Questions...

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QUESTION

Hello TC,

We are trying to locate a doctor in for my daughter, and it's not easy. Do you have any suggestions on find the best MD?

We have the name of an Oncologist (a highly recommended woman doc), and thought that it was the Onco that did the surgery. Now we understand that a surgeon does the operation and the Onco handles the case afterwards. Are we correct about this?

Thanks much.


RESPONSE:

The “traditional medical team” is made up of the following:

Surgical oncologist – this person is integral in the initial stage, but a transitory person in the long haul of the journey. They are the person who your daughter will work with on determining if and if so, which sort of surgery is appropriate (e.g. lumpectomy, mastectomy, nipple-sparring, tissue-sparring, NO surgery at all). Once healed from the surgery, and margins are clean, this medical professional ceases to have a role.

The surgical oncologist, however, is the doctor you request to have the tumor and tissues sent to Genomics in California for the Oncotype DX test. If the surgical oncologist won't do it, then insist that the medical oncologist does. Don't be talked out of this test - it is the only reliable determiner available to us in the U.S. to gauge the efficacy of chemotherapy on our individual cancer. (There is a Mammaprint test available now as well. The problem, the only lab that has the patent on this is in Phoenix, and a Mammaprint can only be conducted on "fresh" from the slab tumor/tissue.) I was also told by several pathologists that the particular patent that the Phoenix lab obtained is not quite the same caliber as the one in Europe.

It is also after the surgery and the pathology analysis that she should then have her results sent to Michael Lagios, MD in Marin County for re-evaluation and adjuvant treatment recommendations. (See blog entry dated January 23, 2010.)


Medical oncologist – this is the person whom you have a life time relationship. They advise and help you determine if and what type of adjuvant treatment she will have (i.e., chemo and other drug protocols [tamoxifen, etc.])They follow you for the first year or two every 3 months, 2-5 years every six months, and thereafter annually – they follow you to track recurrence. This is the medical person that you use to determine your long term quality of life. (And, this is the person that I personally am having a tremendously difficult time in finding that fits with my perspective on my cancer. I have interviewed four so far.)


Radiation oncologist – this is the person who, if you choose to do radiation, will handle that portion of the adjuvant treatment. There are great variances in this field so interview radiation oncologist thoroughly. Ask what type of equipment they have and how they target the chest wall. Radiation can have serious side-effects ranging from skin-burning to weakening of the heart. Make sure that if you choose radiation, that you do your homework!

NO TREATMENT DECISIONS SHOULD EVER BE MADE OUT OF FEAR...! The only long term decisions that you can live with are the ones you make from a point of knowledge.

Reconstructive surgeon – (aka a plastic surgeon who specializes in reconstructive surgery). This specialization is absolutely necessary to have any sort of livable outcome. A good surgical oncologist will work with the reconstructive surgeon and allow them to determine the incisions, since they do so from a perspective of your long term, dare I say . . . aesthetic, outcome.


For me, the integral person has been my naturopathic oncologist. Not many reputable ones around, but I found the one who developed and formalized this area of alternative medicine. It is this doc, Daniel Rubin, ND FABNO, whom I am working with in developing my adjuvant treatment -- I have opted out of the traditional protocol of chemo/drugs/radiation.

Finding is a good medical oncologist is difficult. I suggest that your daughter speak to the surgical onc and get a few names of whom they work with. I would also google med oncs in your area and get names and then start looking up their medical profiles and histories. I also found that using “healthgrade.com” (it’s a paid on line service) was good in reading patient reviews of doctors. Once she has a short list, and has done her due diligence, start face-to-face interviewing – go in with her notebook and questions ready!

The most important thing to remember is that the patient needs to do the interviewing (not the other way around). The patient, is the “employer” and/or “general contractor” of her own healthcare.

TC

TC's Post...Post Script

I completely forgot to mention the involvement of a geneticist! Early on this journey, after my first interview of a prospective surgical oncologist, I met with and got tested by a geneticist. This was to help answer the WHY??? The purpose was to determine if I had any genetic predisposition toward cancer. Having no information or contact of and with my biological father in 42 years, I could not definitively say there was no family history of cancer. The answer to this question would help guide me on this journey, and help answer questions regarding my children's future. This is the testing for the BRCA1 and BRCA2 - in addition to looking at other genetic markers.

I pleased to say I passed the test -- no genetic predispositions!

If you are a women of Ashkenazim descent, there is an additional genetic screening that should be done.

Still free-falling down the rabbit hole

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When you read Alice in Wonderland, you will find yourself trying to make sense of an illogical story. Alice, the key character, also experiences similar frustrations. But in the end, she emerges wiser with the learning involved in each situation. Everyone faces absurd choices in life. If you shrug off these choices as anomalies to your perfect life, you gain nothing. But if you try to learn from these absurdities, you will gain a lot of wisdom. By Simran Khurana

I met with the Radiation Onc (aka "radio-onc") this morning. A friend called while I was waiting in the exam room. She asked: "is this another doc, or one of the med-pro squad?"

