for those with tumors <1cm, at least the issue is being addressed!

[Lani]

1: J Clin Oncol. 2006 May 1;24(13):2113-22. Related Articles, Links

Prognosis and management of patients with node-negative invasive breast carcinoma that is 1 cm or smaller in size (stage 1; T1a,bN0M0): a review of the literature.

Hanrahan EO, Valero V, Gonzalez-Angulo AM, Hortobagyi GN.

Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77230-1439, USA.

PURPOSE: Mammographic screening has led to an increase in the number of small, node-negative breast cancers being diagnosed. Node-negative breast cancers that are < or = 1 cm are stage T1a,bN0M0. Controversy surrounds the prognosis of these patients with locoregional therapy only and the need for adjuvant systemic therapy. METHODS: We performed a comprehensive review of the literature describing outcome and prognostic factors in stage T1a,bN0M0 breast cancer. We also reviewed current guidelines for systemic therapy in these patients. RESULTS: Early studies reported 10-year relapse-free survival (RFS) rates higher than 90% without adjuvant systemic therapy, but some more recent data suggest inferior outcomes. High tumor grade is the most consistent factor associated with poor prognosis. Other adverse prognostic factors are younger age, lymphovascular invasion (LVI), high Ki-67, and larger tumors within the T1a,b subgroup. Patients with high-grade tumors and/or LVI may have 10-year RFS rates of less than 75% in the absence of systemic therapy. The prognostic significance of hormone receptor status is unclear. Current guidelines for the systemic management of early-stage breast cancer differ when applied to stage T1a,bN0M0, reflecting the controversial nature of the issue. CONCLUSION: Adjuvant systemic therapy is advisable for most patients with stage T1a,bN0M0 breast cancer who have grade 3 tumors and/or LVI. Other T1a,bN0M0 cases should be considered for systemic therapy based on clinicopathologic factors with known prognostic significance and assessment of the risk-benefit ratio. More reliable tools are needed to assess the prognosis of patients with stage T1a,bN0M0 breast cancer and their potential to benefit from specific therapeutic agents.

[Lani]

According to the American Joint Committee on Cancer, stage I breast cancer has a tumor size 2 cm (T1), no lymph node involvement (N0), and no distant metastases (M0).1 T1 tumors are further subdivided based on greatest diameter into T1a ( 0.5 cm), T1b (> 0.5 cm but 1.0 cm), and T1c (> 1.0 cm but 2.0 cm).

Mammographic screening has led to an increase in the number of stage I breast cancers being diagnosed.2-5 The Surveillance, Epidemiology, and End Results (SEER) Program is a network of cancer registries in the United States. The rate of T1 tumors diagnosed among women aged 50 to 69 years in nine SEER registries increased from 143.5 per 100,000 in 1990 to 163.5 per 100,000 in 1998.5 Among 171,479 breast cancer patients registered in the SEER Program between 1996 and 2000, 62.1% were node-negative.6 A number of important recent clinical trials have focused on the systemic management of node-positive disease, but it is expected that the number of node-negative breast cancers diagnosed will continue to rise, especially T1a,b primaries.7-9 The clinical course of these early lesions after locoregional therapies, and the incremental gains obtained with adjuvant systemic treatments have not been well characterized to date. The optimal management of this increasing population with small node-negative breast cancers is controversial.

Adjuvant chemotherapy for breast cancer has been shown to reduce the risk of recurrence and improve survival in both node-negative and node-positive disease, and in both hormone receptor (HR) -positive and -negative cases.10,11,12 The reduction in the annual recurrence rate according to the most recent report by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) is 23% with polychemotherapy (37% for women < 40 years).12 There is a 41% reduction with 5 years of tamoxifen in estrogen receptor (ER) -positive cases.12 The magnitude of benefit for an individual will depend on their risk of recurrence in the absence of adjuvant systemic therapy (ADST). Established prognostic factors, such as nodal status, tumor size, histologic grade, histologic type and HR status, can give an appreciation of this risk.13 The earliest report of outcome for patients with stage T1a,bN0M0 breast cancer treated with local therapy alone suggested 10-year relapse-free survival (RFS) rates of more than 90%.14-16 Considering the risk reductions described by the EBCTCG, we can estimate that the absolute benefit in terms of 10-year RFS in these patients would only be about 2.5% with chemotherapy. For a patient with an ER-positive tumor, the absolute benefit with 5 years of tamoxifen alone would be approximately 4%, with only a small additional increase in absolute benefit (approximately 2%) if chemotherapy were to be added. If we accept that the 10-year RFS rate for these patients is truly more than 90%, many would not advocate ADST with its associated toxicities for such small absolute differences in outcome.17 However, a number of subsequent publications reported lower RFS at 10 years, and the work of Fisher et al suggests that these patients benefit from ADST.18-22 In an attempt to better understand the natural history of stage T1a,bN0M0 breast cancer and the role of ADST in these cases, we performed a review of the literature.

Of course these are not stats for her2+ tumors but for all tumors combined.

[AlaskaAngel]

Hi Lani. I'm very grateful for all of the studies you posted, so thank you very much.

However, I find it very discouraging that T1c's are yet again left to stumble around in the dark, especially those who fall beyond the cutoff time to get Herceptin. Do you know of any clear evidence demonstrating that T1c's clearly benefit hugely from chemotherapy? Especially, is anyone interested in finding out if the Stage 1 HER2's (since T1cs are apparently condemned to do chemo in the blind) would do just as well with just traztuzumab and perhaps an AI?

Thanks,

A.A.

[CLTann]

I am grateful for you to post the article regarding T1a,T1b and T1c patients. This is precisely my own concern. Because the benefit of chemo for this group of patients is so small, I decided early on that I would not go through with chemo. So far, I feel that my decision was sound. I am on Arimidex, since my age, 60, is also favorable. The only concern is my HER2+++ status. The study indicated that they mixed all HER2 status positive/negative as one group. All showed quite high survival rate. I keep my fingers crossed that my decision of doing mastec gave me another edge up in this battle.

Ann

[MCS]

Lani,


really appreciate for information. I'm printing and re reading again to get all the stats. It also helps me to get answers from the onc.

XO

MCS (maria)