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Carboplatimum vs ACT

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Madison5454 View Drop Down
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    Posted: Jul 23 2020 at 10:16am
Hi All, I have been recently diagnosed with Stage 1(a) (1.8 cm tumor, nodes are clean). I have undergone a lumpectomy and now have seen two oncologists for their opinion on next steps. One recommended ACT and the other Carboplatin with Taxoterre (taxol). There is very little online regarding the carboplatinum being used post surgery and wondering if anyone has undergone the carboplatinum/taxol treatment and their experience. Thanks
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Vivian View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Vivian Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 11:46am
I had the same diagnosis as yours: 1.8cm tumor, clear nodes. I had AC-T before lumpectomy, and had pCR. I am getting radiation. I asked my doctor about Carboplatin for my treatment. He said it is not standard of care for early stage breast cancer and the side effects are concerning for what I might gain. 
Dx 12-27-2019 TN,Stg 1, Grade 3 Ultrasound 1.5cm/MRI 1.8cm, node-,BRAC-.
DD AC x 4, ultrasound cCR; Taxol x4
Lumpectomy:5-28-2020; 0/2 nodes. pCR.
Radiation: 20(16WBR+4 boosts) Total: 42.56Gy +10Gy
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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: Jul 23 2020 at 12:19pm
Madison,

Did you have genetic testing done?  Are you BRCA positive?  If yes, then this might be why one recommendation was Carboplatin.  

The following are from the NCCN Guidelines (Page 57):

Guide 12
Systemic therapy for HER2-
  Preferred options
  • Doxorubicin and cyclophosphamide followed by paclitaxel 
  • Docetaxel and cyclophosphamide (TC)

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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Madison5454 View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 1:52pm
Thanks Vivian. Donna, I am not BRCA positive. Waiting for full panel of genetic testing to come in.
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Madison5454 View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 2:02pm
FYI I am 48 yrs young.
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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: Jul 23 2020 at 2:05pm
Madison,

I looked again at the NCCN Guidelines (page 55) and none of the adjuvant recommendations included Carboplatin and Taxol as first line treatment.  I’m wondering why the onc recommended this course?

FYI - you are one year younger than my first diagnosis.  

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 Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 2:27pm
I don't know why... I believe it was based on a recent study. I will find out. When she first told me I had not done any research so could not question her immediately on her recommendations.  She said it was between this treatment and ACT but thought I should do the carboplatin/taxol. I will dig deeper. She is also retesting my tumor (we have ordered my slides), ordered a CT scan with contrast and an MRI which may help with further treatment recommendation.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 2:32pm
I will definitely circle back and let you know when I find out.
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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: Jul 23 2020 at 6:25pm
Madison,

Do you think the onc meant adding Carboplatin to the Taxol portion?  There was a study at 2020 ASCO where they talked about adding Carboplatin to Taxol for Neoadjuvant treatment.  The patient will still get A/C, then follow by Taxol/Carboplatin.

Here’s the link:


Strategies To Improve The Treatment of Early Stage TNBC

Adding neoadjuvant carboplatin to pre-surgery chemotherapy improved disease-free survival for patients with TNBC

Previously reported clinical study results have suggested that adding carboplatin to anthracycline/taxane-based neoadjuvant chemotherapy can increase the proportion of patients with TNBC who had attained a pathologic complete response [pCR], from 36.9 percent to 53.2 percent.

In the currently reported study researchers enrolled 315 patients with TNBC to receive 18 weeks of neoadjuvant chemotherapy consisting of paclitaxel, non-pegylated-liposomal doxorubicin, and bevacizumab and were randomly assigned to concurrently receive weekly carboplatin or nothing extra and then directly compared.

After a median follow-up of three years, 85.5 percent of TNBC patients treated with the additional carboplatin survived without evidence of cancer recurrence compared to only 76.1 percent of patients treated with paclitaxel, non-pegylated-liposomal doxorubicin, bevacizumab, and no carboplatin.



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 Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 6:53pm
Yes I think the Carboplatin would be added to the Taxol. However, she made it clear that if I did this I would not need to do the AC before. She did advise me that other oncologists would recommend the ACT. I will revisit with her once I get my test results back and meet with her again. Technically I am post surgery now that the tumor is out (weighing if I should just get a double mastectomy in order to avoid recurrence - so may get another surgery eventually) but because tumor is out I am not in a neoadjunct situation, so game plan from the study you sent me doesnt seem applicable. So will have get rationale from my Dr. as to why she is recommending this in light of all of this...
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SagePatientAdvocates Quote  Post ReplyReply Direct Link To This Post Posted: Jul 23 2020 at 11:19pm
Dear Madison,

I would be happy to talk with you, if you wish. I am not a medical professional but I have helped over 100 women on the TNBC Foundation over the last 10+ years and I may be of use to you. I know you said you had genetic testing done and I have a good relationship with a precision medicine physician in San Diego who might be helpful, once your genetic testing comes back.

Please feel free to send me a PM, although I have been having some difficulties getting them at times. If I don't respond the same day please email me @
steve@patientadvocates.org 

I am in San Diego. Pre-Covid I would have offered to come and meet you. I traveled 6 months away from home last year accompanying folks to various cancer centers around the country or going to conferences but have not been on a plane since February. 

Whatever, you decide, I sincerely wish you the best of luck. Also, I treat every case, confidentially, and will never write about you on the board, or anywhere else. Also, there are no charges, but again I will not give you a medical opinion but will try to put you in touch with good medical professionals. Hopefully, I can be of some use to you.

with my love to all here,

Steve



I am a BRCA1+ grandson, son and father of women affected by breast/oc-my daughter inherited mutation from me, and at 36, was dx 2004 TNBC I am a volunteer patient advocate with SAGE Patient Advocates
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Madison5454 View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Aug 03 2020 at 2:07pm
Donna I’m going to do the ACT... Any tips for tolerating treatment welcome from all! Thanks
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Aug 03 2020 at 2:10pm
Vivian did you consider mastectomy over radiation at any point?
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Vivian Quote  Post ReplyReply Direct Link To This Post Posted: Aug 03 2020 at 5:30pm
Madison, 

I did not consider mastectomy. Lumpectomy renders higher rate of local recurrence and I am aware of the risks. But mastectomy has its own, different risks that I can't overlook. My genetic test showed no BRAC mutation, so lumpectomy became a reasonable option. 

Here is an article about lumpectomy & recurrence in different tumor subtypes. 
......the overall rate of local recurrence after lumpectomy at 5 years from trial registration was 4.2%, but researchers observed variations based on receptor type. Data showed that recurrence rates were highest for patients with triple-negative disease (6.9%) and lowest for triple-positive patients (3%). For patients with estrogen receptor–negative, HER2-positive disease, the recurrence rate was 4.7%. 

I just completed the radiation therapy. It was easy and quick done in 4 weeks (16 for whole breast + 4 boosts). 

Hope it helps. 

Vivian

Dx 12-27-2019 TN,Stg 1, Grade 3 Ultrasound 1.5cm/MRI 1.8cm, node-,BRAC-.
DD AC x 4, ultrasound cCR; Taxol x4
Lumpectomy:5-28-2020; 0/2 nodes. pCR.
Radiation: 20(16WBR+4 boosts) Total: 42.56Gy +10Gy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Madison5454 Quote  Post ReplyReply Direct Link To This Post Posted: Aug 24 2020 at 11:32am
Yes this is extremely helpful. Thank you!
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Plume Quote  Post ReplyReply Direct Link To This Post Posted: Aug 25 2020 at 5:37am
Vivian, just want to say thank you for posting a very interesting article and, for me, a most encouraging one.  Phew.....!  How we fret and worry and then, one fine day, someone posts an article and renews your hope and damps down a little your anxiety.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Vivian Quote  Post ReplyReply Direct Link To This Post Posted: Aug 27 2020 at 1:33am
Hi Plume, I too find positive messages from the article. We have been through extreme fear; some hopeful information is much needed to know we are on the right pathSmile
Dx 12-27-2019 TN,Stg 1, Grade 3 Ultrasound 1.5cm/MRI 1.8cm, node-,BRAC-.
DD AC x 4, ultrasound cCR; Taxol x4
Lumpectomy:5-28-2020; 0/2 nodes. pCR.
Radiation: 20(16WBR+4 boosts) Total: 42.56Gy +10Gy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Aug 27 2020 at 12:03pm
Madison,

I just came across this study that I think your onc was talking about (Carboplatin plus Taxol only).  It was a Phase 3 Study Results done in China that was just published this month in JAMA.  It compared Carboplatin plus Taxol with a chemo combo similar to ACT (CEF-T: cyclophosphamide, epirubicin, and fluorouracil followed by docetaxel).

August 13, 2020

Effect of Adjuvant Paclitaxel and Carboplatin on Survival in Women With Triple-Negative Breast CancerA Phase 3 Randomized Clinical Trial


Abstract

Importance  The value of platinum-based adjuvant chemotherapy in patients with triple-negative breast cancer (TNBC) remains controversial, as does whether BRCA1 and BRCA2 (BRCA1/2) germline variants are associated with platinum treatment sensitivity.

Objective  To compare 6 cycles of paclitaxel plus carboplatin (PCb) with a standard-dose regimen of 3 cycles of cyclophosphamide, epirubicin, and fluorouracil followed by 3 cycles of docetaxel (CEF-T).

Design, Setting, and Participants  This phase 3 randomized clinical trial was conducted at 9 cancer centers and hospitals in China. Between July 1, 2011, and April 30, 2016, women aged 18 to 70 years with operable TNBC after definitive surgery (having pathologically confirmed regional node-positive disease or node-negative disease with tumor diameter >10 mm) were screened and enrolled. Exclusion criteria included having metastatic or locally advanced disease, having non-TNBC, or receiving preoperative anticancer therapy. Data were analyzed from December 1, 2019, to January 31, 2020, from the intent-to-treat population as prespecified in the protocol.

Interventions  Participants were randomized to receive PCb (paclitaxel 80 mg/m2 and carboplatin [area under the curve = 2] on days 1, 8, and 15 every 28 days for 6 cycles) or CEF-T (cyclophosphamide 500 mg/m2, epirubicin 100 mg/m2, and fluorouracil 500 mg/m2 every 3 weeks for 3 cycles followed by docetaxel 100 mg/m2 every 3 weeks for 3 cycles).

Main Outcomes and Measures  The primary end point was disease-free survival (DFS). Secondary end points included overall survival, distant DFS, relapse-free survival, DFS in patients with germline variants in BRCA1/2 or homologous recombination repair (HRR)–related genes, and toxicity.

Results  A total of 647 patients (mean [SD] age, 51 [44-57] years) with operable TNBC were randomized to receive CEF-T (n = 322) or PCb (n = 325). At a median follow-up of 62 months, DFS time was longer in those assigned to PCb compared with CEF-T (5-year DFS, 86.5% vs 80.3%, hazard ratio


 = 0.65; 95% CI, 0.44-0.96; P = .03). Similar outcomes were observed for distant DFS and relapse-free survival. There was no statistically significant difference in overall survival between the groups (HR = 0.71; 95% CI, 0.42-1.22, P = .22). In the exploratory and hypothesis-generating subgroup analyses of PCb vs CEF-T, the HR for DFS was 0.44 (95% CI, 0.15-1.31; P = .14) in patients with the BRCA1/2 variant and 0.39 (95% CI, 0.15-0.99; P = .04) in those with the HRR variant. Safety data were consistent with the known safety profiles of relevant drugs.

Conclusions and Relevance  These findings suggest that a paclitaxel-plus-carboplatin regimen is an effective alternative adjuvant chemotherapy choice for patients with operable TNBC. In the era of molecular classification, subsets of TNBC sensitive to PCb should be further investigated.

Trial Registration  ClinicalTrials.gov Identifier: NCT01216111

https://jamanetwork.com/journals/jamaoncology/fullarticle/2769305


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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