mastectomy versus lumpectomy for HER2

[Kaa1102]

My sister has a .6 mm HER2 positive invasive ductal tumor and insitu in addition close to it as well as some calcifications that appear to be scattered about her left breast. Mammogram and MRI of right breast are clear. She is 49. She wants a lumpectomy. She is only considering a mastectomy because an MRI came back with possible additional insitu. She thinks a mastectomy and reconstruction are horrible. How do I help her decide? She expresses negativity in regards to reconstruction. How do I help her decide whether to do reconstruction or just scrap it and just have mastectomy? She expresses concern regarding silicone, expresses concern with the recovery, expresses concern with being vain when cancer should be the main concern, expresses worry that reconstruction will delay treatment? Can any of you shed some light on these concerns.

[LeahM]

Hi Kaa1102,

This can be a very hard choice for so many women. And she is right, cancer is the main concern. I too had a very small tumor (signature below) but I chose a b/l mastectomy without hesitation. I had a history of benign tumors and my cancer was hiding behind one. I decided I didn't want any other cancers to have a place to hide.

I did choose to have reconstruction surgery. I had expanders placed during my b/l and would get them "expanded" by my plastic surgeon every two weeks or so till they were the size I wanted. Nice little added bonus...being able to choose the size of your new boobs...

My reconstruction surgery (silicone implants) wasn't done for almost a year after the b/l. Reconstruction didn't delay my treatment (chemo/rads), my treatment delayed my reconstruction as there is a wait period after rads before you can be reconstructed.

There are many woman on this board who have had mastectomies without reconstruction and I am sure they will chime in. It is a very personal choice and I strongly suggest your sister find out all her options.

Best
Leah

[sarah]

She should see another surgeon and another oncologist and listen to what they say and then take the time to come to a deicision she's comfortable with.
reconstruction can be done with parts of your own body - I'm not up to date on where they think is best now, mine was taken from my stomach and I found that hard but I'm told it's much easier now and I believe they take it from the back but she'd have to talk to others who've done it.
getting Herceptin and radiation are important.
good luck to her
hugs
sarah

['lizbeth]

With scattered calcification - I don't understand the consideration of a lumpectomy. I ran into the same situation with my first surgeon. The 2nd surgeon seemed to have a better grasp on my situation. I had multiple lesions and DCIS in the right breast - so mastectomy was the best option and the 2nd surgeon understood this.

I did not want to be left with a huge breast on one side and no breast on the other. I was mortified.

The 2nd surgeon made arrangements with plastic surgeon for an immediate reconstruction. At that time the best option given to me was a TRAM reconstruction - which took one rectus abdominus muscle and about 6 inches of adipose tissue from my abdomen. This is a major surgery compared to a mastectomy with more risk and a longer recovery period. However I now have 2 breasts and the majority of people do not even notice the difference in size. I did not opt for silicone or saline implants.

The back surgery mentioned by Sarah is the Latissimus Dorsi flap reconstruction. Which detaches the muscle from the Iliac crest and brings it and the adipose tissue up and around to form the base and blood supply of the breast. Other sources of tissue for a reconstruction could come from areas of the buttocks.

Today microsurgery options such as the DIEP and others exist - that do not use a muscle for the blood supply. Reconstruction surgery has advanced and I've read of harvesting of 2 sources of blood supply (different veins or arteries). I had a partial loss so would recommend asking about this.

You can go to the Plastic surgery website, or Google for more info.

http://www.plasticsurgery.org/recons...struction.html

Having a breast reconstruction is not just for vanity. It can help one recover from the breast cancer experience by restoring a feeling of wholeness.

I will chime in with the others - I think it would be helpful to have a second opinion on the surgery options.

[Becky]

I had a lumpectomy and radiation but only had one point of concern. I question my choice all the time in not having a bilateral masectomy which 3 surgeons told me to absolutely not have. I had other opinions because I couldn't fathom what the first surgeon was saying. I will say that I am super diligent about mammograms, MRI and self exam. If anything ever happens again, both will be promptly removed without hesitation. I sometimes think about just getting them removed with immediate reconstruction and know what surgical/reconstruction team I would use regardless.

So far (over 9 years out), I am happy with my choice but I still have both breasts and they both look good but I have that concern of a new breast cancer in the back of my mind. Certainly something about me and my genetics got me in this situation once and I feel I am at more risk than the average woman for it to happen again. I also sometimes think of just getting them removed with no reconstruction because maybe that's how I am supposed to be. But that's me not anyone else. I agree with the others that a second opinion may be in order. I get second opinions on all major things.

