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Don't Delay Chemo

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Forum Name: Let's Talk About Chemotherapy
Forum Description: A place to discuss Chemotherapy
URL: http://forum.tnbcfoundation.org/forum_posts.asp?TID=11759
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Topic: Don't Delay Chemo
Posted By: 123Donna
Subject: Don't Delay Chemo
Date Posted: Jan 27 2014 at 8:09pm
Breast Cancer: Don't Delay Chemo

Delaying adjuvant chemotherapy for breast cancer more than 60 days significantly increased the odds of premature death and distant metastasis, a review of almost 7,000 cases showed.

As compared with starting adjuvant therapy within 30 days of surgery, initiating chemotherapy at 61 days or later was associated with a 19% increase in the risk of premature death. In the subgroup of patients with stage III disease, the mortality risk increased by 76%. Relapse-free survival (RFS) and distant relapse-free survival (DRFS) worsened regardless of stage at diagnosis, according to  http://faculty.mdanderson.org/Mariana_ChavezMacGregor/Default.asp" rel="nofollow - Mariana Chavez-MacGregor, MD , of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

Patients with high-risk breast cancer (triple negative, HER2-positive, or stage III) seemed most susceptible to the adverse effects of delayed chemotherapy, as reported online in the http://jco.ascopubs.org/content/early/recent?home-right" rel="nofollow - "The adverse outcomes occurred when chemotherapy was delayed ≥61 days, which in most circumstances, gives medical oncologists enough time to initiate adjuvant chemotherapy," the authors concluded.

"Among patients with stage II and III breast cancer, triple-negative breast cancer, and HER2-positive tumors, every effort should be made to avoid postponing initiation of adjuvant chemotherapy. This may lead to an improvement in outcomes for these subsets of patients."

Multiple studies have documented survival benefits associated with adjuvant chemotherapy in early breast cancer. Equally well recognized is the heterogeneity of breast cancer, affecting both risk and the benefit of adjuvant chemotherapy.

In most instances, adjuvant chemotherapy begins within a few weeks of surgery. However, the potential impact of a delay in initiation of therapy is unclear, although mathematical models have suggested deleterious effects, in particular, an increased likelihood that treatment-resistant micrometastases would emerge, the authors noted.

Moreover, little information exists relative to the impact of time to chemotherapy on outcomes in different breast cancer subtypes.

In an attempt to fill in some of the information gaps, Chavez-MacGregor and colleagues retrospectively reviewed medical records of 6,827 patients treated for early breast cancer at MD Anderson from 1997 to 2011 and followed for a median duration of 59.3 months.

Patients with stage I-II disease accounted for 84.5% of the study population, and the remaining 15.5% of patients had stage III disease at diagnosis. The study group comprised 2,716 (39.8%) patients who started therapy within 30 days of surgery, 2,994 (43.8%) who initiated adjuvant therapy 31 to 60 days after surgery, and 1,117 (16.4%) who initiated treatment ≥61 days after surgery.

The cohort had a 5-year overall survival (OS) of 84%, 5-year RFS of 69%, and DRFS of 72%. Not unexpectedly, patients with larger tumors and greater nodal involvement had worse OS, RFS, and DRFS, the authors noted.

Analysis of factors that influenced outcomes of interest showed no difference in OS, RFS, or DRFS in patients with hormone receptor-positive or HER2-positive tumors, regardless of when they initiated therapy.

The 5-year OS estimate did differ among HER2-positive patients who received trastuzumab (Herceptin), as better survival was observed in patients who started therapy within 30 days of surgery (88%) compared with 31 to 60 days (87%) or ≥61 days (75%, P=0.01). The difference between ≥61 days and ≤30 days translated into a hazard ratio of 3.09 (95% CI 1.49-6.39).

Similarly, patients with triple-negative breast cancer had a 5-year OS estimate of 70% when they started chemotherapy within 30 days, 59% for therapy starting between 31 and 60 days, and 67% for therapy ≥61 days after surgery (P=0.005). Comparing the latest and earliest initiation times resulted in an HR of 1.54 (95% CI 1.09-2.18).

Neither RFS nor DRFS differed by time to chemotherapy in patients with stage I disease. Among patients with stage II disease, the hazard for DRFS increased by 18% to 20% when chemotherapy was started more than 30 days after surgery.

The subgroup of patients with stage III disease had a 76% increase in mortality risk if they started chemotherapy ≥61 days after surgery versus 30 days or less (HR 1.76, 95% CI 1.26-2.46). Risks associated with RFS and DRFS increased by 34% and 36%, respectively.

