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Category:

Chemotherapy

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Question:  #1 11/16/2009		Q:	At Breastcancer.org, an article (dated August 1, 2009) about chemo states that the "dose-dense" schedule (every two weeks "can improve survival and lower the risk of the breast cancer returning compared to a traditional (every three weeks) schedule." Cancer has recurred (after mastectomy two years ago) for the THIRD time in my left breast. I''m considering chemo on the advice of my oncologist, and would like to get it over with ASAP...but would like know what your experience is with this dose-dense schedule and results.
		A:	Dose dense is generally only given in the adjuvant setting, ie not for recurrence, and if you've already had AC you probably can't get dose dense AC and T which is the regimen it was designed for. It is thought to be better than regular AC and T, but it is also more toxic and requires growth factor support (neulasta) to administer it on time. From what you have told me, I'm not sure dose dense would be appropriate for your clinical situation, but I'd encourage you to discuss this with your oncologist and/or seek a 2nd opinion. Best regards!
Question:  #2 11/15/2009		Q:	I am a 40 year old white female that was diagnosed with triple negative ductal invasive carcinoma approximately 3 weeks ago. I am BRCA 1/2 negative. I have undergone a lumpectomy and am scheduled to start my chemotherapy within 1 to 2 weeks. My oncologist has asked if I am interested in participating a clinical trial to determine if the drug Ixempra is superior to Taxol for treating early stage triple negative BC. I am not sure if I should participate in the clinical trial or go with the standard TAC treatment. Can you help? My chemo options are listed below. - 6 treatments of TAC (taxotere and AC) every 3 week intervals - standard treatment - 4 treatments of AC and 4 treatments of Ixempra 3 week intervals - clinical trial, or - 4 treatments of AC and 12 weekly treatments of Taxol - clinical trial I have done a lot of reading about Ixempra and am concerned about the neuropathy side effects and the fact that it was taken off the market in Europe. If I choose the clinical trial, I am not sure if I will be on the Ixempra arm or Taxol arm. Which option do you recommend? How can I be sure I am making the right decision? Thanks,
		A:	I'm an advocate of clinical trials and participate in them personally whenever possible. you will be monitored very very closely, actually closer than you would be if you didn't participate. so worth your while.
Question:  #3 11/16/2009		Q:	39 yrs old brca1+ just had Bi Lat Mast final pathology 1cm IDC low grade NH 4 ER93% PR82% HER2- onco dx score to follow. scheduled for prophylactic hysterectomy in 3mos. What course adjuvent therapy would best suit my case . Would CMF chemo or Anthracycline base regiment provide lowest rate of reoccurance over my lifetime . What is the overall % of survival at 15yrs
		A:	Great questions. Assuming you are node negative, the oncotype DX score would be the best prognostic indicator of your recurrence at 10 years. Your type of breast cancer (Node negative, ER positive, HER2 negative) has a lot of variability in the risk of recurrence which is why ONcotype was developed in the first place. As far as which chemotherapy is best, that is still an unanswered question for this group, but as a whole population, if your recurrence score comes back as high risk, there is good evidence that adding chemo would be of benefit. Given your BRCA mutation status, you may want to talk to your oncologist about any adjuvant therapeutic clinical trials with PARP inhibitors and/or platinum drugs which are not standard for adjuvant therapies for breast cancer yet.
Question:  #4 11/1/2009		Q:	Getting different opinions about kind or if I should get treatment. I have a 6mm Invasive Ductal recurrence after 6 years. Tumor was about the same size during original diagnosis and had lumpectomy with 10mm marginal clearance, radiation and no chemo. I am ERPR-and Her2+++, Stage 1, Grade3. I am going to have a bilateral mastectomy. What is John Hopkins doing about treatment for small her2+ tumors that have recurred after radiation? Have they looked at Her2 small tumor recurrence rate of their patient base over last 10 years? Thank you for such an informative web site.
		A:	Not enough information on how to definitively guide us for these small HER2 positive tumors, but since your tumor is also ER negative, we would likely recommend you receive Herceptin therapy and along with that, chemo since that is how it is always given. If you were ER/PR positive with HER2 positivity, we and others are running small trials to give less chemo with the Herceptin in this regard. This all assumes that you did not receive chemo/Herceptin after your original diagnosis 6 years ago. Either way, this sounds like something that could benefit from a formal 2nd opinion either here or at another large NCI comprehensive cancer center with expertise in breast cancer.