[Becky]

I also want to add that before my surgery, my biopsy came back inconclusive so I had no pathology report. The surgeon I went with just said that my tumor was "spider-like" and it would be unethical not to remove it. She was also concerned in that I had a 1.9 cm tumor and nothing was there in a mammogram I had had 3 months prior and then it was there and discovered in a self exam which I do monthly (and I didn't feel it the month before).

I did not find out I was Her2+ until about a week after my surgery at my post surgerical appointment. Maybe knowing I was Her2+ prior to surgery would have changed my mind. I just can't say because surgery was done and within 3 weeks I was in the chemo ward.

[Debbie L.]

Kaa, I don't think there is one right answer, nor any right advice for you to give your sister. The main thing is to be sure she has all the information on the table, and then to support her in whatever decision seems right to her.

If they are able to get clean margins at lumpectomy, and your sister is okay with the ongoing vigilance that will be needed to keep an eye on the calcifications -- then I don't see why a lumpectomy wouldn't be an option.

It's such a personal decision. For one example -- some would weigh the anxiety associated with the ongoing vigilance as most important to their decision. Others would want less surgery, less mutilation. All reasonable priorities and it's only the individual herself (or himself) who can decide what's right for her (or him).

One piece of advice you can give your sister is that she doesn't have to feel like this is an emergency that she must decide on quickly. She has time to get other opinions, and to let the options sit with her long enough that she feels confident she's making the right choice.

For what it's worth, I think all the concerns your sister expresses are reasonable and normal. It's a matter of how much weight each one gets, in her personal priority list. I know it's natural (and wonderful) of you to want to help her make the right decision -- but I think your role is to help her gather information and to support her decision. Not to try to decide what you think is the best move (because the "best" move is different for each person), but to support your sister's choice(s). She's lucky to have you for a sister. Good luck, keep us posted, okay?

Debbie L.

[tricia keegan]

What do her Dr's say?? I had a tumour much larger than your sisters and three nodes positive but chose a lumpectomy with rads and I'm now going into my ninth year out with no regrets. However I was in treatment for around eighteen months and treated this very aggressively too, if I had had a mast I wouldn't have bothered with reconstruction, one because I've met too many women who had to have more surgeries as they were unhappy, and two because it really wasn't that important to me. I've met a few women who for one reason or another recon failed, I really didn't want to put myself through that.
My advice would be to allow your sister to make her own choice's, she'll know what she wants and she can always do recon at a later date if she choose's to.

[norkdo]

I'm Irish so vanity is a big big deal. But I gotta say, even though in my signature and my blog I bemoan my initial surgeon's decision, and my plastic surgeon's error in judgment re: my reconstruction....."let's deal with survival first" and much later...issues of vanity...in the end was the bomb. I am alive. NEDenise, who died a coupla days ago, had th same everything as me, upon discovery of the cancer, and isn't.

[sassy]

The calcifications would prompt me to seek a second opinion. I would womder if the calcifications are an indicator of the aggressiveness of the cancer. I had a very small tumor, but also had micro calcifications and five positive nodes. All this too had appeared in a very short time following a previous mamo.

I had a mastectomy and delayed a recon decision until after chemo and radiation.

Never had it done.

For me, and my husband, it wasn't that important. The risks of another surgery outweighed any phycological benefit. I just put my boob on like I put on the rest of my clothes.

Encourage your sister to seek the best medical information and support her in her decision based on that information. If the medical opinion leaves her options in regard to surgery and reconstruction, all the better.

My best to you both. Your sister is lucky to have your care and concern.

['lizbeth]

From Susan G. Komen's website:




Calcifications and microcalcifications

Calcifications are bits of calcium that can show up on mammograms as small, bright white spots. Most calcifications are benign (not cancer). However, certain patterns of calcifications are suspicious and need more testing. Tight clusters or lines of tiny calcifications (microcalcifications) can be a sign of breast cancer.
Calcifications are common and appear on about half of all mammograms of women ages 50 and older (and on about one in 10 mammograms of younger women) [7]. They may be related to older age, past injury to the breast or inflammation (swelling) of the breast tissue (from an infection, for example) [7]. For breast cancer survivors, calcifications can also be related to past breast surgery and radiation therapy.
Non-invasive breast cancer - ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer (learn more). On a mammogram, DCIS usually looks like a cluster of microcalcifications. It can be hard to know from a mammogram image whether the cluster is DCIS or invasive breast cancer.