The study is consistent with other reports in the literature, said  http://oncology.queensu.ca/divisions/divisions/medical_oncology/james_j._biagi" rel="nofollow - Jim Biagi, MD , of Queen's University in Kingston, Ontario.

"The study adds to the available literature suggesting that delays may be detrimental to a patient's cancer outcome," Biagi told MedPage Today by email. "Indeed, patients who had the highest-risk features for breast cancer recurrence, and who would thus derive the greatest benefit from adjuvant chemotherapy, were the most vulnerable to this effect."

"While discrepancies in their results limit our ability to make a strong statement about delays, the study is an important addition to our understanding of the impact delays might have on patient outcomes. It seems to me that if we are asking our patients to undergo 4 to 6 months of chemotherapy, that we offer the treatment in a timely manner."

Biagi participated in a  http://www.ncbi.nlm.nih.gov/pubmed/21642686" rel="nofollow - meta-analysis  of studies evaluating the impact of time to chemotherapy on survival in colorectal cancer and found a significant association between increasing time to therapy and worse OS and overall survival and disease-free survival. However, in another study Biagi was involved in, an analysis of time to chemotherapy showed  http://www.ncbi.nlm.nih.gov/pubmed/23131995" rel="nofollow - no significant effect on survival in non-small-cell lung cancer.

The study was supported by the National Cancer Institute, Komen for the Cure, American Cancer Society, and the Nelly B. Connally Breast Cancer Research Fund.

http://www.medpagetoday.com/HematologyOncology/BreastCancer/44002" rel="nofollow - http://www.medpagetoday.com/HematologyOncology/BreastCancer/44002



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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




Replies:
Posted By: Bayside
Date Posted: Jan 29 2014 at 1:00am
This is a bit scary since my wife is starting on Monday which will be day 61, after the Xmas holidays, surgeons being on holiday, changing doctors, and then the PET scan and port surgery.

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wife DX IDC TNBC 11/13. Grade 3, Stage 2a. Lumpectomy 12/13. margins clear, 0/2 nodes


Posted By: Lillie
Date Posted: Jan 29 2014 at 11:25am
Dear Bayside,
 
I posted on another site about what chemo regimen your wife might want to consider.  Since you are getting a late start, I would consider aggressive treatment.  The ACT is more aggressive than TC.  Also discuss getting dose dense treatments.  It is not a piece of cake, but it is doeable and may make the difference in success or failure. 
I'm trying to encourage your wife to throw everything but the 'kitchen sink' at this TNBC. 
Please feel free to PM me if you wish.
 
God Bless,
Lillie


-------------
Dx 6/06 age 65,IDC-TNBC
Stage IIb,Gr3,2cm,BRCA-
6/06 L/Mast/w/SNB,1of3 Nodes+
6/06 Axl. 9 nodes-
8/8 thru 11/15 Chemo (Clin-Trial) DD A/Cx4 -- DD taxol+gemzar x4
No Rads.
No RECON - 11/2018-12 yrs NED


Posted By: lilyrose
Date Posted: Mar 24 2014 at 9:32am
Donna,
Thank you for this info. I am 2 weeks post surgery. Am seeing the oncologist this week. I don't know what he will be suggesting for treatment...but chemo scares me. I'm wondering if I should get more than one opinion on chemo and what drug(s) would be best for my situation. I have read many on here talking about 'dose dense'...can someone explain that to me? Thanks.


Posted By: petersdraggon
Date Posted: Apr 28 2014 at 7:46pm
My wife's chemo was delayed, was started at day 60 for reason explained other than that is the way they do it.  I wasn't happy about it. Her surgery was in November and chemo was put-off until January.  I talked about going to another hospital but by the time we did and got set-up it would have led to the same or longer time frame.  I sure found out how important it is to educate yourself as very soon as possible after diagnosis.


Posted By: 123Donna
Date Posted: Dec 10 2015 at 5:07pm
Delaying chemotherapy in breast cancer patients reduces overall survival, especially for those with triple-negative breast cancer

Postponing the start of adjuvant chemotherapy for more than 90 days following surgery may significantly increase risk of death for breast cancer patients, particularly those with triple-negative breast cancer (TNBC), according to a new study from The University of Texas MD Anderson Cancer Center. Further, the researchers found that factors such as socio-economic status, insurance coverage and ethnicity were associated with delayed treatment.

