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    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)


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




Edited by 123Donna - Jan 07 2019 at 8:23pm
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 Kellyless Quote  Post ReplyReply Direct Link To This Post 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.
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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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post 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.



Edited by 123Donna - Dec 10 2018 at 7:46am
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 Plume Quote  Post ReplyReply Direct Link To This Post 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....
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lucky22 Quote  Post ReplyReply Direct Link To This Post 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.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Plume Quote  Post ReplyReply Direct Link To This Post 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.  





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.
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Post Options Post Options   Thanks (1) Thanks(1)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Jul 10 2018 at 8:10am
bumping for new members
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: 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.  



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 Wildburg Quote  Post ReplyReply Direct Link To This Post 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.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Dec 18 2017 at 8:05am
bumping for new members

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 (1) Thanks(1)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post 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
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 (1) Thanks(1)   Quote Tamara Quote  Post ReplyReply Direct Link To This Post 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
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Motherofall6 Quote  Post ReplyReply Direct Link To This Post 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
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
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SusaninVA Quote  Post ReplyReply Direct Link To This Post 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.  

Edited by SusaninVA - Oct 11 2017 at 2:12pm
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Post Options Post Options   Thanks (1) Thanks(1)   Quote Meadow Quote  Post ReplyReply Direct Link To This Post 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.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SusaninVA Quote  Post ReplyReply Direct Link To This Post 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.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Jul 15 2017 at 1:09pm
bump
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: May 01 2016 at 11:41pm
Bump
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 (1) Thanks(1)   Quote petersdraggon Quote  Post ReplyReply Direct Link To This Post 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.
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Post Options Post Options   Thanks (1) Thanks(1)   Quote Lillie Quote  Post ReplyReply Direct Link To This Post 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
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
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