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Newly diagnosed - chemo before surgery?

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123Donna View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 7:22pm
Lee,

I'm not aware of any specific study on TNBC regarding neoadjuvant/adjuvant therapy.  Many of the studies we see are all breast cancers lumped together.  Mindy555 was just recently going through this same decision for chemotherapy.  Maybe you can PM her and see if she has any specific information to share with you.



DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote christina1961 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 7:32pm
I had neoadjuvant although they thought I was only stage 2A at diagnosis because none of my lymph nodes showed on scans and the palpable one was not found at first physical exam.  My tumor per mammogram was 2.5 then (2/11.)  At the beginning of neoadjuvant chemo, they found the one palpable lymph node and one of the rad oncs thought another node looked enlarged.  I had six cycles of TAC.  I only had clinical exams during the chemo - wish I had pushed for MRI during chemo - we thought I had a pcr or close to it during the chemo but when the mastectomy was done (my choice, surgeon's preference- could have had lumpectomy) - they found 2 cm of tumor in breast and 2 positive nodes.  VERY disappointing and scary. I was told I had a 50% chance of recurrence following a residual cancer burden test that showed RCB 3.2.  So I opted for more chemo in a clinical trial with eribulin for patients who have less than a complete response to neoadjuvant chemo. So - cons, I am scared much of the time due to the fact that I know my cancer did not respond well to chemo - and pros, I am able to opt for more chemo - so IF it helps, it is a plus to know whether or not the tumor responded to the initial chemo.  It would have been great if we had known it wasn't responding and were able to switch chemos pre surgery but can't waste time worrying about that now.  If I could rewrite history, what I would have done - I would have gone to a TNBC specialist at one of the big hospitals at first; I would have enrolled in the most promising clinical trial with neoadjuvant chemo - then if I had less than an optimal response, I still could have gotten standard of care chemo before surgery. I'm not at all disappointed in having had neo chemo, just concerned about the result I had.
2.5 cm TNBC, BRCA-, diag. 2/11, neoadj chemotherapy, uni MX, y2cm,2/16 nodes, RCBII, tumor retested 5-10%ER+,PR-,Her2-, rads, clin trial eribulin 10/11-2/12, tamox.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote christina1961 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 7:45pm
Lee,
Almost forgot - I am BRACA negative but have strong cancer history in family - grandfather, paternal uncle had colon, dad had prostate then squamous cell esophageal cancer (in his mid 80s), sister had lobular highly estrogen positive BC at age 58 (after 17 years of HRT), and mother had lung cancer age 69 (but she had childhood treatment for asthma with arsenic inhalers - and had dual primary tumors.) Mother and father quit smoking 30-40 years prior diagnosis and neither one drank more than once every five years or so. Lots of great aunts lived into their 80s without breast cancer - my sister and I are only known breast cancer patients and both of us have researched family geneaology.
2.5 cm TNBC, BRCA-, diag. 2/11, neoadj chemotherapy, uni MX, y2cm,2/16 nodes, RCBII, tumor retested 5-10%ER+,PR-,Her2-, rads, clin trial eribulin 10/11-2/12, tamox.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Grateful for today Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 8:01pm
Hi,

Just to share.
Just read the above noted link:
http://www.cancer.gov/cancertopics/factsheet/Therapy/adjuvant-breast
The info it had on neoadjuvant was small and thought I had read other info on neoadjuvant chemo
especially in relation to TNBC. If I find the reference for what I have read ( as do not remember
exactly what I read), will post.
Looks like this fact sheet was last reviewed 6/16/2009.
When I checked the footnotes for the section on neoadjuvant chemo they were from 1998, 2001
and 2005.

Lee,   thanks for opening up this forum topic again. Am sure many are interested in this topic.


With caring and positive thoughts to all,

Grateful for today...............Judy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Charlene Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 8:25pm
Hi, Lee,
On this site, if you go to Welcome New Members and read "Attention Newbies:  Important New Chemo Study," you will find some information from one study.  Not only does it discuss the order of the chemo drugs, it also includes some stats on adjuvant versus neoadjuvant.  Of course, it is also possible the those who had neoadjuvant had more complex cases to begin with.  To answer your original question, I was never offered neoadjuvant.  My MRI had stated that my largest mass was 1.7, but after surgery it turned out to be two foci--1.1 and .6.  Wish you the best!
Charlene
DX 3/10 @59 ILC/TNBC
Stage 1, Grade 2, Multifocal; Lumpectomy/re-excision
SNB 0/4 nodes, BRCA-; Taxotere/Cytoxan X4, 30 rads
3/14:NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote ds21 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 8:27pm
Also a couple of logistical questions.  If you had neoadjuvant (preoperative) chemotherapy, how long was your treatment?  How long after your chemo was your surgery?  I realize that there are many issues involved in selecting each individual patients treatment plan, but still would be helpful to know the range of experiences.