Question:  #5 11/1/2009		Q:	is benefos been used in MBC to bone instead of zometa ?
		A:	Although other bisphosphonate drugs can and have been used other than zometa (with some still being tested head to head in clinical trials) I am not aware of benefos and would have to defer to your doctor on that. I don't believe this is a bisphosphonate class of drugs, and if so, then it would not be appropriate for use in MBC to the bone.
Question:  #6 11/1/2009		Q:	dearest lillie is it a common practice to move from monthly zometa to every 6wks or even two months after tow years in MBC TO REDUCE ONJ RISK ?
		A:	It is becoming more and more common as we learn that the ONJ is a risk and that every 6 to 8 weeks is still likely to confer benefit.
Question:  #7 9/6/2009		Q:	Is AC 4 cycle plus 12 Taxol weekly plus herceptin suitable for 68 years old with Ca breast stage 2A IDCA H3N3 ERPGR - negative HER-2 3+ ? Are there another recommended regimen if the patient can not stand for nausea vomitting sore mouth and febrile neutropenia on C1 ? Will the 20 % of dose reduction in next cycle prove to reduce these side effects ?
		A:	we really don't know the effects of the reduced dose. ask about kytril or zofran given ahead of time to prevent the nausea.
Question:  #8 9/6/2009		Q:	Thanks for answering one more question. Just successfully completed Mammosite radiation on Friday. Stage one IDC, 1.6 cm. clear margins, clear nodes, Grade 3(9 of 9). Chemo 6 sessions of cytotoxin and taxotere. Oncologist says Oncotype test would show high number since stage 3. Radiologist wants me to wait 3 weeks to start chemo, I would like to start sooner? Am I at greater risk delaying start. My surgery was August 11th. Thanks, again for your help. Finally, I have Myasthenia Gravis and need to have an IV-Ig treatment. My neurologist and oncologist think this is fine. Do you have an opinion? Thanks so much for your help.
		A:	you mean grade 3 i think (not stage 3). that said, oncotypeDX has shown to surprise doctors sometimes with a lower score even when the grade is 3. if all oncotypeDX scores for grade 3 tumors was a high number then there would be no sense in doing the test. inquire again about it.
Question:  #9 9/5/2009		Q:	I wrote you a few weeks ago with prothesis questions-thank you. Now my questions are concerning adjunct therapy. I was diagnosed 4 yrs ago with Stage 1 invasive, hormone negative, her2+. My tumor was 3mm and caught early. Had a lumpectomy with radiation. Family history is my sister had ovarian and a great-aunt and aunt who had breast cancer. All were caught early with good success and no reoccurance. I tested negative for the gene and sister/aunt refused to be tested. I now have a local reoccurance, again 3mm, identical to original. Because my tumor is so small I am again being told no chemo or herceptin but now a mastectomy. Believe me I do not want these therapies but I am very worried about the aggression of my cancer to have survived radiation. I also am worried that the cancer has been around now for probably what-8 yrs? I am told that I fall into a grey area for treatment since there are no studies. I am choosing to have a bilateral mastectomy and do not want to find myself ten years down the road dealing with cancer in another part of my body. 1. Any known protocols for adjunct treatment options with this size tumor, hormone neg and her2+ anywhere in the U.S. or U.K.? 2. Any known tumor markers or blood test follow-ups being done long term? 3. Are MRI''s being done annually for followup to chest area after mastectomy? 4. Pet Scans/Cat Scan followup every 3-4 years????? Thank you so much for all your knowlege. It helps me to know what is being done in another area of the country since my situation seems to not be studied.
		A:	1. 10-15% of women who have lumpectomy with radiation and are not candidates for hormonal therapy will have local recurrence so it is not that odd at all. it is tiny. that's the good news. not aware of any special protocols as you referenced. 2. no 3. no 4. definitely not. more helpful to rely on clinical exam and symptoms.
Question:  #10 9/5/2009		Q:	Hi lillie I completed chemo and rads in June 06. I am a 50 y/o university professor, my school is suggesting flu vaccines for every one my help in case of a swine flu outbreak. My question Am I allowed to take vaccines????? Thanks
		A:	YES. and all breast cancer survivors should. so do!!