"This one" (female), I reply, "is a member of my original 'team.' and she insisted that I meet with her. She is uncomfortable with my decision to opt out of standard protocol treatment." She asked, wisely, why then are you there????  It was then I realized that the single most motivating factor for my presence in that exam room was likely because, for a mere $40.00 co-pay, I get fodder for this blog! Sick!

How was I to know that this was a portend for the conversation that took place between "radio-onc" and I over the next 45 minutes?

Radio-Onc took it upon herself to drive home her fears regarding METASTATIC BREAST CANCER / SIZE OF MY TUMOR / MY AGE / COMPLEXITY / RECURRENCE / REMISSION. (My last appointment with her was on her birthday. At this point I began to wonder if she is harboring some latent disappointment on how that day turned out.)

The first two minutes where the most "cheerful" part of our conversation. Radio-Onc relays to me that Kato (medical onc) informed her that I had insisted on foregoing chemo. And, that he was still recommending it because of... SIZE OF MY TUMOR.

I proceed to inform her that what I insisted upon was the conducting of the Oncotype DX test to determine if I would derive any benefit from what he was brewing up. And, that the test indicated NO.

I even informed Radio-Onc that I had pointedly asked medical onc if the size of my tumor gave him reason to question my RS score and the subsequent determination that I would derive little to no benefit from chemo...to which he had replied: "No, not at all." Hmmm, she says.

Radio-onc then says she wants me to speak to one, if not two, other medical oncs. She explains that if two out of three of them agree on a course of action, or inaction, she will respect my ultimate decision. . . . And, I am wondering: (1) shouldn't she respect my health care decision, regardless; and (2) is this truly genuine concern for me as the individual or rather, general discomfort on her part because I am challenging the protocol set forth by the ICBC*.  Or, could it be that she and Kato pulling a "good cop/bad cop" scene on me?

I walked out of there thinking that I am not feeling really comfortable about coming back to her. And I know I will not be gracing Kato's examining room again. . . . But hey, I got my $40 worth!!

Sidebar:

Radio-onc speaks to me about having only "one shot" at a cure (aka "remission"). She informs me that if and when the cancer recurs all that the ICBC* can do for me thereon is "maintenance." . . .Hmmm, I say.

I speak to her about the blood work my naturopathic onc ("nat-onc") conducted. How each and every one of the results were "perfect." And I instruct her that these were done while I had a malignant 6.2 cm tumor nestled into me. I share with her that nat-onc equated my results to those that would be expected from a tri-athlete who maintained a vegan diet. . . .Hmmm, she says.

Radio-onc speaks to me of the size of my tumor; and she clarifies that "tumor" and "cancer" are interchangeable labels, and that this should frighten me.. . . Hmmm, why?

I speak to her about how Kato lamented that he has had women with ILC that have a recurrence within 7, 8 and 10 years after diagnosis despite chemo. And, should not this fact frighten them? . . . Hmmm, she says.


* ICBC = Industrial Complex of Breast Cancer (see prior entries where this was fully explained.)

Breaking the Cookie ... ta-da-ta-da-ta-da-da- dum ...

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So. The inscrutable Kato (my medical oncologist) sat down with me yesterday morning. He smiles his worn smile and says: "based on the results of the Oncotype DX* test I would not benefit from chemotherapy." And, why the surprise? 

Rewind: this is the same onc who, if I had unquestioningly followed his prescribed standard of care protocol, would have started chemo . . . LAST WEEK! The "Red Devil"** being pushed first and heavy!

Rewind: the Oncotype DX is the test I researched, brought to him, and insisted be conducted!

Why the 180? Because ... ta-da-ta-da-ta-da-da- dum ... the Oncotype DX determined that my Recurrence Score ("RS") is 16 / 100.***
What does this mean, besides the fact that the toxic soup has been pulled from my menu? Well, women with a low risk RS will receive little, if any, benefit from chemotherapy after surgery. Hmmm...

So. I asked, why I had to ask for the Oncotype DX test to be done?
So. I asked, why was it not offered to me as a matter of protocol, especially in light of the 180 in his medical recommendations?

The inscrutable Kato simply and calmly stated, because my tumor was so large. "You see," he says, "The 'problem' with Oncotype testing is that it usually does not test tumors greater than 5 cm." Hmmm...

So. I asked, does the size of my tumor give him reason to question my RS score and the subsequent determination? He said: "No, not at all." Hmmm...?