According to the study, published in JAMA Oncology, patients who start chemotherapy more than 90 days after surgery are 34 percent more likely to die within five years. Patients with TNBC who delay treatment have a 53 percent increased risk of death.

Adjuvant chemotherapy, which is given after primary surgery, has been demonstrated to benefit patients by decreasing the risk of recurrence and death, explained Mariana Chavez Mac Gregor, M.D., assistant professor, Health Services Research and Breast Medical Oncology. However, delaying the start of adjuvant chemotherapy may allow small remnants of the tumor to grow or become drug-resistant.

Currently, there are no guidelines recommending the optimal time to initiation of adjuvant chemotherapy. The Centers for Medicare & Medicaid Services (CMS) considers the administration of adjuvant chemotherapy within 120 days of diagnosis for certain patients as a quality metric. Eleven cancer hospitals, including MD Anderson, are now reporting on this metric.

Past studies have suggested that delaying the initiation of therapy could result in adverse patient outcomes, but the optimal timing for starting adjuvant therapy has not been defined. To clarify this time frame relative to modern treatments and identify factors contributing to delayed treatment, the researchers analyzed data from the California Cancer Registry.

This population-based study examined data from 24,823 patients with Stage I to III invasive breast cancer diagnosed between January 1, 2005 and December 31, 2010 and treated with adjuvant chemotherapy. This is the largest study investigating the effects of delayed chemotherapy initiation with contemporary treatment regimens.

"Compared to patients starting chemotherapy in the first month after surgery, we observed that those who initiated chemotherapy between 30 and 90 days following surgery did not have adverse outcomes," said Chavez Mac Gregor, lead author of the study. "However, starting chemotherapy more than 90 days after surgery was associated with a statistically significant increase in the risk of death and breast cancer-specific death."

Those patients who started chemotherapy more than 90 days after surgery, represented by 9.8 percent of those included in the study, were 34 percent more likely to die within five years and 27 percent more likely to die from breast cancer in that time frame compared to patients who had surgery within 30 days from surgery.

As the data also included information on breast cancer subtype, the researchers analyzed whether delayed chemotherapy had a differential effect according to disease subtype. For patients with TNBC, a delay of more than 90 days was associated with a 53 percent increase in the risk of death. There was no significant effect from delay for those with hormone-receptor-positive or HER2-positive breast cancers.

"These data suggest that timely initiation of chemotherapy is particularly important among patients with triple-negative breast cancer," said senior author Sharon Giordano, M.D., professor and chair, Health Services Research and professor, Breast Medical Oncology.

This study also sought to determine factors contributing to delayed administration of chemotherapy in order to identify patient groups in need of improved care delivery. While patients with later stage disease and TNBC were less likely to experience delays, increased age, reconstructive surgery and certain socio-demographic factors were associated with postponed treatment.

"We observed, not surprisingly, that socio-demographic factors determined, in great part, some of this delay. Patients with low socio-economic status (SES), those without private insurance and those of Hispanic or African-American descent were more likely to have delays in their treatment," said Chavez Mac Gregor.

Worse overall survival was also associated with patients of African-American descent, lower SES and those with Medicare and Medicaid coverage. In contrast, those patients receiving care at National Cancer Institute-designated cancer centers had a 34 percent lower risk of death compared to those who were treated elsewhere.

"We need to identify the determinants of delays in treatment so we can act on them and potentially improve the delivery of care in vulnerable populations. In most clinical scenarios, administering chemotherapy within three months is more than feasible," said Chavez Mac Gregor.

The results of the current study support including time to chemotherapy initiation as a quality metric, and additionally suggest that treatment should begin within 90 days of surgery, explained Chavez Mac Gregor.

While the authors acknowledge the study may be limited by its retrospective nature, they conclude that all breast cancer patients receiving adjuvant chemotherapy should do so within 90 days of surgery or 120 days of diagnosis.

"We need to start chemotherapy in a timely manner," said Chavez Mac Gregor. "In those patients who want to delay their chemotherapy, I share this data and let them know that a delay can dilute the benefits of treatment. If at all possible, we should not delay."

http://www.eurekalert.org/pub_releases/2015-12/uotm-dci120915.php" rel="nofollow - http://www.eurekalert.org/pub_releases/2015-12/uotm-dci120915.php



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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



Posted By: Lillie
Date Posted: Dec 10 2015 at 8:22pm
Thanks for this article Donna.  It carries a really important message, especially for all TN sisters.
 