Question:  #11 8/30/2009		Q:	I have had a lumpectomy with sentinel node biopsy 12 days ago, scheduled to begin Mammosite tomorrow, and chemotherapy soon. Stage one, grade 3, ER and PR positive, Her2 negative, 1.6 cm, node negative, 59 years. My oncologist has recommended cytotoxane and taxotere. Is this a standard recommendation or the best recommendation? I''m a professor/health sciences and have read that 30% of node negative breast cancer patients have micrometasis in the bones. Is this true and do I have a more negative prognosis with grade 3 (score 9) or is chemotherapy more effective? Thanks for your help. So many decisions.
		A:	don't think its true about micromets and bones. that said, you have very favorable prognostic factors. ask about getting oncotypeDX done to determine if chemo is recommended or if hormonal therapy is where your benefit is greatest. do that before deciding drug combo.
Question:  #12 8/16/2009		Q:	Lille, I know there are many promising therapies on the horizon. I understand there is excitement about PARP inhibitors, as well as vaccine therapies. I also know autologous transplants are ongoing in clinical trials with reduced incidence of graph versus host disease. One, do you think PARP will eventually work on non BRCA patients, and two, any real promise with vaccine or stem cell transplants for metastatic disease? Thanks, as always, for being there for us.
		A:	PARP inhibitors do seem real for cancers with BRCA1 and 2 mutations, but the jury is still out whether they will work on other cancers like triple negatives. In fact the jury is still out whether they will work at all, but again, preliminary data for BRCA related cancers are very encouraging. Will probably be another 3 to 5 years before we learn more. As far as vaccine or stem cell transplants, vaccine therapy work is ongoing including here at Hopkins. Time will tell whether real responses can be reliably reproduced but we are all hopeful. Stem cell transplants for metastatic disease was tested in the 1990's and found NOT to be useful so that is a relatively old topic that will likely not be revisted, but may be reexplored for high risk patients in the near future.
Question:  #13 8/16/2009		Q:	dear lillie whats salinomycin and how promising such a discovery is,where to get more information? thank you
		A:	This is far too new information to be concerned with. It is at the very early stages of lab research and is a drug that was found that has toxicity for breast cancer stem cells. There is still great controversy whether these stem cells even exist let alone whether drugs can target this, but a recent paper in the journal Cell describes work from MIT researchers regarding this drug and breast cancer stem cells.
Question:  #14 8/3/2009		Q:	Hi Lillie I have asked you many questions over time and always very thankful for your honest responses. My wife has been battling breast cancer with metastics to the liver for the past 3 and half years. PR ER + her 2 neg. She has had AC, Tamoxifen, Letrozole, xeloda, Avastin, diocetaxel and carboplatin and just found a refractory response to these last two chemos that she has had 20 rounds of. She is well in herself and the oncologists has suggested "Caelyx". Do you have any information regarding success or otherwise of this chemo? And are the side effects severe? Thankyou in advance
		A:	THis is a very good chemodrug and is a liposomomal formulation of doxorubicin. It is very good at treating breast cancer and its side effects are reduced compared with normal doxorubicin (adriamycin) because of the liposomes. If she is in otherwise good health, it may be of help, but balancing toxicity and chance of benefit is key here. Best wishes.
Question:  #15 8/3/2009		Q:	I''m new to this forum and website, but I''d be very grateful for any feedback/ advice. I just got my Oncotype DX result and it is 14, and now I am agonizing whether to do chemotherapy. My med oncologist is recommending it because of my age. I am 35. Here''s a rundown of my pathology report: invasive ductal carcinoma, 1.1 cm, Stage 1, grade 2. I did a sentinel lymph node biopsy-- 0/2 nodes (they were clean), and ER+/PR+, HER2-.
		A:	With a recurrence score of 14 it is difficult to say whether or not there would be benefit from chemo which is why the big TailoRx study is ongoing. However, you are extremely young and that usually does make us feel that giving chemo would be of higher benefit. If you are really torn, I would recommend a 2nd opinion. Best wishes.