[Aussie Girl]

Hi, Kaa,

Difficult to give a definite answer - the exact findings on all the scans and site of the lesions make all the difference. MRI can over- and under-diagnose DCIS (It did both in my case.)

Remember that she has the option of having a lumpectomy with biopsy of any other calcifications/suspect areas that aren't included in the biopsy site. It does depend on how those lesions are scattered and whether the ones away from the main area have calcifications or not. An MRI only detected area in the biggest problem, if it isn't close to the main tumour, because MRI guided biopsies are very expensive (depending on your insurance) A sentinel node biopsy should occur at the same time as the lumpectomy (but if she has proven node mets already, then an axillary dissection straight up).

Should there be DCIS at the edges of the lumpectomy, she can then chose to have re-excision at the edges of the lumpectomy or move on to mastectomy.

Her invasive cancer, presumably measured on scans and core biopsy is small (good prognosis), but a lumpectomy +/- some extra biopsies should provide a fuller picture.

Given that you sister doesn't like the idea of mastectomy and reconstruction, a lumpectomy plus radiation plus probably chemo may suit her better. If the other breast shows nothing and there is no strong family history, then bilateral mastectomy is not required from a treatment stand point, unless there are emotional or particular physical reasons.

You have some thinking time, but occasionally tumors that are high grade can grow fast. Try to get some sort of therapy happening within the month.

I unfortunately had to go on to mastectomy because of the size of my invasive and in situ tumor and my terribly fibrotic breasts. I probably would have needed a bit of lateral padding if my large lumpectomy had been enough. I miss my left breast and haven't decided on reconstruction yet. I'm not comfortable with my prosthesis yet, but that's because the chemo makes the site tender. I'm glad I have a sensitive nipple remaining on the right side though.

Best of luck to your sister and good on you for finding her info when she must be overwhelmed.

Aussie Girl

['lizbeth]

My impression from the scattered calcifications was the cancer was multi focal.

Perhaps we are looking at this from the wrong order. I would advise your sister to seek opinions from two oncologists and request neoadjuvant treatment with Taxotere, Carboplatin, Perjeta and Herceptin.

This combination resulted in almost 2/3rds of patients achieving a pathological complete response of the breast tumor.

Having chemotherapy prior to surgery could shrink the tumor, sometimes to undetectable levels, and most importantly reduce the amount of breast tissue that would have needed to be removed if surgery was done first.

The neoadjuvant treatment was first approved 2 months ago. I was treated in traditional order surgery, radiation, chemo . . . and just wasn't thinking.

The neoadjuvant treatment can help your sister reach her goal of a lumpectomy.

['lizbeth]

Here is Genentech's press release about the approval and the treatment:

FDA Grants Genentech’s Perjeta Accelerated Approval for Use Before Surgery in People With HER2-Positive Early Stage Breast Cancer

• The Perjeta regimen is the first treatment approved under a new FDA pathway for neoadjuvant use in breast cancer
• This new approval pathway makes Perjeta available to people with high-risk, early stage breast cancer more quickly than is possible with traditional approvals