God Bless,
Lillie


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Dx 6/06 age 65,IDC-TNBC
Stage IIb,Gr3,2cm,BRCA-
6/06 L/Mast/w/SNB,1of3 Nodes+
6/06 Axl. 9 nodes-
8/8 thru 11/15 Chemo (Clin-Trial) DD A/Cx4 -- DD taxol+gemzar x4
No Rads.
No RECON - 11/2018-12 yrs NED


Posted By: petersdraggon
Date Posted: Dec 16 2015 at 1:31pm
I'd read about this in late November 2013 when my wife was having her operation for tnbc and I pushed to not delay the start of chemo,  so we started immediately after Christmas. I am happy to report she just passed her 2-year anniversary and doing quite well aside from mild lymphodema after a stage 3b diagnosis and having breast conservation surgery. To me it appears to be common sense and shouldn't take years ticking by before it becomes the prescribed treatment when we're dealing with someone's life.  There ought to be a law that dictates they start the chemo as soon as possible regardless of social-economic-insurance status. 
Thanks for the post and getting the word out there!
Greg.


Posted By: 123Donna
Date Posted: May 01 2016 at 11:41pm
Bump

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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



Posted By: 123Donna
Date Posted: Jul 15 2017 at 1:09pm
bump

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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



Posted By: SusaninVA
Date Posted: Jul 15 2017 at 4:07pm
I remember hanging my head in frustration because my surgeon was insisting on doing a 3rd surgery and would not release me to start chemo.  Everything I was reading here and on other sites emphasized starting chemo ASAP for Triple Negative.  My Nurse Practitioner took my concerns seriously and talked to the surgeon.  Thankfully, he relented and I did meet this deadline.  (While taking the chemo, I requested to talk with my Radiation doctor for his opinion on the 3rd surgery, and he was able to use boosts of radiation to the site of concern and saved me from that surgery.)  If you live in Virginia, you may have met him.  He is Dr. Arthur out of Virginia Commonwealth Univ. and is now chairman of Radiology at VCU.  Unfortunately, that means he no longer carries a patient load, but I imagine he still consults with his physicians.


Posted By: Meadow
Date Posted: Oct 10 2017 at 4:01am
My cousin and I were the same - same age, same stage, same treatment. She delayed treatment for personal and insurance reasons and started chemo 4 months after diagnosis. I had surgery 3 weeks after diagnosis and started chemo three weeks after that. My doctors really pushed me to be aggressive, probably based on the quoted studies. I even delayed port placement so I could get going with AC (I had port surgery in between the first and second AC infusions).   My cousin had a recurrence and passed away in 2012. I am fine, with enough years behind me to be confident I am 100% cured. It's just one story, not statistically significant. But I always wonder if my cousin would be celebrating with me if she'd gotten treatment sooner. Thanks for bumping this discussion. I hope it makes a positive difference for our TNBC sisters who are facing treatment.


Posted By: SusaninVA
Date Posted: Oct 11 2017 at 1:24pm
Meadow, Thank You for sharing your story on this.  I personally think that 4 months could make a difference in something that grows as quickly as TNBC.  I'm sorry you lost your cousin.  I'm glad your doctors encouraged you to treat this aggressively.  All cancer is serious, but TNBC seems to have a shorter window of time in which treatment can make a such a difference.  


Posted By: Motherofall6
Date Posted: Nov 26 2017 at 10:58am
Hi what stage was your cancer and um how did the ac chemo go in ok without a port?? I really don’t want a port and wondering how your first chemo went without one. Thanks

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diagnosed 10/27/2017
triple negative breast cancer
stage 1 grade 3
lumpectomy 11/10/2017
radiation
chemo 1/3/2018
A/C x4 then taxol x 12


Posted By: Tamara
Date Posted: Nov 26 2017 at 9:34pm
Motherofall6,
I had a port put in just hours before my first AC/T chemo treatment in May 2014. I really did not want a port either, because I did not know what to expect. Looking back, I am so thankful for that port. I was stage 1, grade 3 and had a lumpectomy, then radiation followed by AC/T and Taxol.
God bless,
Tamara


Posted By: 123Donna
Date Posted: Nov 26 2017 at 10:43pm
Motherofall6,

A port is really the best way to go.  It will make infusions and blood draw so much easier.  

When I had chemo the first time, I did not get a port.  The infusions were through a vein in my hand.  After the 3rd treatment, the chemicals burnt the vein.  It burnt from the inside out and damaged the vein, making my hand unusable for the 4th treatment.  When I had my recurrence, I knew I was going to need a port.  I had a love/hate relationship with it, but it made infusions very easy and no problems with it during treatment.  

Donna


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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



Posted By: 123Donna
Date Posted: Dec 18 2017 at 8:05am
bumping for new members



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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



Posted By: Wildburg
Date Posted: Jun 11 2018 at 1:47pm
My surgery was 4/26 will not meet with onc till 6/19 due to issues with tissue expanders....however, I'm not sure I need chemo...had 3.5cm fully contained tumor with 16 nodes removed...all clear. Want to hear first if long term side efffects of chemo are worth the percentage of increase in survivalrate.


Posted By: 123Donna
Date Posted: Jun 11 2018 at 6:41pm
Hi Wildburg,

I'm posting the link to the NCCN Guidelines for TNBC.  The recommendation is chemo for any tumor larger than 1.0 cm.  Unfortunately surgery, chemo and radiation are the only options for triple negative breast cancer.  We don't have targeted therapy yet and we only get one shot of trying to stop this beast the first time.  TNBC is more likely to spread through the lymphatic and blood than other types of breast cancer.  Chemo is used to hopefully mop up any stray cells that might have escaped.  

https://www.nccn.org/patients/guidelines/stage_i_ii_breast/index.html#48" rel="nofollow - https://www.nccn.org/patients/guidelines/stage_i_ii_breast/index.html#48




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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



Posted By: 123Donna
Date Posted: Jul 10 2018 at 8:10am
bumping for new members

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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



Posted By: Plume
Date Posted: Jul 28 2018 at 9:52am
Originally posted by 123Donna 123Donna wrote:

Hi Wildburg,

I'm posting the link to the NCCN Guidelines for TNBC.  The recommendation is chemo for any tumor larger than 1.0 cm.  Unfortunately surgery, chemo and radiation are the only options for triple negative breast cancer.  We don't have targeted therapy yet and we only get one shot of trying to stop this beast the first time.  TNBC is more likely to spread through the lymphatic and blood than other types of breast cancer.  Chemo is used to hopefully mop up any stray cells that might have escaped.  

https://www.nccn.org/patients/guidelines/stage_i_ii_breast/index.html#48" rel="nofollow - https://www.nccn.org/patients/guidelines/stage_i_ii_breast/index.html#48




Donna, thank you for the link.  Brilliant and takes away a lot of the anxiety about opting for chemo.  These are very clear guidelines.

I have found the forum rather late as I have just passed my first anniversary.  But it's confirmed to me that my treatment plan was absolutely spot-on and could not have been bettered.

I hope your link helps lots and lots of people who are confused and frightened about chemo.


Posted By: Lucky22
Date Posted: Jul 31 2018 at 9:52am
Yes, you want to get chemo as soon as you can, but women who have chemo delayed for true reasons, like I had a severe infection, should not live in fear. I had my chemo 57 days after my first surgery, less after my re excision. I wanted to hurry it up, but it is much worse to dtart chemo with an infection than to delay.
Also, using my stats as an example, with chemo my chance of death in five years is 8%. If my delay truly did screw things up as much as possible per this article, my mortality rate would go to a little over 12%. I Judy think we need to be careful of scaring people unnecessarily, because sometimes delays are unavoidable.


Posted By: Plume
Date Posted: Jul 31 2018 at 10:52am
Lucky22, I do completely take on board your point of view.  But I don't agree about "scaring people unnecesarily".  Just having our diagnosis is in itself completely frightening.  I think people, like cancers, come in all shapes and sizes.  Some like to know the worst case scenarios, all the facts however dreadful, whilst others prefer to look on the bright side and hope for the best.

If the facts and stats are out there, then that is the "truth" as far as our present knowledge allows.  BTW, I would not find a 50% increase in mortality rate, as described by you, is a small matter.

Having said that, I am truly happy that you are getting on OK.  You are right of course that some delays are unavoidable.  Doesn't make the delays acceptable or easily ignored.  Me, I am a bit of a precision fiend:  I'd have all the bad news, whatever it is, and live (or die) with ALL of the facts....


Posted By: 123Donna
Date Posted: Dec 10 2018 at 7:46am
From SABCS 2018:

Earlier Adjuvant Chemotherapy Benefits Patients with TNBC
Adjuvant therapy is treatment given to patients after they undergo surgery and radiation therapy for their cancers. A new study indicates that in TNBC beginning treatment sooner is better. The study done in Peru showed that patients who began their adjuvant therapy within 30 days of completing treatment have better outcomes than those whose treatment is delayed. These results support evidence from other trials.