Question:  #16 8/3/2009		Q:	Was recently diagnosed with invasive ductal ca of left breast by stereotactic bx. ER/PR+, HER-. Moderately differential. MRI showed 6 separate, but contiguous, tumors in UOQ of Left breast all less than 14mm. Abnormal area of increased uptake posterior to RT nipple. I am definitely opting for bilat mastectomy with immediate recon. Question: Does it matter if I do chemo before or after surgery and How do I know if I need chemo before nodes are biopsied. Thank you!
		A:	Outcomes of chemo before or after surgery are generally considered equivalent so the reasons for doing upfront chemo are for inflammatory breast cancers (most of the time) and for breast conserving surgery, which you are not receiving (and probably are not a candidate for given the multifocal nature of your cancer). So for you, getting chemo afterwards makes sense. The reason is exactly because of your next question, we can't adequately assess the nodes after chemo because the chemo may have destroyed disease both in the nodes and the breast. Although a good problem to have, it takes away our ability to prognosticate. It may be that after surgery your nodes are clean, the tumor looks favorable and you may be recommended only hormone therapy.
Question:  #17 7/27/2009		Q:	Do you know of any success with ifosfamide? If so, What kind of cancer is treated with it successfully. Thank you for your time
		A:	Ifosfamide is used to treat other cancers, but not so commonly for breast cancer. Some sarcomas in particular are treated routinely with ifosfamide. It's "cousin" cyclophosphamide or cytoxan, however, is used routinely for breast cancer chemotherapy.
Question:  #18 7/27/2009		Q:	Hi Lillie - have a quick question. Am triple neg, 1.2 cm IDC, no node involvement, Stage 1, Grade 3, Ki-67 is 61% and had my 4 DD AC''s and so far 1 round of DD Taxol x4 every two weeks. Had horrific bone pain and achiness two days after getting it and also developed neuropathy in all fingertips and feet. Over the two weeks, feet improved greatly, but fingertips remain the same. When I went for 2nd Taxol, onc refused to give it to me due to fingertips and delayed me one more week and is switching to Taxotere. Isn''t the Taxotere just as bad with neuropathy as the Taxol. I am confused. Since I am a paralegal, she didn''t want to "disable" my hands. Have you heard of this happening before? Thanks, so much and hope my post finds you well and happy.
		A:	It can and does happen. Taxotere can also cause the same neuropathy, but some people have worse side effects to one vs. the other. Sounds like your doctor is doing all the right things. Best wishes.
Question:  #19 7/27/2009		Q:	Hi My friend had mast 2 years ago for 5 cm IDC no lymph nodes Er PR Her positive she was 42 and refused chemo but took rads. she has been on monthly zolodex and 20m tam a day. She is very worried now and thinks she should have not refused Chemo. Is there any thing that could be done this late???????
		A:	Unclear. But if she was really HER2 positive, then she should have gotten chemo with Herceptin. No one knows if there is any benefit taking it this far out, and probably most oncologists wouldn't do it. If she is that worried, she should talk with her oncologist again and see what he/she thinks.
Question:  #20 7/19/2009		Q:	dearest lillie how is taxol and taxotee different in ther antineoplastic activity,and s there any evidence of cross resistance between the tow?
		A:	Short answer is that the two work very similarly and yes, in general resistance to one can lead to resistance to another. However, cancer and people are all different so that isn't always the case, but in general, if a woman progresses on either taxol or taxotere, the next chemotherapy used wouldn't be the other drug, but usually a drug that works by a different mechanism.
Question:  #21 7/18/2009		Q:	My wife, in 1996 at the age of 26, was diagnosed with DCIS and had a lumpectomy with radiation treatment. In 1997, the cancer returned as DCIS in essentially the same place. At that time, she had a mastectomy of that breast. In April 2009 at the age of 39, a 1.2 centimeter tumor was discovered in her other breast. This tumor was invasive, but based on lymph node testing, had not spread to the lymph nodes. She is undergoing four chemo treatments and has one to go. We just found out today the results of testing for the TP53 genetic mutation, for which she is positive. The oncologist has suggested adding four additional chemo treatments using taxol for those additional treatments, and has told us that the positive TP53 mutation means that my wife has Li-Fraumeni Syndrome. Is that true? And, if so, is additional chemo treatments the accepted strategy? Are there other options? What does this mean for her life expectancy?