Sidebar: When all of the MedPros thought my tumor was no larger than 5 cm not one of them, and certainly not Kato, even hinted at the possibility of Oncotype testing -- they spoke only of chemo and radiation -- and their incredulity that I did not want to do either. Additionally, post-mastectomy, I spoke directly to Genomic Health, the lab that conducts the test. I wanted to confirm the criteria of the test and applicability to my situation. I was told I was a "fit" -- all 6.2 cm of me.

Walking out of Kato's office yesterday I felt like I had just "dodged the proverbial bullet." More so than after and since the mastectomy.

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Side Notes:

* Women with early-stage invasive breast cancer receive a standard risk assessment that includes their age, stage of the cancer, grade and size of the tumor. New, sophisticated tests, such as MammaPrint+ and Oncotype DX allow women with estrogen receptor-positive, node-negative tumors to also obtain a refined risk assessment that predicts their risk of recurrence and how much chemo will help. In my situation, prior and up until the results of my Oncotype DX test results each and every one of my MedPro squad were adamant that I commence chemo within one-month after my mastectomy. Their argument: my age (47) since "younger" women have a statistically higher risk for recurrence; and the size of my tumor (6.2 cm).

** "Red Devil" (a.k.a. "Red Death") refers to Doxorubicin; trade name Adriamycin; also known as hydroxydaunorubicin). This lovely pharmaceutical has a plethora of side-effects. Acute side-effects can include nausea, vomiting, and heart arrhythmias. It can also cause a decrease in white blood cells (making you highly susceptible to infections), as well as complete hair loss. When the cumulative dose of doxorubicin reaches 550 mg/m², the risks of developing cardiac side effects, including congestive heart failure, dilated cardiomyopathy and death, dramatically increase.

*** The Recurrence Score, a number between 0 and 100, also signifies the likelihood of metastatic recurrence within 10 years of the initial diagnosis. An RS of 17 or below is considered "low risk," meaning the breast cancer has a low chance of recurring. My RS essentially states that out of 100 women, statistically, 16 will have a metastatic recurrence within 10 years. Will I be one of the 16? Well, even if I am, chemo won't be any help -- and most importantly, would not have had any impact even if I had opted for it presently.

+   MammaPrint is the European version of the Oncotype DX test. The biggest difference, however, is that to conduct a MammaPrint the tumor tissue has to be "fresh off the surgical site." The only place in the U.S. that you can have a MammaPrint conducted is ... ta-da-ta-da-ta-da-da- dum ... PHOENIX. Why? Because T-Gen, HQ'd here in Phoenix (where my surgery was done), just recently bought the MammaPrint patent. And, according to Kato, T-Gen reps are wining and dining all the Arizona breast cancer surgeons. Guess my surgical oncologist (one of the top 3 in the Phoenix area) must have missed (or had too much of ) either the wine or dine. (BTW - I asked Kato why he thinks I was not presented with the MammaPrint as an option. He smiled, and said: (did you guess?) "Probably because my tumor was so large" (!!!) ) Hmmm...

A Distant Drum Roll

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Either the well was very deep, or she fell very slowly, for she had plenty of time as she went down to look about her and to wonder what was going to happen next. - Alice in Wonderland

Tomorrow is oncology day - my first since the mastectomy. I start bright and early with the medical oncologist to go over the results of the PetScan (that I had to request) and the Oncotype DX test (that I insisted upon). After doing the conventional MedPro, I do a sit down with the naturopathic onc in the afternoon to go over same.

It's curious. Although we will be reviewing the same diagnostic instruments, the perspectives will most likely be at opposing ends of the spectrum. One will be offering me synthetics to address statistical probabilities; the other will be looking at how I got to this place and how to adjust my body to overcome my individualistic propensities.

Recap: Oncotype Dx is a unique diagnostic test that looks at the activity of 21 different genes in the tumor tissue and helps identify which women with early-stage, estrogen receptor positive and lymph node-negative breast cancer (this is me) are more likely to benefit from adding the toxic cocktail to their adjuvant treatment. It also helps to quantify the likelihood of recurrence for the individual woman (this is me too!...AS WELL AS each and every other individual woman who has stood where I am).

The results of the PetScan will not be a surprise. I snagged the written report from the onc's office on a drive-by 10 days ago. Nothing in those results, in my lay-opinion, justifies opening up my veins to the "red-devil."

It's the Oncotype that I am anxiously anticipating. These results are another integral piece to enable me (the patient / general health-care contractor) to make an informed decision as to adjuvant therapies.

Hmm, the anticipation raises another curious dichotomy. It appears that the distant "drum roll of anticipation" is both deafening and comforting when you find yourself free-falling down a "rabbit hole." Ta-da-Ta-da-Ta-da-da-dum!

Random Acts of Kindness - A New Year Reflection

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As I prepare for the upcoming new year, Rosh Hashanah, and the commensurate 10 days of teshuvah, I find my thoughts fixating not on thoughts of forgiveness, but rather appreciation.