Thank you,

David
Co-survivor
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 8:28pm
If you go to the TNBC Forums page and go to TNBC News, Resources & Tips, you'll see several articles/studies posted by Pam (Trip2).  Lots of good research listed there.  Here are a couple she posted:


DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote Grateful for today Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 9:51pm
Hi Lee,

The all important information will be from your oncology MD's answer to:
in YOUR case, what are the pros and cons of neoadjuvant vs adjuvant chemo.

Here's the reference I could not find earlier:
International St Gallen "consensus discussion" in support of neoadjuvant chemo.
(Note: Not a prospective clinical study)
(Could not find a list of all U.S. participants.
Did see name of Harold Burstein MD of Boston's Dana-Farber Cancer Institute)

From:
Strategies for subtypes—dealing with the diversity of breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011
(The biennial St. Gallen International Breast Cancer Conference is one of the most influential conferences in the field of breast cancer treatment all over the world, aiming at highlighting the significant progress in the treatment of Early Breast Cancer (EBC). Moreover, the International St. Gallen Consensus on The Treatment of Early Breast Cancer is the most widely recognized international consensus in the field of breast cancer. The 12th St. Gallen International Breast Cancer Conference was held on March 16th-19th, 2011 in St. Gallen, Switzerland. More than 4 000 authoritative experts in the field of basic research and clinical practice of breast cancer from over 100 countries rallied and shared the up-to-date information and technique in the field of EBC therapy, and eventually, updated the consensus on the treatment of early breast cancer based on scientific evidence and patient-centered treatment.)

"A majority of the Panel considered that neoadjuvant cytotoxic therapy was of value beyond its role in facilitating conservative surgery and noted the improved prognostic information associated with pathological complete response to such therapy, particularly in patients with ‘HER2 positive’ and ‘Triple negative (ductal)’ tumors [89], which may allow earlier change from an ineffective regimen.

The Panel considered that the choice of neoadjuvant chemotherapy should be made on the same basis as applied in the selection of postoperative adjuvant treatments. The Panel supported the incorporation of an anti-HER2 drug in the neoadjuvant therapy for patients with ‘HER2 positive’ disease, but did not support dual HER2 targeting at this point in time. The Panel did not support cytotoxic neoadjuvant therapy for tumors with low proliferation or high endocrine responsiveness."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100376/
(St. Gallen 2011: Summary of the Consensus Discussion)
                                  -------------
There is research backed info and consensus practiced info.
Then there is other info.
Know of one women with TNBC (small lesion ? size) who went to a Comprehensive
Cancer Center and had surgery first due to the small size of her lesion. Do not know the
threshold of what is a small lesion...or if it varies slightly among the comprehensive centers.
This would be something you may want to clarify and get more information on with
your MD as believe you were told at a comprehensive cancer center that surgery
was recommended first.

With caring and positive thoughts,

Grateful for today.......Judy

-------------------------------------------------

Hi David,

I had: neoadjuvant chemo.
DD (dose dense) AC x 4 doses q 2 weeks then Taxol x4doses q 2 weeks.   Total time: 16 weeks.
Unilateral mastectomy with ALND (axillary lymph node dissection) 4 weeks after
      last chemo dose.
Clinical: (before surgery)       Stage IIb    T2N1
Pathology after Surgery:        ypT1cN1a
Post surgery: radiation started 6 weeks after surgery. 29 radiation treatments over 6 weeks.

With caring and positive thoughts,

Grateful for today...........Judy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote christina1961 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 10:31pm
David, My chemo lasted 15 weeks (6 rounds of TAC) and my surgery was 31 days after last chemo. Before chemo I was measured 2.5 cm (T2) and afterward, 2 cm (T2.) My radiation started almost 9 weeks after surgery because I had a consult with another oncologist out of state in between and we were not sure if I would start chemo before radiation. I began the clinical trial of adjuvant chemo one week after my radiation was completed (I could have started it during the last two weeks of radiation but chose not to.)
2.5 cm TNBC, BRCA-, diag. 2/11, neoadj chemotherapy, uni MX, y2cm,2/16 nodes, RCBII, tumor retested 5-10%ER+,PR-,Her2-, rads, clin trial eribulin 10/11-2/12, tamox.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 10:39pm
Curr Treat Options Oncol. 2011 Dec;12(4):369-88. doi: 10.1007/s11864-011-0168-y.

How do I treat "triple-negative" disease.

Source

Comprehensive Cancer Center, University of Alabama at Birmingham, AL 35294-3300, USA. chris.vaklavas@ccc.uab.edu

Abstract

OPINION STATEMENT: Over the recent years, there has been an increasing recognition that triple-negative breast cancerconstitutes a separate, albeit heterogeneous, entity arising from distinct oncogenic pathways. Despite its aggressive clinical behavior, triple-negative disease responds favorably to cytotoxic chemotherapy resulting in high response rates. Nonetheless, the relapse rates are high and, in the absence of targeted therapies to significantly alter its natural history, the prognosis can be poor. Most of the trials conducted in the past that led to the formulation of the current guidelines have indiscriminately lumped triple-negative disease with receptor-positive subtypes. Therefore, there are relatively scant data regarding how standard approaches specifically apply for triple-negative disease. By virtue of its chemosensitive nature and high probability of achieving a complete pathologic response, neoadjuvant chemotherapy in early-stage/operable and locally-advanced/inoperable triple-negative disease is highly recommended. The indications for adjuvant chemotherapy are the same as in receptor-positive tumors, although endocrine therapies or agents targeting Her2 signaling have no established role in triple-negative disease. The optimal chemotherapy is not entirely clear; however, by virtue of their efficacy in breast cancer in general, anthracycline-containing regimens are the most widely used. The incorporation of taxanes in the regimen is supported by retrospective analyses. There is scant evidence to recommend any particular agent in the metastatic setting, although the combination of ixabepilone with capecitabine was shown to be active specifically in triple-negative disease. Given the uncertainty in the optimal management of triple-negative disease, the shortcomings of contemporary regimens, and the strong rationale of novel therapies, participation in clinical trials should be strongly considered at any stage of the disease.

PMID:
 
22048876
 
[PubMed - in process]
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 10:43pm
Breast J. 2011 Nov 20. doi: 10.1111/j.1524-4741.2011.01175.x. [Epub ahead of print]

The Paradox of Triple Negative Breast Cancer: Novel Approaches to Treatment.

Source

Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York City, New York Centre Georges-François Leclerc, Dijon, France, 1 rue Professeur Marion, BP 77980 Dijon Cedex France.

Abstract

  Breast cancer that lacks expression of estrogen/progesterone receptors and overexpression of the human epidermal growth factor receptor2 (HER2), i.e. triple-negative breast cancer (TNBC), is not amenable to current targeted therapies and carries a poor prognosis. This review discusses the natural history of TNBC and published literature in the relevant treatment landscape, with a focus on newer therapies. Compared with other subtypes of breast cancer, TN tumors have higher response rates to neoadjuvant chemotherapy; however, this advantage is not clearly translated into the metastatic setting and has not improved these patients' overall survival. Numerous cytotoxic and targeted strategies have demonstrated efficacy or are under investigation. Strategies showing promise in this difficult-to-treat group of patients include cytotoxic therapy with platinum-containing agents, ixabepilone, and novel targeted approaches such as poly(ADP-ribose) polymerase inhibitors.

© 2011 Wiley Periodicals, Inc.

PMID:
 
22098334
 
[PubMed - as supplied by publisher]
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 30 2011 at 8:43am
Thank you all for sharing a wealth of information, both medical and personal.  I am very grateful.
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote xidoli Quote  Post ReplyReply Direct Link To This Post Posted: Dec 30 2011 at 9:17pm
Originally posted by christina1961 christina1961 wrote:

Lee,
Almost forgot - I am BRACA negative but have strong cancer history in family - grandfather, paternal uncle had colon, dad had prostate then squamous cell esophageal cancer (in his mid 80s), sister had lobular highly estrogen positive BC at age 58 (after 17 years of HRT), and mother had lung cancer age 69 (but she had childhood treatment for asthma with arsenic inhalers - and had dual primary tumors.) Mother and father quit smoking 30-40 years prior diagnosis and neither one drank more than once every five years or so. Lots of great aunts lived into their 80s without breast cancer - my sister and I are only known breast cancer patients and both of us have researched family geneaology.
 