		A:	this is correct. and actually genetic testing should have been mentioned to you both a long time ago. her clinical presentation is pretty classic for being genetically caused. she is young so being aggressive with treatment makes sense. so mastectomy again would be the answer to reduce risk of local recurrence which for genetically positive women is high. also risk of other types of cancers-- ovarian, pancreatic in particular. so meet with a genetics doctor to discuss options for reducing and/or monitoring risk for these types of cancers too.
Question:  #22 7/13/2009		Q:	My wife has been on a trial of docetaxel carboplatin and avastin. Due to an infection and open wound she has been taken off Avastin for last 6 months and has just been told due to length of time she will not be allowed to continue with Avastin when the wound finally heals. She is devestated as in her mind it was the wonder drug. What are the real results of Avastin? I have told her that it does not mean in future trials she may have a chance of having it again.
		A:	WE don't know the effects of Avastin in the adjuvant setting (presumably what your wife was getting), but it is far from a wonder drug. Avastin works in the metastatic (non-curable) setting, but ONLY when given with chemo; as a single agent it failed miserably. In addition, even though it can prolong disease progression by about 4 months, it has NO EFFECT on overall survival, the gold standard in all big clinical trials. Because of this, it barely (5 votes to 4) got FDA approval and in fact the recommendation panel initially recommended ( 5 to 4) NOT to approve it for breast cancer because it can have bad side effects, is extremely expensive, and has no overall survival benefit. Many docs here are less than impressed with Avastin and certainly no one would call it a wonder drug. Hope that helps.
Question:  #23 7/13/2009		Q:	dear lillie what are the recent evidence on monotherapy tykerb after progression on herceptin,my second question please is on tykerb effect in bone metastases
		A:	No great evidence as it (Tykerb) has always been given with chemotherapy. Also no definitive studies on bony metastases, but one would presume the drug would also be effective there as well.
Question:  #24 7/13/2009		Q:	Recently diagnosed infiltrating ductal carcinoma. Breast MRI shows tumor size to be 5-6 cm. ER positive, PR negative, HER2 negative 1+. Onc recommend neoadjuvant therapy first to shrink the tumor prior to surg. Currently receiving AC x 4 rounds (currently have had two) then to Taxol x 12 weeks. I''ve read HER2 negative tumors may not benefit from AC and Taxol. What are your thoughts? Haven''t had a chance to discuss with onc yet but will this week.
		A:	Not true. A recent big study that HOpkins was a part of even suggests the opposite if you are getting weekly Taxol for 12 weeks. That said, the trial (and most others) were not specifically set up to address that question so we cannot say for sure; but if anything, HER2 negative patients did better with this regimen than HER2 positive
Question:  #25 7/12/2009		Q:	I am 43 yo with invasive ductal CA stage 2, 3-4cm tumor ER+/PR+/HER2+. I would like to know the course of chemo I will be offered most likely for neoadjuvant tx. Should I also consider an oopherectomy and bilateral mastectomy since I have a sister who had a non-malignant ovarian tumor. I am waiting on BRCA1&BRCA2 results.
		A:	your sister's benign ovarian mass has no bearing on your genetics (or hers). there are a variety of neoadjuvant chemotherapy regimens that may be recommended. to learn about them requires a formal consultation. it can't be done via an email. so seek out 2 opinions from breast medical oncologists who work in 2 different practices. anticipate herceptin being part of the treatment as well, for a year.
Question:  #26 7/13/2009		Q:	My mom is 57 and just had a breast tumor removed last week. The tumor size was 2cm with clear margins. Test result is mostly DCIS but with microinvasion of 1.5mm (involved 2-3 milk ducts, not sure what exactly that means. how bad is it?). The doctor said we had options of taking hormone medicine for 5 years or have a short course of chemo. Could you give some advice on which one is better for long term? Also, we didn''t do sentinel node biopsy. Do you think the risk of spreading to lymph nodes is high? Is it too late to do the lymph nodes biopsy? Is the surgery to remove all lymph nodes necessary? I do have a lot of questions under stress. Thank you for your time!
