Types of chemo tx, neo-adj vs. adj. etc

[Val Pfeiffer]

I was surfing around this site tonight and I happened to read Kate's signature line -- many of us list the facts about our case, and Kate had listed her neo-adjuvant chemo, which was 4 A/C and 4 taxatore, and this was her treatment very recently, one year after my treatment regime.

Here is my question: what is considered the "gold standard" with regard to chemo tx for Her2+++ breast cancer? When I received the combination of Taxol, Carboplatin and Herceptin for three months prior to my mastectomy and the same drugs for three months after surgery, it was my understanding that was the best approach for this type of cancer. Yet women are still getting A/C and Taxatore. Does anyone know why this is the case? Maybe I was misinformed in December 2004 when I started my treatment.

I find the differences in treatment approaches frustrating at times; I met a woman who had a very similar case as mine, and her oncologist practices in the same group as mine does. Yet she had surgery first, rather than three months of neoadjuvent chemo, which produced such dramatic results in my case.

This certainly isn't an urgent question, but since recurrence is so likely in Her2 cases, I want to get this answer...someday I may need it!

Val

[Lani]

It is unlikely that your tumor is the same size, has the same amount of (if any) lymphvascular invasion, has the same ER%or PR% , the same Ki-67value, has the same amount and degree of lymph node involvement, that you are in the same state of pre/peri/or post menopause, that you have the same medical problems (liver failure, history of hepatitis C, neurological disease, heart disease) or have the same wishes than another person. And there is not yet one RIGHT way to treat this disease...every year the Europeans and the North
Americans (it may not be as often for the No. Americans I will have to go back and look ) try to publish a consensus OPINION on how to treat different patients but it is A WORK IN PROGRESS.

Some oncologists hear reports at major meetings and start to change their practices before it becomes common practice(or even is entirely validated). At San Antonio last December , Dr. Slamon presented early results of a study showing the her2 and topoIIa tend to be coamplified (they sit near each other on the same chromosome and the error which causes her2 to be copied over and over again like a broken record can also cause the nearby topoIIa to be copied over and over again)

[Lani]

Their paper hypothesized that when this was the case Anthracyclines would
be more effectively combined with herceptin than when this was not the case and proposed that IF THIS PROVED OUT IN THE LONG-RUN that perhaps one could save thousands of patients the toxicity of anthracyclines and markedly reduce the cardiotoxicity of herceptin (as it seems to be the combination of the anthracycline caused damage and the herceptin caused damage which causes most cases of herceptin-induced cardiotoxicity)

Dr. Slamon gave a preliminary report on a relatively small number of patients treated with TCH instead of A/C T and H which showed survival benefit of approximately 42-45% instead of 50% (numbers not exact, but not far off) compared to chemotherapy alone. Again, he proposed that if these numbers continued to show
similar results as the study matured that perhaps TOPO IIa testing MIGHT BECOME the new standard of care, with those testing negative for TOPO IIa PERHAPS receiving TCH, with anthracyclines(ie A/C+TH) reserved for those who were TOPO IIa positive.

Since San Antonio I have read two papers, from other groups stating that topoIIa positivity is not always associated with anthracycline efficacy. Perhaps the story is not so simple or perhaps their study was done in some different way or their patients tended to have different tumor subtypes than Dr. Slamon's. It appears there are different types of her2+ tumors besides the ER+PR+, ER+PR- and ER-PR-.

I think some oncologists went home from San Antonio thinking this WOULD
become the new standard of care. Since all those being treated off protocol with adjuvant and neoadjuvant herceptin for early breast cancer are still being treated with a drug which has not been FDA approved for the purpose, oncologists feel they can have some leeway in how they treat any individual patient.

Neoadjuvant chemotherapy is in general as I understand it only offered to those with larger tumors in order to allow them to have breast conserving surgery instead of a mastectomy. This allows one to tell if the treatment is working or not
(change in the tumor by exam, US, MRI, PET/CT,etc). Some patients are now getting neoadjuvant hormonal therapy in clinical trials.

Having recently helped an 84 year old with her2+ breast cancer with information on which to base her decisions I can say that it is a good thing that there is no one way to treat all her2+ breast cancers. Would you want chemotherapy as an 84 year old?

[Lani]

Hope this helped!

[tousled1]

Val,

I don't know why my oncologist chose the neo-adjunct chemo that she did. At that time I was very uninformed and still in a state of shock. I just went along with what she decided. The only thing I knew was that I did not want surgery first -- too close to the Holidays (stupid reasoning??). I can tell you that my onc did state that with the A/C and then Taxatore there was good results in tumor shrinkage. I can attest to that -- the tumor did indeed shrink but I still opted for the bilateral mastectomy. I didn't want to have to go through surgery again if I had recurrence. Another factor may be that I was 57 at the time of my diagnosis and we already knew that there was lymph node involvement. I had lymph node needle aspiration biopsy done at time of initial biopsy. Other factors that were unfavorable in my biopsy report were Ploidy/DNA index (Aneuploid/1.61) and S-phase 24.2%. Like Lani said, it's like comparing apples and oranges. The most important thing in any treatment plan is the end result.

[Val Pfeiffer]

Thanks, Lani and Kate. I certainly understand that each patient is completely different. I still can't help but wonder about using Herceptin vs. not using Herceptin with chemo... why it is chosen for some Her2 cases and not for others. The adjuvant vs. neoadjuvant is an entirely different topic (in which I am also very interested). I know there aren't any exact answers to this, but I find this topic fascinating. I am looking more for debate and discussion with this thread than answers :-)

Val