THE single most important thing that I have experienced since my breast cancer diagnosis is the random act of kindness. The appreciation and gratitude that I feel cannot be overstated. Some of the acts have been done knowingly. Some have been inadvertent. Some have come from “expected” sources. Other acts have been from totally unexpected realms. All have been warmly welcome.

For someone who is professional (and emotionally) immersed in an area of law that daily exposes me to the ugly underbelly of human character (I am a children’s advocate whose professional and philanthropic endeavors are centered around abused and neglected children) I am not that accustomed to the kinder gentler side of the human condition. Additionally, as both a “Type-AAA+” and “care-taker” personality, I typically don’t allow myself to be on the receiving end of assistance. I suppose for me during these days of teshuvah, appreciation is a requisite step toward redemption.

As such, I have been blown away, and softened, by the large hearts that beat around me. To share just a few…

…the email support that I received from the lady who started the “Breast Camp Boot Camp” who communicated diligently with me from diagnosis to surgery. I wouldn't be able to pick her out of a police line-up (we have never met face-to-face), but her words were memorable. THANK YOU!

…the store manager and sales clerk at the Brighton boutique at the Chandler Fashion Center who gave me a selection of jewelry gift pouches to aesthetically conceal the “D-bombs” that were my forced companions up until this past Friday, asking only that I “get better.” THANK YOU!

…the additional complimentary weekly “house maintenance” offered by my cleaning lady of 6 years. THANK YOU!

…the “hospital care package” that a big-hearted lady gave me, that included a pound of dark chocolate (to be used for medicinal purposes only, oh yeah), a selection of Burt’s Bees lip balms, a super cute hospital cami (complete with skull & cross bones (eh ?????) and a “Don’t Lose Your Style” breast cancer survival book. One of the inadvertent “gifts” that was the “value-added” to this care package was NOT encasing it in the odious ICBC PINK. (she chose purple). The other, was found within the pages of the Style book that provided me with my first introduction to the existence of the Oncotype DX test! THANK YOU!

…the amazing meals that extremely busy friends brought over to our Phoenix home, both while I was hospitalized and afterwards. The ladies who went out of their way to care for my family and myself are those friends who, because we are all busy professionals and moms, cannot find social time for ourselves. Yet, despite their own stress-filled lives (and the fact that we have not had time even for a phone call all summer), brought meals that not only sustained the body, but truly nourished my family’s collective soul. (My 8-year old exclaimed his appreciation, rather dramatically, for one in particular. After he took his first mouthful he cried out joyfully “brisket made by G-d”.) THANK YOU!

…the flowers, letters, and cards from so many people, including the unexpected communications from my adopted-sibling’s mother; the mother of a chess team-mate of my 8 year old; and the 80-something year old cousin of mine that I have not seen in 45 years (and she's still alive and kicking!). THANK YOU!

…the diligent and caring, blog-following, communication, outreach and support, and pressies (some that made me blush and giggle) from old friends – even a couple from boarding school of who’s friendship had been dormant for 30 years, but rekindled without question. THANK YOU!

And so much more… THANK YOU! ... L’shanah tovah!

What is NOT wrong with this picture ?

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The phrase "above all, do no harm" is usually attributed to the Hippocratic Oath. Hmmm...if this is true, then it begs the question: what is NOT wrong with this picture . . . ?

I spent a full month researching and locating the "top" breast cancer specialists in Arizona. I narrowed the search down by personally interrogating (I mean, interviewing) the reported "best of the best." Those who made my final cut (OUCH!) were fully vetted. When I speak to the lay people involved in the ICBC, Inc.* I got, and still get, the collective nod of approval. (visualize bobble-head dolls.) This should give me peace of mind, no? (and I am not referring to the bobble heads). Having such a prestigious medical team should allow me the needed space to relax and trust in their learned opinions, right? After all, I chose them. So, if this is the case, then WHY is it...

...that I had to ask my medical oncologist to order a PetScan? Each varied member of the med-pro squad kept talking about the integral information that a PetScan can provide to assess the need and breadth of adjuvant treatments. Not to mention that the results would significantly add to the conversation of prognosis. Despite this apparent necessity not one of the Med-Squad wrote a script for a PetScan, until I insisted.

...that I had to request my medical oncologist send my tumor to the only lab in the U.S. that conducts an Oncotype DX test on malignant breast cancer tumors. Recall back to the PSA on August 31.. Why did I have to be the one to ask when my cancer, prima facie, fits the criteria to be tested. And, the results of this test can be a key factor in whether and what adjuvant treatment(s) would have the greater positive impact soup.

...that the "insurance compliance division" of the Oncotype DX lab is required to inform me, prior to running the test, that my health insurance policy (and I am talking about top-of-the-line PPO coverage) may not cover the cost of the test, unless the ICBC, Inc.*  is satisfied that the test is medically necessary?

Whaaaa ??? Rewind !!! