed to identify the proportion of patients with breast cancer who do not undergo primary operative treatment, to identify the reasons surgery is not performed, and to determine the outcome for this group of patients.
Methods: Data was obtained from the Bedford Breast Cancer Registry for all non-metastatic patients presenting between January 1990 and December 2004 who were initially treated non-operatively. Robust diagnostic, therapeutic, and follow-up data on all patients was collected prospectively during this period.
Results: One hundred and eighty-five out of 2110 episodes of breast cancer were treated non-operatively during this period. Sixty-eight percent of patients were unfit for surgery, 15% had inoperable tumours, and 17% refused surgical intervention. Median survival and 5-year survival rate for all non-operative patients were 3.7 years and 41.2%. Median survival for inoperable patients was 3.7 years, compared with 3.5 years for those unfit for surgery and 4.2 years for those who refused surgery. The 5-year survival rate for patients refusing surgery was 43%, compared with 61% for a matched group of patients undergoing standard surgical therapy.
Conclusions: This study provides useful data on the reasons for, and outcome of, the non-operative management of breast cancer.

[Lani]

at a major cancer center.

Should she not choose mastectomy, I would expect they would plan to radiate and you would need to find a radiation therapist willing to do that in this setting...so that also becomes part ot the equation. Those at major cancer centers will have experience in treating those who don't fall in the normal category ie, those with one tumor only.

I know that multicentric (multiple tumors in one breast) bc was one of the criteria which did not allow patients to be placed into the APBI (ACCELERATED PARTIAL BREAST IRRADIATION) clinical trial at Stanford. That made sense, as you wouldn't want to limit the field (ie, partial breast) when the whole breast was at risk.

No wonder people usually just take the easy way out and don't ask questions--it is hard work.

[Lani]

just in case someone thinks I am advocating people not have surgery for breast cancer you are WAY OFF THE MARK.

I am not advocating anything and would never recommend anyone any course of treatment or nontreatment. I am only well-read and attend quite a few conferences and wanted to let you know that there are new ways of thinking about how bc occurs, whether it metastasizes early, whether it might be a stem cell disease, that people are rethinking how they treat it surgically and radiation-therapywise.

Thinking about it shouldn't do any harm.

Discussing it with doctors shouldn't do any harm.

Having done the thinking and the discussing, one should be able to feel more comfortable with whatever decision one makes.

Hope this helps.

[Linda]

Hi again.
I think this is a grey area, how to proceed with surgery after neo chemo. Many surgeons have no experience with this -- and the ones that do will admit that it's unpredictable. I had neo chemo, and then a lumpectomy. My surgeon said that he can't tell how the tumor has disolved until he gets in there (it can completely disolve, disappear from the outside in (literally get smaller) or leave scattered pieces.

The doc won't know for certain how well the chemo has worked until he/she gets in there, and then the surgical pathology is completed. In my opinion, this is the surgeon's call, and so you want the most experienced, progressive surgeon you can find. You want someone who only does breast surgery, believes in breast conservation and does bc surgery so often that he's seen everything.
So, find that surgeon! (I know one in LA, but that's pretty far for you) Frankly discuss your preferences before surgery, and then leave it in his/her hands -- since the surgeon is the only one who will really be looking at the tissue, then analyzing the path report. A good surgeon will also be sensitive to and talented at cosmetic outcome -- so a lumpectomy will only be done if the outcome will be physically and psychologically positive.
Let me know if you need more info.
Best
Linda

[Linda]

Ps. I did not have a CR (far from it) but still was not advised to do more chemo. More chemo is not necessarily better -- get different opinions. Chemo is very hard on your body and isn't something to take unless really justified. Herceptin will continue nonetheless.
I'm over 2 years out and doing fine.
L

[Alice]

I know this is a tough decission. I also had multifocal BC. I went through the neoadjuvant chemo, surgery and then radiation. I opted to have a mastectomy. At the decision time my surgeon gave me the option of lumpectomy. I had 4 tumors and am small breasted to begin with. I chose to have the mastectomy one because I figured that being small to start with it would be very disfiguring and second I would always wonder if I would have a recurrance. At the time of the mastectomy I only had one lymph node that was considered inflamatory! All the other tumors had a complete responce, so it is possible. The oncs sometimes will continue chemo after and sometimes not. I wandered through the whole thing if I was doing the right thing by having chemo first and now when I look back, I am very glad I did. You didn's say if you have any node involvement or stage?

Good luck with your decission, Alice