Physicians and patients need to balance the time required to recover from surgery and radiation with the benefits of starting adjuvant therapy sooner. Current guidelines call for beginning treatment within 4-6 weeks but these studies may change the view of the optimal timing.

“We can see that the time to adjuvant therapy is an independent prognostic factor for overall survival,” sad Zaida Morante, MD, who presented the study.

Carlos Arteaga MD of the University of Texas Southwestern Medical Center, who moderated the session in which this data was presented noted that more patients would be treated within 30 days in the United States.



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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



Posted By: Kellyless
Date Posted: Dec 12 2018 at 10:43am
DR. CARLOS L. ARTEAGA, mentioned here was named the Director of my facility, the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern in 2017. I feel very lucky that this renowned breast cancer physician and researcher is now our guy! I just wanted to point that out, for anyone needing TNBC care in North Texas.

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IDC, 2.2 cm, Stage IIb,lumpectomy 1/30/09 ACx4,Tx4 36 rads
6/1/16 Local recurrence same breast, same spot 1.8cm Carb.4x every 3 wks, Taxol 12x once wk. Dbl Mast. PCR!! Reconstruction fail, NED!


Posted By: 123Donna
Date Posted: Jan 07 2019 at 8:20pm
Delaying Adjuvant Chemo Associated with Worse Outcomes for Patients with Triple-Negative Breast Cancer

Patients with triple-negative breast cancer who delayed starting adjuvant chemotherapy for more than 30 days after surgery were at significantly higher risk for disease recurrence and death compared with those who started the treatment in the first 30 days after surgery, according to a retrospective study presented at the 2018 San Antonio Breast Cancer Symposium.

"For this study we included triple-negative breast cancer patients who underwent surgery as first treatment followed by chemotherapy and/or radiotherapy," said Zaida Morante, MD, a medical oncologist at Instituto Nacional de Enfermedades Neoplásicas in Lima, Peru. "Most guidelines recommend starting this adjuvant chemotherapy within four to six weeks after surgery for any type of breast cancer. Others recommend starting as soon as clinically possible within 31 days of surgery; however, the optimal time to initiate chemotherapy is unknown.

"We have seen in our clinical practice that, for many reasons, there is often a delay in starting adjuvant chemotherapy for patients with triple-negative breast cancer," continued Morante. "We analyzed real-world data to determine whether these delays impact disease-free or overall survival for patients."

Morante and colleagues found that patients who delayed starting adjuvant chemotherapy for more than 30 days after surgery had a more than 90 percent increased risk for disease recurrence and death compared with those who started the treatment in the first 30 days after surgery. This risk is increased if the adjuvant treatment is given after 60 days.

"Our data show that it must be a priority for patients with triple-negative breast cancer to begin adjuvant chemotherapy within 30 days of completing surgery," said Morante. "After this period of time, the benefit of the chemotherapy is significantly diminished."

Morante and colleagues retrospectively analyzed data obtained from the medical records of 687 patients with stage 1-3 triple-negative breast cancer who had undergone surgery and went on to receive adjuvant chemotherapy in a public institution. The median follow-up was 101 months and the median time to starting adjuvant chemotherapy was 41 days; 189 patients started the treatment at or before 30 days, 329 started it from 31 to 60 days, 115 started it from 61 to 90 days, and 54 started it more than 90 days after surgery.

As the time to starting adjuvant chemotherapy increased, the 10-year disease-free survival rate decreased; it was 81.4 percent, 68.6 percent, 70.8 percent, and 68.1 percent among patients who started the treatment at or before 30 days after surgery, 31 to 60 days after surgery, 61 to 90 days after surgery, and more than 90 days after surgery, respectively. The 10-year overall survival rate also decreased as the time to starting adjuvant chemotherapy increased; it was 82 percent, 67.4 percent, 67.1 percent, and 65.1 percent for the four groups of patients, respectively.

The researchers then studied how the extent of delay in starting chemotherapy was associated with an increased risk for disease recurrence and death. They found that compared with patients who started adjuvant chemotherapy in the first 30 days after surgery, risk for disease recurrence was increased by 92 percent for those who delayed starting the treatment for 31 to 60 days after surgery, by 138 percent for those who delayed starting the treatment for 61 to 90 days after surgery, and by 147 percent for those who delayed starting the treatment for more than 90 days after surgery. The risk of death compared with patients who started adjuvant chemotherapy in the first 30 days after surgery increased by 94 percent, 145 percent, and 179 percent for the three groups, respectively.

