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Medical Forum / Diseases and Disorders / Breast Cancer / May 2008Chemo? or no?
My stepdaughter's story: Hodgkins 18 years ago, treated with surgical staging, splenectomy, radiation to max. No recurrence. Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs say C. was caused by radiation therapy for Hodgkins. Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor. Stage One. Question: is chemo indicated? She can't do radiation. What decides? Any science here? Thanks, Anxious Stepdad > My stepdaughter's story: > [quoted text clipped - 13 lines] > Thanks, > Anxious Stepdad The oncologist is the one to decide. Yes there is science, but fortunately but unfortunately for your step daughter her case is rare . Good news early stage Breast Cancer and radiation is usually not given after mastectomy. > My stepdaughter's story: > [quoted text clipped - 13 lines] > Thanks, > Anxious Stepdad That is not always an easy thing to decide. There are different ways to present the relevant statistics. When presented as improvement over the present state, the argument might run something like this (statistics are guesses): With no further treatment, your chances of no recurrence are 95%. Chemotherapy will cut the risk of recurrence by half--you should do it. 50% improvement looks impressive, but that means merely a 2.5% improvement in the probability of getting by without recurrence. Balanced against that is the discomfort of chemo and perhaps complications of chemo. Her age might affect her decision. The ER/PR status might make the starting odds worse (or perhaps better, but I think morelikely worse). If the probability of no recurrence is 50% instead of 95%, a 50% improvement would take her from 50% to 75% and that looks, to me at least, a whole lot more attractive. The 95% and 50% were numbers given my wife, who had a slightly larger primary but with ER+ and PR+, about 10 years ago. She declined, based in part on the experience of an aunt who accepted chemo and radiation after removal of a very large primary but died after several years of a somewhat miserable fight. The oncologist remarked that he had seenonly three other women decline, all, like my wife, physician's wives. My wife is doing well so far, but that doesn't prove much of anything. I don't know the right answer for your stepdaughter; I wish to suggest only that she ponder whatever numbers are given her carefully. >> My stepdaughter's story: >> [quoted text clipped - 40 lines] > don't know the right answer for your stepdaughter; I wish to suggest > only that she ponder whatever numbers are given her carefully. Thanks, Doc. Fascinating that only refusals were MDs. I am anxious to review stats also. She is not a numbers person, so it may be uphill to give her a reason to avoid a lot of grief for so little potential benefit. Everyone talks in percentages when absolute numbers are what count as you so succinctly pointed out. She also wants to have more kids (has 2 now) and this may make a difference. AS >>> My stepdaughter's story: >>> [quoted text clipped - 51 lines] > > AS Her desire for children would make her quite a bit younger than my wife, who was 57 at the time. I think the odds are not so good for younger women. Again,, the oncologist will have current numbers. If she wishes, having someone else along to listen and take notes may be helpful. There is inevitably anxiety at this stage. > My stepdaughter's story: > [quoted text clipped - 13 lines] > Thanks, > Anxious Stepdad I am facing a similar decision soon. In addition to the info you mentioned, you might want to find out - if there is any mention of how aggressive the tumor appeared. Terms like "highly differentiated" are more alarming, I think, than "moderately differentiated", for example. - how much margin (shortest distance between an edge of the tumor and an edge of the tissue removed) was there? More than 1cm is, I think, considered very good. - was there any other suspicious or cancerous tissue in the tissue removed? None of this will make the answer obvious, but it may help you and your daughter reach a conclusion you can be comfortable with. >> My stepdaughter's story: >> [quoted text clipped - 27 lines] > None of this will make the answer obvious, but it may help you and > your daughter reach a conclusion you can be comfortable with. "Highly differentiated" is good, "poorly differentiated" is bad. The more mutated a cancer cell line becomes, the more the cells become unrecognisable as their original type. Differentiation is the process by which universal stem cells turn into specific body tissue cells, so if a cancer cell is said to be poorly differentiated, then it doesn't look much like a healthy tissue cell (ie a breast cell in the case of b.c.). Highly aggressive cancers tend to be associated with cells that have lost much of their form. The decision whether or not to use chemotherapy is obviously a personal one, but one that should be very much informed by the oncologist's expert opinion. In favour of it are the lack of excess hormone receptors, and