South San Francisco, Calif. -- September 30, 2013 --
SOUTH SAN FRANCISCO, Calif. – September 30, 2013 – Genentech, a member of the Roche Group (SIX: RO, ROG; OTCQX: RHHBY), today announced that the U.S. Food and Drug Administration (FDA) granted accelerated approval of a Perjeta® (pertuzumab) regimen for neoadjuvant treatment (use before surgery) in people with high-risk, HER2-positive early stage breast cancer. This approval is based primarily on data from a Phase II study showing that nearly 40 percent of people receiving the combination of Perjeta, Herceptin® (trastuzumab) and docetaxel chemotherapy had no evidence of tumor tissue detectable at the time of surgery (known as a pathological complete response, or pCR). The Perjeta regimen is the first neoadjuvant breast cancer treatment approved by the FDA and also the first to be approved based on pCR data.
Neoadjuvant treatment may allow a doctor to quickly assess whether a medicine is working, and may also reduce a tumor's size so it is easier to surgically remove. pCR is a common measure of neoadjuvant treatment effect in breast cancer and can be assessed more quickly than traditional endpoints in early stage breast cancer. Treating people with breast cancer early, before the cancer has spread, may offer the best chance of preventing the disease from returning.
“A new approval pathway has made Perjeta available to people with HER2-positive early breast cancer several years earlier than previously possible,” said Hal Barron, M.D., chief medical officer and head, Global Product Development. “Together with the FDA, we’ve charted new territory. We look forward to working with health authorities around the world to explore additional ways to bring promising medicines to patients more quickly.”
This new neoadjuvant indication for Perjeta is for use prior to surgery in combination with Herceptin and docetaxel chemotherapy in people with HER2-positive, locally advanced, inflammatory, or early stage (tumor is greater than two centimeters in diameter or node positive) breast cancer. Perjeta should be used as part of a complete treatment regimen for early stage breast cancer. This use of Perjeta is based on an improvement in the percentage of people who had no evidence of cancer in the breast or lymph nodes at the time of surgery. Currently, no data have shown whether or not treatment with Perjeta prior to surgery improves survival. The safety of Perjeta as part of a doxorubicin (chemotherapy)-containing regimen has not been established. The safety of Perjeta administered for greater than six cycles for early stage breast cancer has not been established.
The Perjeta neoadjuvant indication was granted under the FDA’s accelerated approval program, which allows conditional approval of a medicine for a life-threatening disease based on early evidence suggesting clinical benefit. The approval is based on results from the NEOSPHERE study, a Phase II study of Perjeta in high-risk, HER2-positive early stage breast cancer. Additional data from the TRYPHAENA study, as well as longer-term safety data from the Phase III CLEOPATRA study of Perjeta in HER2-positive metastatic breast cancer, were also submitted in support of the approval. TRYPHAENA is a Phase II study of Perjeta in HER2-positive early stage breast cancer designed primarily to assess cardiac safety.
A full review of data from the ongoing Phase III APHINITY study will be required for the accelerated approval to be converted to a full approval. APHINITY compares Perjeta, Herceptin and chemotherapy with Herceptin and chemotherapy for adjuvant (post-surgery) treatment in people with HER2-positive early stage breast cancer. Data from APHINITY are expected in 2016.
Roche is discussing the option of submitting Perjeta in the neoadjuvant setting to regulatory authorities in other countries around the world. Perjeta is already approved in a number of countries including the United States for people with HER2-positive metastatic breast cancer (an advanced form of the disease in which the cancer has spread to other parts of the body) or locally recurrent, unresectable (inoperable) breast cancer who have not received previous anti-HER2 therapy or chemotherapy for their metastatic disease.
Perjeta Data in HER2-positive Early Stage Breast Cancer
NEOSPHERE Study
The NEOSPHERE study (Neoadjuvant Study of Pertuzumab and Herceptin in an Early Regimen Evaluation) ) is a randomized, multicenter, international Phase II study that was conducted in 417 people with newly diagnosed HER2-positive, locally advanced inflammatory, or early stage breast cancer. Participants were randomized to four study arms and received four cycles (12 weeks) of neoadjuvant treatment. The primary endpoint was pCR. Secondary endpoints included clinical response, time to clinical response, safety profile, disease-free survival (DFS), breast-conserving surgery rate and biomarker assessment. Study data showed the following:

• Treatment with Perjeta, Herceptin and docetaxel chemotherapy significantly improved the rate of total pCR by 17.8 percent compared to Herceptin and docetaxel alone (39.3 percent vs. 21.5 percent, p=0.0063).
  • pCR of 21.5 percent for Herceptin and docetaxel
  • pCR of 39.3 percent for Perjeta, Herceptin and docetaxel
  • pCR of 11.2 percent for Perjeta and Herceptin
  • pCR of 17.7 percent for Perjeta and docetaxel
• The most common severe (Grade 3 or higher) AEs for the Perjeta regimen were neutropenia (decrease in a certain type of white blood cell, 44.9 percent), febrile neutropenia (fever associated with decrease in a certain type of white blood cell, 8.4 percent), leukopenia (decrease in overall white blood cells, 4.7 percent) and diarrhea (5.6 percent).

TRYPHAENA Study
The TRYPHAENA study (ToleRabilitY of Pertuzumab, Herceptin and AnthracyclinEs in NeoAdjuvant breast cancer) is a randomized, multicenter Phase II study that was conducted in 225 people with HER2-positive, locally advanced, inflammatory, or early stage breast cancer with tumors greater than two centimeters. Participants were randomized to one of three neoadjuvant Perjeta regimens. The primary endpoint was cardiac safety. Secondary endpoints included pCR, clinical response, breast-conserving surgery rate, DFS, progression-free survival (PFS), overall survival (OS) and biomarker assessment. Study data showed the following:

• The study was not powered to compare the three study arms. The rates of total pCR in the three arms were as follows:
  • pCR of 56.2 percent for Perjeta, Herceptin and anthracycline-based chemotherapy, followed by Perjeta, Herceptin and docetaxel
  • pCR of 54.7 percent for anthracycline-based chemotherapy, followed by Perjeta, Herceptin and docetaxel
  • pCR of 63.6 percent for the anthracycline-free arm (Perjeta, Herceptin, docetaxel and carboplatin chemotherapy)
• No new or unexpected cardiac AEs, or other AEs, were observed in any of the study arms. AEs observed were consistent with those seen in previous studies of Perjeta, Herceptin and chemotherapy, either in combination or alone.
• The most common severe (Grade 3 or higher) AEs in any of the three study arms were:
  • In the concurrent arm: neutropenia (47.2 percent), leukopenia (decrease in overall white blood cells, 19.4 percent) and febrile neutropenia (18.1 percent)
  • In the sequential arm: neutropenia (42.7 percent), leukopenia (12.0 percent), febrile neutropenia (9.3 percent), diarrhea (5.3 percent) and left ventricular dysfunction (4.0 percent)
  • In the anthracycline-free arm: neutropenia (46.1 percent), febrile neutropenia (17.1 percent), anemia (decrease in red blood cells, 17.1 percent); the AEs of diarrhea, leukopenia, anemia and thrombocytopenia (decrease in platelets) all had an incidence of 11.8 percent

About Perjeta
Perjeta is a medicine that targets the HER2 receptor, a protein found on the outside of many normal cells and in high quantities on the outside of cancer cells in HER2-positive cancers. Perjeta is designed specifically to prevent the HER2 receptor from pairing (or “dimerizing”) with other HER receptors (EGFR/HER1, HER3 and HER4) on the surface of cells, a process that is believed to play a role in tumor growth and survival. Binding of Perjeta to HER2 may also signal the body’s immune system to destroy the cancer cells. The mechanisms of action of Perjeta and Herceptin are believed to complement each other, as both bind to the HER2 receptor, but to different places. The combination of Perjeta and Herceptin is thought to provide a more comprehensive blockade of HER signaling pathways.
Perjeta Indication Statements
Perjeta is approved for use in combination with Herceptin and docetaxel chemotherapy in people who have HER2-positive breast cancer that has spread to different parts of the body (metastatic) and who have not received anti-HER2 therapy or chemotherapy for metastatic breast cancer.
Perjeta is approved for use prior to surgery in combination with Herceptin and docetaxel chemotherapy in people with HER2-positive, locally advanced, inflammatory, or early stage (tumor is greater than two centimeters in diameter or node positive) breast cancer. Perjeta should be used as part of a complete treatment regimen for early stage breast cancer. This use of Perjeta is based on an improvement in the percentage of people who had no evidence of cancer in the breast or lymph nodes at the time of surgery. Currently, no data have shown whether or not treatment with Perjeta prior to surgery improves survival. The safety of Perjeta as part of a doxorubicin (chemotherapy)-containing regimen has not been established. The safety of Perjeta administered for greater than six cycles for early stage breast cancer has not been established.
Important Safety Information
Most Serious Side Effects of Perjeta
Perjeta may cause heart problems, including those without symptoms (such as reduced heart function) and those with symptoms (such as congestive heart failure).

• A patient’s doctor may run tests to monitor the patient’s heart function before and during treatment with Perjeta.

Receiving Perjeta during pregnancy can result in the death of an unborn baby and birth defects.

• Patients who think they may be pregnant should contact their healthcare provider immediately.
• If patients are exposed to Perjeta during pregnancy, they are encouraged to enroll in the MotHER Pregnancy Registry by contacting (800) 690-6720.

Perjeta should not be used in patients who are allergic to pertuzumab or to any of the ingredients in Perjeta.
Other Possible Serious Side Effects

• Infusion-related reactions: Perjeta is a medicine that is delivered into a vein through a needle. This process can cause reactions known as infusion-related reactions. The most common infusion-related reactions when receiving Perjeta, Herceptin and docetaxel chemotherapy were feeling tired, abnormal or altered taste, allergic reactions, muscle pain and vomiting
• Severe allergic reactions: Some people receiving Perjeta may have severe allergic reactions, called hypersensitivity reactions or anaphylaxis. This reaction may be severe, may happen quickly and may affect many areas of the body

Perjeta has only been shown to work in people with HER2-positive breast cancer.
Most Common Side Effects
The most common side effects of Perjeta when given with Herceptin and docetaxel chemotherapy for treatment of breast cancer that has spread to other parts of the body (metastatic) are:

• Diarrhea
• Hair loss
• Low levels of white blood cells with or without a fever
• Nausea
• Feeling tired
• Rash
• Damage to the nerves (numbness, tingling, pain in hands/feet)

The most common side effects of Perjeta when given with Herceptin and docetaxel chemotherapy as part of an early stage breast cancer regimen before surgery are:

• Hair loss
• Diarrhea
• Nausea
• Low levels of white blood cells with or without a fever

The most common side effects of Perjeta when given with Herceptin and docetaxel chemotherapy following three cycles of epirubicin, cyclophosphamide and fluorouracil as part of an early stage breast cancer regimen before surgery are:

• Feeling tired
• Hair loss
• Diarrhea
• Nausea
• Vomiting
• Low levels of white blood cells with or without a fever

The most common side effects of Perjeta when given with Herceptin, docetaxel chemotherapy and carboplatin chemotherapy as part of an early stage breast cancer regimen before surgery are:

• Feeling tired
• Hair loss
• Diarrhea
• Nausea
• Vomiting
• Low levels of white blood cells with or without a fever
• Low platelet count
• Low levels of red blood cells

Report side effects to the FDA at (800) FDA-1088 or http://www.fda.gov/medwatch. Patients and caregivers may also report side effects to Genentech at (888) 835-2555.
Please see Perjeta full Prescribing Information including Most Serious Side Effects for additional Important Safety Information at http://www.perjeta.com.
About Breast Cancer
Breast cancer is the most common cancer among women worldwide. According to the American Cancer Society, approximately 235,000 people in the United States will be diagnosed with breast cancer, and 40,000 will die from the disease in 2013. In
HER2-positive breast cancer, increased quantities of the Human Epidermal growth factor Receptor 2 (HER2) are present on the surface of the tumor cells. This is known as “HER2 positivity” and affects approximately 25 percent of people with breast cancer. HER2-positive cancer is a particularly aggressive form of breast cancer.
About Genentech and Roche in HER2-positive Breast Cancer
Genentech and Roche have spent more than 30 years studying the role of HER2 in cancer, and Perjeta is a result of this research. A companion diagnostic test is used to determine if a person is HER2-positive and whether treatment with Perjeta and Herceptin is appropriate.
About Genentech Access Solutions
Genentech is committed to people having access to our medicines. Genentech Access Solutions is a team of more than 350 Genentech employees who help those who need our medicines. Our knowledgeable and experienced specialists can help patients and medical practices navigate the access and reimbursement process and provide assistance to eligible patients in the United States who do not have insurance coverage or who cannot afford their out-of-pocket co-pay costs. For more information, please visit http://www.Genentech-Access.com.
About Genentech
Founded more than 35 years ago, Genentech is a leading biotechnology company that discovers, develops, manufactures and commercializes medicines to treat patients with serious or life-threatening medical conditions. The company, a member of the Roche Group, has headquarters in South San Francisco, California. For additional information about the company, please visit http://www.gene.com.

[norkdo]

'Lizbeth: re:Calcifications and microcalcifications

Calcifications are bits of calcium that can show up on mammograms as small, bright white spots. Most calcifications are benign (not cancer). However, certain patterns of calcifications are suspicious and need more testing. Tight clusters or lines of tiny calcifications (microcalcifications) can be a sign of breast cancer.
Calcifications are common and appear on about half of all mammograms of women ages 50 and older (and on about one in 10 mammograms of younger women) [7]. They may be related to older age, ....

Wow. This is gold. How I wished, reading it, I could have had a chance to know what these calcifications were back two yrs before i found my stage 3 cancer when the dumb radiologist, in my case (the one reading my followup mammo and ultrasound ) wrote "no this patient doesn't have breast cancer." Had I known that these calcifications were the basis upon which he/she made that decision, and had I known what u just provided us with....well.....I might have been able to have further testing elsewhere.

The majority of us found our cancer in stage three according to the polls. One researcher wrote that he believed (according to my medical oncologist) "HER2 cancer lines the ducts in spider-like formations for a really really long time before it gathers momentum to burst into a tumour formation."
I thought about this...the behaviour of her2 cancer cells after reading Denise's husband, Ted's, description of her last MRI revealing a massive tumour, suddenly appearing (it wasn't there one week earlier in that brain MRI) at the base of her brain stem. I was thinking maybe Her2 was working in her brain like it did on my breast....lying low inside tubes for a long time, waiting to gain the momentum to form an actual tumour, i.e. an object detectable on a scan.

[IrvineFriend]

After my initial biopsy, the pathology report came back that I had DCIS. The "suspicious" node was also biopsied and was negative. Due to strong family history of BC I chose bilateral with reconstruction. Also the tumor size encompassed the majority of my size C breast (over 14 cm) due to multiple tumors. The only reason I did not suspect it was BC is because there no "lump" per se ever; my entire breast was hard becaue it all cancerous. Two years prior negative mammogram. I also had calcification throughout that breast (had for 10+ years). My sister the same calcification with the same end results (but not HER2+).

I do want to share that my pathology report for my removed breast/nodes came back with TWO types of cancer, the predominant one being missed in the biopsy. I also had 4 positive nodes and only learned I was HER2+ from that pathology report. My doctor and likely my insurance does not test for HER2 status for DCIS.

Prior to that surgery, my treatment plan was completely different. Chemo and radiation was not being considered. I'm grateful I had the mastectomy as it's something I don't have to worry about as much about. I chose to spare the nipple in the non-cancerous breast and truly glad for that. With the reconstruction and great surgeons, I feel my breast looks normal/fine. The other I don't care for much but I'm looking forward to finishing up early next year. Had the cancer not been located at the nipple I would have kept that one too. I'm the same age as your sister and not married so appearance of my breasts was important for me. Quality of life thing.

Just wanted to share my experience regarding the two completely different pathology reports prior to and after mastectomy.

Wishing your sister good luck and wishes.

-Julie

[Aussie Girl]

Hi again Kaa,

As a pathologist working with a breast cancer team (when I'm not dealing with my own breast cancer) I can tell you that breast cancer accompanied by scattered calcifications and equivocal MRI spots is the bane of the medical team's existence. So many of the calcifications turn out to be benign and other people turn out to have extensive DCIS which was undetectable by any method.

I suspect given the small size of the known cancer, that the medical team won't want to go straight to neo-adjuvant therapy. They will look at all the info they have and I suspect they'll advise biopsy of at least some of the suspicious areas followed by or concurrent with lumpectomy of the known cancer (with sentinel node studies). If scattered calcifications are invasive cancer, they'd likely use neo-adjuvant chemo before surgery. ('Lizbeth's provided a great summary of the latest neo-adjuvant therapy above) In Australia, if the calcifications turned out to be DCIS, they'd go for surgical removal first because DCIS is harder to treat with neo-adjuvant chemo and we don't have access to Perjeta as a component of the therapy here either (yet).

If it turns out there is extensive DCIS around the cancer, they may be able to remove it without taking the whole breast or they may have to go to mastectomy. Sometimes if calcifications are really diffuse and biopsies are inconclusive, mastectomy turns out to be the only way of knowing what is happening with the disease. I hope that won't be necessary for your sister, Kaa, but sometime you have to bite the bullet.

Mastectomy sounds scary but removal of all the primary tumor can save your sister's life. It is also comforting to know that all the bad areas in the breast are gone. Chemotherapy is also going to be necessary because HER2 cancer really requires this in almost every case. Radiation may or may not be required.

Reconstruction is a personal choice. I haven't decided yet. While surgery/ chemo/ radiation needs to go ahead fairly promptly, decisions about reconstruction can often be delayed (I went to an international breast cancer conference on this before I got cancer and delayed DIEP seemed to be a good option from what I understood). The plastic surgeon should be able to advise about this, after the diagnosis of the extent of your sister's disease is clearer.

As far as I can tell from the current information you've provided, it sounds like your sister is in the early breast cancer group. You'll know for sure once more workup/ surgery is done. Recent advances have revolutionized the treatment of early HER2 cancer markedly improving survival. New treatments have even helped many ladies with more advanced disease live much longer.

Through this website, we'll try and support you and your sister on this journey. You'll note that we'll sometimes provide too many suggestions and it gets confusing - sorry! Some people get overwhelmed by information and some people gobble up every snippet.

If possible go with your sister to her oncology and surgical appointments. Take a notebook and pen!. Some places have a breast care nurse who can translate the info for you. A good primary care doctor can sometimes help too. I'm attaching a link to a helpful book.

http://www.booktopia.com.au/breast-c...980631111.html

The main large hospital chemo centers have good info on the web, but remember that your sister's health team know her individual circumstances so they'll have to guide her.

Wishing you both strength for the journey,

Aussie Girl

['lizbeth]

So the calcification issue is a tricky one. I had been given the impression that they always meant cancer. So on a mammogram the radiologist came in to talk about interesting calcifications a few years ago - I was freaked out. But he was talking about calcifications in the TRAM which were never explained, but perhaps necrosis?