According to Morante, the main limitation of the study is that it is a retrospective analysis of a single institution experience.

SOURCES:
2018 San Antonio Breast Cancer Symposium, December 4-8, 2018, San Antonio, TX
American Association for Cancer Research ( http://www.aacr.org" rel="nofollow - http://www.aacr.org )


http://www.hopkinsbreastcenter.org/artemis/201901/6.html




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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



Posted By: 123Donna
Date Posted: Jun 21 2019 at 11:44am
bumping for new members


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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



Posted By: Danzig482
Date Posted: Jun 22 2019 at 7:38am
why are some people having surgery first? I’ve consulted a few doctors and it was not even considered for me. They said in general with tnbc you don’t know if the cancer is responding to chemo if you remove tumors first


Posted By: Alicia89
Date Posted: Nov 08 2019 at 4:00pm
I found my lump in early August. Did not get a full diagnosis until the end of September as the local pathologist was unable to identify the type of cancer. And my surgery was scheduled for late October. I am now two weeks post surgery and awaiting my final Pathology report. Hopefully these delays don't prove to be a problem. 


Posted By: Kellyless
Date Posted: Nov 08 2019 at 4:35pm
Danzig, I've been puzzling over that for a long time now and I still can't figure it out. We are seeing many women come thru here after having surgery first that are upset that there's no way to know if the chemo is working. Upset that they can't know if they achieved a "PCR". I wonder if they are only seeing a surgeon and not a medical oncologist before letting the surgeon go for it? That's sorta what happened to me the first time. When I learned better I changed not only surgeons but cancer facilities entirely. I read something yesterday that said only 50% of TNBC patients respond to the usual chemo drugs?? That seems extreme, I'd like to know if that's true. If it is, then having surgery first is dangerous. And getting scans during each type of chemo should be mandatory - standard operating procedure. More than half the time the women I stay in touch with have to ASK for ultrasounds and mammos during chemo. We need some clarity on these things. 

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IDC, 2.2 cm, Stage IIb,lumpectomy 1/30/09 ACx4,Tx4 36 rads
6/1/16 Local recurrence same breast, same spot 1.8cm Carb.4x every 3 wks, Taxol 12x once wk. Dbl Mast. PCR!! Reconstruction fail, NED!


Posted By: sophie
Date Posted: Nov 08 2019 at 5:15pm
I did surgery first and hegemonies, my MO performed petscan on me last week see nothing ... so does this mean chemo works for me or at least if any cancer cell remains not growing at least during the chemo? Can I drew a conclusion that chemo works on me?


Posted By: sophie
Date Posted: Nov 08 2019 at 5:16pm
I did surgery and then did the chemo


Posted By: dono7392
Date Posted: Nov 26 2019 at 11:28am
Sadly I did not know about this information until after surgery (in which I chose immediate reconstruction). That automatically put me on a 6 week delay for chemo based on surgery recovery times. I wish my doctors were aware of this ... my plastic surgeon told I had 3 months to start.


Posted By: Plume
Date Posted: Nov 26 2019 at 3:27pm
I had surgery first, then chemo within 30 days.  Was not given the option to have chemo first.  But, if I HAD to choose, I would have chosen surgery first because the tumour was growing very fast and I was very frightened of it and wanted it out.

I think if the medical team thought chemo first would have been best for me, they would have done that.  I am not party to what criteria they based their collective decision on.

So far (but it's early days) so good.  I had my second year check-up with the surgeon followed a few months later with the onco and all seems well.  I expect to have my reconstruction next year.  Apparently it's best to wait for 2 years after the end of radiotherapy.

At the moment, it is envisaged that I will have what they call a lipomodelage; that is liposuction from the abdomen and the fat transferred to my breast.  Then a bit of a lift to the other breast to match.

The promise of this procedure has kept me going and I am massaging my breast scars to keep them supple and eating good, nutritious food to get my body surgery-ready...ha!ha! 