the patient's age: younger people have a lot more life to lose. When we say for example a 5% reduction in mortality risk, it's 5% of a lot more life expectancy for a 40 year old than it is for an 80 year old. Against are the general undesirability of doing it, and the fairly early tumour stage. If the oncologist is equivocal, then on the whole if it were me I think I'd bite the bullet and do it. But I'd follow the expert's opinion first, and if not confident in it, get a second opinion. Tim Jackson > "Highly differentiated" is good, "poorly differentiated" is bad. > [quoted text clipped - 3 lines] > cancer cell is said to be poorly differentiated, then it doesn't look much > like a healthy tissue cell (ie a breast cell in the case of b.c.). Does that apply to other cancers, Tim? Thanks for all this, Mary >> "Highly differentiated" is good, "poorly differentiated" is bad. >> [quoted text clipped - 9 lines] > > Mary Yes Thanks for all for the thoughtful responses. We have new information. The pathology after the dbl mastectomy showed the single tumor as grade 3/9 indicating maximum aggressiveness (I am told). 2 sentinel lymph nodes showed nothing. All Hormone receptors are negative. Thus, we are told the stage is 1C. So AC is the recommended Chemo therapy. 8 sessions every 2 weeks for 4 months. The next step prescribed is MUGA baseline cuz AC can hurt heart. Also CT Scan on Chest, Abdomen and Pelvis. Now this girl has had 'maximum lifetime radiation' with her prior Hodgkins therapy. And she has had Cervical cancer. The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is done - otherwise 10-20%. What real advantage is there to chemo? If she has heart problems is there some other suite of probabilities? What are the probabilities of chemo problems that take her out of the set. And is there any study done on 35 yo Females with history of rad treated Hodgkins (with no recurrence) and cervical ca (2 yrs ago)? In other words does chemo make statistical sense here? Any absolute numbers to rely on? Any studies? Thanks to all!! Step-Dad - so worried!! >>> "Highly differentiated" is good, "poorly differentiated" is bad. >>> [quoted text clipped - 12 lines] >> > Yes > Thanks for all for the thoughtful responses. We have new information. > [quoted text clipped - 25 lines] > > Step-Dad - so worried!! You seem to have answered your own question, the real advantage of chemo is that it roughly halves the risk of a fatal recurrence. That seems to me to make it a good thing. Generally the younger you are the more you have to gain from chemo, simply because you have more to lose by dying. Yes there it causes some loss of heart muscle, but this is of little concern if the heart is initially healthy and is monitored. It isn't often a problem. I think you'd be lucky to find any statistics of 35 yr old breast cancer patients with previous cancer history, they are pretty thin on the ground because breast cancer is quite rare in that age group. From the SEER database (http://seer.cancer.gov) the annual incidence of breast cancer in under-50s is 0.0007, of cervical cancer is 0.0001 and of Hodgkins lymphoma is .000025, so multiplying up the probabilities there are probably no more than a dozen such cases in the whole USA. Of course if this is a syndrome with some common underlying cause (eg genetic or environmental) rather than random events, then the incidence could be a lot higher. Tim >> Thanks for all for the thoughtful responses. We have new information. >> [quoted text clipped - 46 lines] > > Tim Thanks Tim, 1) Syndrome: possible since dad had exposure to Dioxin in VietNam. And there is a high correlation w/ dioxin and Hodgkins. Also, one doc said that breast cancer in young radiation-treated Hodgkins survivors is a virtual certainty. So we are not dealing with isolated probabilities here. There should be some good data somewhere. 2) What is the meaning of maximum lifetime radiation dose (she was told this) if yet more radiation is prescribed with CT Scan and MUGA scan both of which involve yet more substantial rads? That is, what increased risk does this promote? 3) The huge ranges, 10-20%, 20-30% stated do not inform me that risk of recurrence (nobody modified this with 'fatal') is halved. So where do these numbers come from? For example if the chance of recurrence w/ chemo is 19% and the chance w/o is 21%, then we are not talking about halving at all. What science justifies these numbers? That is my fundamental question here. 4) What is the probability of fatality due to chemo (or over-radiation) alone? Should that not be considered separately? Phil >>> Thanks for all for the thoughtful responses. We have new information. >>> [quoted text clipped - 72 lines] > > Phil How is your statistics knowledge? Understand these ranges as distributions: by 10-20% the oncologist means a distribution with a mean around 15% and a standard deviation around 5%. It is important in this business for the oncologist to emphasise that the standard deviation is large, because people tend not to understand it. So looking at medians he is talking about a reduction from something like 25% to something like 15%. OK that's a bit less than half, but it's a reasonable ball-park figure to thing of chemotherapy in the case of a medium-risk cancer to be roughly halving the risk. Justification of figures, well there have been papers published which analyse the statistics retrospectively, plus there are clinical trials of each treatment regime as it comes into use. This gives general risk factors for certain categories of patient. But then it is up to the skill and experience of the oncologist to place any individual patient in the appropriate category, or to interpolate between them. Nobody mentioned fatal? No they would rather not. But it is the fatal ones we are interested in counting. Whether or not you include treatable local recurrences, and distant metastases that go into spontaneous long-term remission, doesn't make a lot of difference to the results - all the risks move together. Likewise the risk of fatality from chemo is small compared to the risk of fatality from cancer, somewhere down under 1%, lower for young and otherwise healthy patients. Of course it's significant, that's one reason why for some patients it's better not to give chemo, but in the 25% bracket that really isn't a consideration. Radiation limits: Radiotherapy is a much bigger dose than scans, so that is the main concern. As for the risk factors, you'd best ask a radiographer, I really don't know; but its obviously a progressive risk, you don't suddenly hit a brick wall. It also depends which tissues are being irradiated - different tissues have different tolerances and different histories. It's a matter of making a risk-benefit judgement. Tim >>>> Thanks for all for the thoughtful responses. We have new information. >>>> [quoted text clipped - 110 lines] > > Tim Thanks, Tim, much appreciated indeed. I would like to see the data. I am always suspicious of numbers like 15% and 25%. Nothing ever falls that neatly in statistics. My sense is that these numbers are pretty much generated for patient consumption based on WAGS and intended to assuage those who lean to quantification. In my step-daughter's case, I suspect that with her history she is at much higher risk of recurrence than someone her age with a similar dx without prior Ca. And I wonder if that is factored in to the oncologist's analysis, prescription and prognosis. Phil > I would like to see the data. I am always suspicious of numbers like 15% > and 25%. Nothing ever falls that neatly in statistics. My sense is that [quoted text clipped - 5 lines] > without prior Ca. And I wonder if that is factored in to the > oncologist's analysis, prescription and prognosis. That's the whole point of giving wide ranges isn't it? They emphasise that these are very rough figures. I don't see anything neat about saying somewhere around 20-30%, this is just like the navigator laying his hand flat on the chart and saying somewhere around here. It is an acceptance that the answer is uncertain. But unlike the navigator the oncologist will never make landfall and pinpoint his position, he will only know what actually happened to that individual, not what the precise probabilities were. But the probability figure is an important factor in the risk benefit analysis to determine treatment, and helpful for the individual to plan their lives. The factors you mention are positive for chemotherapy, and little else, so as he has already proposed doing that, there is probably little to add even if he wanted to. I think he has included such factors in the 25% figure, that sounds rather high for a 'normal' 1.5cm stage 1. A little story. When my wife was diagnosed with metastases, it was hard to get the oncologist to give any sort of prognosis. We of course wanted to plan for what remained of her life, although no-one had even mentioned the word "terminal". I had to convince the man that I was statistically literate and could understand that any median given might have a geometric standard deviation of about 5, i.e. if he said 2 years that means anything between 5 months and 10 years. So please could he tell us, for patients with this sort of condition, what was the median survival time? OK, he said, about 18 months. So we borrowed a little money and booked a Christmas holiday to the Canary Islands, something she'd always wanted to do, About 8 months after we got back, she was bedridden, and six months after that she was dead. Given the time it takes to organise things like holidays when you've got school-age children, this statistical information even if uncertain, is all you've got to go on to make significant decisions. I wish the medical community could find an easier way of communicating it to patients and their families. Tim Tim, thanks for hanging in with me and leading me here. You have been extremely helpful to me and her mother. Phil >> I would like to see the data. I am always suspicious of numbers like >> 15% and 25%. Nothing ever falls that neatly in statistics. My sense is [quoted text clipped - 43 lines] > > Tim |
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