ASCo report--the more things change, the more things change

[Lani]

A Swedish study looked at primary tumors and biopsied their metastases to see if ER, PR status changed

I dubbed it the"the more things change....the more things change" study

ERstatus changed + to - 27% of the time, from - to + 8% of the time
PRstatus changed + to - 38%of the time, from - to + 5 % of the time

They plotted out the survival curves (prognoses) of all four combinations of
primary vs met an found

+ primary assoctd w + met did best
- primary assoctd w +met did second best
+ primary assoctd w - met did next to worst(had 1.5 tp 2 times the risk of dying at any one point of time)
- primary assoctd wit - met did the worst

Another study showed the rates of concordance between primary tumor and mets (including her2) were

14.5% had a change of ER statys
49%had a change of PR status
14% had a change of her2 status

overall the treatments of 12%of those patients developing metatasis should have changed after biopsy

The above study looked at liver mets

her2 discordance was 3.5% + to -, __% -to +(hope the talk is on the virtual meeting as I missed that %)

I hope this encourages doctors, patients and insurance companies to come together and make biopsying mets an integral part of treatment.

It doesn't help if you have a smart bomb if the target has changed!

[hutchibk]

I would agree to a degree... but keep in mind that not all mets are able to be biopsied.

Also, as my docs have confirmed, the biopsied sample may not tell you everything about the met. Within any given tumor, there may be areas with differing cells. Part of a tumor can show ER+ and a different part can show ER-.

My first recurrence was able to be biopsied. It showed what looked like the cancer had switched from ER+ to ER-. At that point we discontinued Aromasin. Last summer, once we kept seeing brain mets, etc., my doc decided it was worth adding back in the Aromasin to see if there was a chance that we were ignoring an important potential target and if the biopsy a few years before was partially misleading. Aromasin being the only change we enacted at that time seemed to gain us some footing and stability. Once we saw the tiniest new spot on the adrenal back in March, we switched again, this time back to Tamoxifen. TMs have continued to drop, scans have continued to show clear in the brain, and we will MRI the adrenal spot next month to see what it is doing, hopefully shrinking.

My point being that yes! biopsying mets is a tremendously important piece of information, but it is not always possible and it can still only yield a part of the whole picture... sadly, if depended on too heavily, it might also mislead and may send you down the wrong path, too.

[Lani]

It seems to me it is better than NOT biopsying.

FYI when they look at circulating tumor cells in metastatic bc patients, they find all kinds of combinations floating around, not just those the patients are being treated for ie, triple negative CTCs in her2+ Stage IV patients being treated with herceptin

[hutchibk]

If it can be biopsied, of course, it is one more piece of info that can be tremendously integral to the whole picture.

I am not arguing your post, I am adding more info to the bigger picture.

[Julie2]

Lani,

Just want to find out if doing biopsy of CTCs is a proven method and whether oncologists will agree to do that.

As Brenda mentioned I have mediastinal mets and I would like them to see if anything changed but my onc. wouldn't do that because it is an invasive procedure.

Julie

[Lani]

Julie, ctcs do not need to be biopsied. They just take a small tube worth of blood from you like any other blood test. No they are not proven to represent mets and often have different characteristics (ER, PR her2 Status) than either the primary or the met.

I believe there is something called a mediastinoscope, sort of like a laparascope for abdominal procedures or an arthroscope for joint procedures. Depending on where your mediastinal nodes are and how big they are, perhaps they could be biopsied by this minimally invasive procedure. I believe it is done by thoracic surgeons.

Oncologists are medically trained and not surgically trained. To many of them a bone marrow biopsy is too big of an invasive procedure (it is minimally invasive as well and has an ill-deserved reputation, probably because oncologists don't like ANY invasive procedure (that is why they went into medicine and not surgery!)

I know little about mediastinoscopy, other than that it can be done. Can you ask for /refer yourself to / have your radiation oncologist**
refer you to a thoracic surgeon just to find out if it would be appropriate. You can cite the ASCO talk I referenced about the percentage of cases in which treatment might be changed depending on the results.

**they seem to interface more easily with the surgeons it seems.

Good luck!