Posted By: Portia
Date Posted: Nov 28 2019 at 2:44pm
Re: Chemo
I’m not really sure what is driving the anxiety and dread about chemo. When my dad had bladder cancer in 1994, chemo was really rough. But it still helped him. He lived longer than expected. 
These days, chemo is nothing like what he went through. It was actually quite gentle to me and I had Taxol/carbo and adriamycin/cisplatin. The anti emetic drugs were so effective that I had mild nausea twice, easily fixed by my complezine.  My biggest side effects were weight gain from steroids, fatigue and low RBC. But it wasn’t debilitating enough to prevent me from getting to work everyday and putting in 8 hours. I didn’t need to take even one sick day. 
Now, I’m not going to say everyone will have the same experience that I had. But I’m going to bet there are a lot more of us getting through it with mild symptoms than there were 24 years ago. 
AND it can be extremely effective. I mean, WOW, my Thing melted away. It was amazing. I’m a believer and hope that all of you have as good a response as I did. I only wish my dad had access to new chemo. 
My chemo nurses told me that my attitude and anticipation would have an effect on how well I tolerated it. So, verily I say unto you, don’t dwell on the scary side effects that the pharmacist is obligated to tell you about. Follow all directions faithfully, don’t drink alcohol do you can give your liver it’s best chance to do its thing without competition and stay on top of your nausea. All I am saying is give drugs a chance. 


Posted By: Portia
Date Posted: Nov 28 2019 at 3:00pm
I asked my oncologist about this. I had neoadjuvant therapy with 12 weekly sessions of paclitaxol to start. It made sense to do it this way. It’s like that saying, “if you’re opponent is drowning, through him an anchor”.  Pounding that sucker week after week, not allowing it to get up while it was down seems to have worked and I knew it about 3 weeks into treatment when I could tell the Thing had started to shrink, a hunch confirmed by my doctor. 
So I asked her, what if it hadn’t worked by then? She said she would have sent me to surgery right away. 
Here is my best guess why I got chemo before: I had one lesion and my pet scan showed no lymph node involvement. She had a little bit of time to play with. Plus, I’m guessing that she had the cells tested for susceptibility to chemo agents. 
One thing I did find kept my anxiety in check was NOT to google too much. I have a background in pharmaceutical research and can read papers with pretty good understanding. I didn’t want to freak myself out. So, my guess about neoadjuvant vs adjuvant chemo criteria is just a guess. 


Posted By: Kellyless
Date Posted: Nov 29 2019 at 9:51am
The oncologists recommending chemo first are not "guessing," it's not just an "opinion", there's rock solid science behind it. Not every chemo works for every person  - we've seen it here over and over and over. Without a tumor to watch there's no way to know if the chemo you are doing is killing YOUR cancer. We're not doing chemo to just kill the tumor in our breast, it's to kill cancer that is systemic. Doing  the chemo that is is right for us, that kills  YOUR particular cancer obviously makes a big difference. 
Studies show that the smaller the tumor at surgery the lower the recurrence odds and higher long term survival odds. And we now know as 100% fact that achieving PCR with neoadjuvent chemo significantly reduces recurrence odds and increases long term survival numbers. 
There is no study showing doing Taxol before AC increases benefit. On the contrary, the AC we do every 2 weeks is Dose Dense - very high dose that does not stop "working" after one week. Actually doing Taxol Dose Dense every two weeks is effective as well - we've gone to lower dose weekly due to side effects, not because weekly chemo "makes more sense". In some cases higher dose less often is indeed more effective. 

Adding carboplatin does increase the odds of obtaining PCR...BUT I've not seen anything comparing doing AC first then Taxol + Carboplatin. The only reason that started was that Merck, the maker of Keytruda, only allows the use of Keytruda with that order and types of chemo. It's not FDA approved, so to use it you play by their rules. Carboplatin often destroys your immune system (ANC), causes extreme anemia and kills platelets. The highest number of treatment delays I see in the last 10 years are on carboplatin. And AC after T+C is a dicey ride - over and over and over I keep seeing women getting hospitalized during AC when doing it after T+C. 

So I would love to see a study on WHY women are doing chemo or surgery first.  How many are only seeing a surgeon prior to surgery, not seeing a medical oncologist? How many are strictly making an emotional decision, the "Just get it out!!!!" decision? What are the fact based, science based reasons for it? That's what intrigues me. 




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IDC, 2.2 cm, Stage IIb,lumpectomy 1/30/09 ACx4,Tx4 36 rads
6/1/16 Local recurrence same breast, same spot 1.8cm Carb.4x every 3 wks, Taxol 12x once wk. Dbl Mast. PCR!! Reconstruction fail, NED!



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