		A:	Lots of questions but really can't answer all of them in this forum. Depending on the surgeon, it may be worthwhile to go back and do the lymph node dissection; we would probalby recommend that here. This could also influence decisions on chemo and hormone therapy. Need to know other factors such as her tumor's receptor status for ER/PR and HER2, as well as other factors on the pathology reports like the margins (not just clear but actual numbers). If you have any concerns, I'd recommend getting a 2nd opinion either from a surgeon and/or medical oncologist. Best wishes.
Question:  #27 7/5/2009		Q:	I have been fighting stage 4 breast cancer for 4 years now. The chemo destroyed my heart after only having 4 rounds of chemo in 2005. It wasn''t found until May of 2008. My heart only pumps blood at 20% and surgery to insert a pacemaker/defibulatar failed the first time and was preformed again with no improvement to my heart. I now have mets to the liver and need to go back on chemo. For fear of me having even more damage to my heart and not making it through chemo my doctor has put me on faslodex one shot a month. Scans will be done this month after my second shot to see if there is any improvement. If not I have to go back on chemo. My question is...is there a chemo out there that could be used that won''t damage my heart? I was also told (not by a doctor) that if the tumors were shrinking in my liver I would have pain and I don''t have any pain. Is this correct? I also have 2 spots in my lower back at this time.
		A:	there are chemo agents that are heart friendly. i've never heard of having pain while liver lesions shrink. strange... let me also mention to you that if you are interested in attending one of our special retreats for women with metastatic disease, send an email to Deb Stewart at dstewa24@jhmi.edu We have one retreat a year for women and one retreat coming up in sept) for women and their spouses dealing with mets.
Question:  #28 7/6/2009		Q:	dear lillie are there any evidence or clinical trials comparing tykerb with herceptin as first line treatment in MBC,IN OTHER WORDS IS THERE ANY EVIDENCE THAT TYKERB IS LESS EFFECTIVE THAN HERCEPTIN? ALSO I WOULD LIKE TO ASK PLEASE ABOUT A STUDY SAYING THAT FOOD ESPECIALLY FAT RICH MAY INCREASE TYKERB ABSORBTION WITHOUT INCREASING SIDE EFFECTS,IS THIS TRUE,I ALSO READ ON RXLIST.COM THAT TAKING IT WITH FOOD MAY INCREASE *TISSUE EXPOSURE TO THE DRUG* WHAT DOES THIS MEAN EXACTLY THANK YOU
		A:	No studies in the metastatic setting, but there is an ongoing trial looking at tykerb versus Herceptin head to head and in combination (concurrently vs. sequentially) in early HER2 positive breast cancer called the ALLTO trial, which we are part of. No great study about food and tykerb absorption, but based upon early studies, tykerb is recommended to be given greater than 1 hour before or greater than 1 hour after a meal, suggesting that taking it with food leads to unpredictable absorption and therefore potential increased or decreased blood levels of tykerb.
Question:  #29 6/20/2009		Q:	Hello Lillie! I am a 40-year-old, premenopausal woman who recently had a mastectomy for ER/PR- (<5%), but very HER2/NEU+++ (FISH 10), T1a IDC. My mastectomy revealed 2 separate areas of DCIS,each about 2cm, with over a dozen areas of invasion between 2-4mm scattered throughout. N0M0, Grade 2 (low mitotic rate, high nuclear grade, no tubule formation). My oncologist said that chemo is "a gray zone for women like you," but that TCH is one of the options to reduce recurrence risk. She tells me that the choice is mine. I''m leaning to chemotherapy as I am very healthy otherwise, with a strong and athletic heart... and I think I can take the hit. Am I overtreating?
		A:	though the amount of invasive disease is small by measurement, you are young and had unfavorable prognostic factors. so makes sense to be aggressive with treatment for peace of mind. you will get a mixed bag of opinions though. grade 2 is less worrisome than grade 3. if you are a worrier then it is surely the right thing to do for you. peace of mind is an invaluable thing to have when moving forward after breast cancer treatment. LS
Question:  #30 6/20/2009		Q:	Hi there, I am about to start 4 cycles of TC for stage 1 IDC (ER/PR+, Her2neu-, grade 2, intermediate oncotype score, lymphatic invasion present, I am 32yo, BRCA-). I am considering using a "cold cap" to prevent hair loss from chemotherapy. Do you know if this is safe? Thank you.
		A:	safe, yes i think so. does it work? i don't think so. bottom line, don't build up your hopes that this device will prevent hair loss.