I now see calcification can be benign as well. Tricky stuff sometimes to read these scans. So happy that mammograms are now digital. I will be thrilled when the next generation technology comes around.

Aussie Girl - this new FDA neoadjuvant approvals seems to be a bit tricky. Yes the tumor is small .6cm, but has an area of DCIS close by. I can see the interpretation of when to use it is not black & white.

So you should know when you make a statement such as DCIS is harder to treat with neoadjuvant chemotherapy than IDC I'm going to want to see the articles on the studies that support this. I find this interesting and would like to see the scientific findings. So can you post it under Articles of Interest please?

Kaa, I'm sorry if we overwhelm you with information and opinions. Some of us started on this journey years ago and are accustomed to the lingo, and the back and forth conversations. Sometimes we are quite guilty of going off on another topic as well.

I hope your sister is getting the information she needs to make a good decision to nip this cancer in the bud. Fingers crossed that the calcifications are benign and she can have the lumpectomy she prefers.

[Aussie Girl]

Not much time to look for articles 'Lizbeth, you information fiend!
(And Kaa - this is too much information and most likely irrelevant to your sister, my apologies.)

So for 'lizbeth

Here's one article http://www.ncbi.nlm.nih.gov/pubmed/21667238

and here's a recent book chapter of interest which suggests that Herceptin added to neo-adjuvant chemo helps get rid of HER2 DCIS providing more complete responses. http://books.google.com.au/books?id=...0chemo&f=false

In the pathology literature, it is well known that DCIS is the last thing to go when we have to assess specimens for complete pathological response. The DCIS cells often looks "sick", like they are ill and dying, but we don't call it complete response unless the bad cells have disappeared.

So the neo-adjuvant therapy has an impact on DCIS but if it is incomplete, what does it mean?

I found this study http://jco.ascopubs.org/content/25/19/2650.full
which suggests the residual DCIS doesn't affect disease free survival.

Then this one showing that residual DCIS post-neoadjuvant Rx is bad. (my translations in red)
http://jco.ascopubs.org/content/30/15/1796.full
"We conclude that pCR defined as ypT0 ypN0 (=no residual tumor) is associated with highly favorable outcome. ypTis (=residual DCIS), ypT1mic (=residual microinvasion), and ypN+ (=residual positive node)residuals only are associated with increased relapse risk and should therefore no longer be considered as pCR. Extent of residual disease and evidence of regression provide helpful additional prognostic information. pCR is a suitable surrogate end point for patients with HER2-positive (nonluminal), TN, and luminal B/HER2-negative tumors but not for luminal B/HER2-positive and luminal A tumors. "

Also earlier in this article:
"We further demonstrate that in subgroups considered to have slowly proliferating tumors, pCR is not associated with prognosis, whereas in subgroups with highly proliferating tumors, pCR can discriminate between patients with good and poor prognosis accurately. The recently proposed clinicopathologic definition of the St Gallen panel nicely recognizes these subgroups. In fact, prognostic impact of pCR is highest in HER2-positive (nonluminal) and TN tumors, where patients achieving pCR show a prognosis comparable to that of patients with luminal A tumors.
Surprisingly, pCR was not prognostic in the luminal B/HER2-positive subgroup irrespective of trastuzumab treatment. In this subgroup, pCR rates were low, despite concomitant anti-HER2 therapies,11,28,29 but similar outcomes were observed in the adjuvant trastuzumab studies.30"

SO...
I think treatment of DCIS with neo-adjuvant chemo is a work in progress - the residual DCIS gets cut out anyway, or at least zapped with radiation, so it wouldn't be a big surprise if eventually residual DCIS is shown not to be so important if a mastectomy is performed.

However, it'd be good to know if you could have neo-adjuvant chemo followed by Limited surgery (or perhaps No surgery, on the basis of core biopsies as an assessment of response. )

And how will neoadjuvant Perjeta work on DCIS?? So much to learn!

Guess how much of my tax I did today (zilch again). I had a nice lie down instead, and took my daughter to an appointment and had a good talk with her, which was probably more productive anyway.

Cheers

Aussie Girl (Diane)

[tricia keegan]

Norkdo, I hate to disagree but I live in Ireland of Irish parents and must admit the majority of the Irish people are not vain at all and not sure where you got that from, I wonder if a persons country of origin does come into the equasion at all? My guess is not to be honest and God forbid, if I had a recurrance I would not go for recon after a mast but thats whats right for me and maybe not suit others.