Dear Christina1961,
 
Thank you so much for your answer. After reading your post, I am just wandering if you have tested some mutations from your breast tissue, say if you have had PIK3AC mutation or PTEN mutation from your researched family geneaology?
 
Happy new year.
 
Xidoli
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Post Options Post Options   Thanks (0) Thanks(0)   Quote christina1961 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 30 2011 at 9:38pm
Happy New Year Xidoli!
No I have not had tests for those mutations but would love to know more about it.  I think there is a genetic link based on the strong recent history - and no known history before the last three generations.
2.5 cm TNBC, BRCA-, diag. 2/11, neoadj chemotherapy, uni MX, y2cm,2/16 nodes, RCBII, tumor retested 5-10%ER+,PR-,Her2-, rads, clin trial eribulin 10/11-2/12, tamox.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 13 2012 at 10:11am


I had my 2 nd opinion on Wednesday at UCSF and they couldn't have come up with a more divergent recommendation from the one from U of M. UCSF strongly recommends neoadjuvant whereas U of M recommended lumpectomy first. Both agree the order will not affect survival; but as you all know neoadjuvant will provide prognostic information on chemo sensitivity. 

UCSF says I would be a candidate for the ISPY-2 trial but U of M is not a participant and I would rather stay local for my treatment than drive 6 hrs to Chicago the nearest site.

 It seems like it comes down to two points 1) UCSF believes in the MRI sizing of my tumor at 3 cm which is almost twice the size seen by ultrasound that U of M is basing their recommendation on ( it seems that pre-op MRI is controversial although I don't think there is disagreement about the relative accuracies of the different modalities).  Not shrinking the tumor down would result in substantial removal of tissue. UCSF doesn't think a mastectomy is indicated.  2) the prognostic importance of neoadjuvant therapy.

I am not sure I have time for a third opinion - it's been more than a month since my surgery and more than two months since the onset of symptoms (discharge).

I know that people on this forum have experience with either approach.  This has been discussed elsewhere in other threads but sometimes it is hard to pick up on those.

I would really appreciate your input on this to help me with my decision.  Why did you go with the approach you took ? Did it work for you? Do you have regrets?

12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote TubeRose Quote  Post ReplyReply Direct Link To This Post Posted: Apr 17 2015 at 11:20am
Hi:

I'm new here. :)  I'm recently diagnosed (for a second time) and happen to see this thread from 2012. I'm glad to find the information as I'm in the middle of making tough decisions. I wonder what you ladies think of this article:

http://e-crt.org/journal/view.php?doi=10.4143/crt.2014.262

Does this mean we should have neo-adjuvant AND adjuvant treatments with different, tailored regimens to enhance our odds?

Thank you for any insight!
Dx 9/10 @ 42, Lt DCIS 1 cm w Microinvasion, (+++), 0/3 Nodes. BRCA 1/2 Neg. Tx Lt UMX with TE (11/10) + Tamoxifen 3 yrs.
Dx 3/15, Rt, ILC, <1cm, Stage IA, (TN), 0/6 Nodes. BRIP1 pos. Tx Rt UMX (5/15)
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Apr 17 2015 at 6:44pm
Hi TubeRose,

Was the 2nd diagnosis on the same breast side or the other side?  I'm sorry you are dealing with this again.  It looks like the first time you weren't TN?  Were you tested for the BRCA gene?

Here's your link made hot:


From what I gather from reading the article is that even though you might be one subtype (eg,  TNBC) before neoadjuvant chemo, the tumor should be retested again after surgery as some change subtype.

Donna
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote TubeRose Quote  Post ReplyReply Direct Link To This Post Posted: Apr 18 2015 at 5:40pm
Donna, Thank you for your reply and making the link work! I updated my profile to answer some of your questions. :)

I'm very scared due to articles like the following two from 2012. I'm beginning to think planning for adjuvant treatment ahead might be logical since pCR might not happen to everyone. Getting the tumor tested quickly after surgery would be one such maneuver in case the neoadjuvant changes the tumor's characteristics.Confused



Dx 9/10 @ 42, Lt DCIS 1 cm w Microinvasion, (+++), 0/3 Nodes. BRCA 1/2 Neg. Tx Lt UMX with TE (11/10) + Tamoxifen 3 yrs.
Dx 3/15, Rt, ILC, <1cm, Stage IA, (TN), 0/6 Nodes. BRIP1 pos. Tx Rt UMX (5/15)
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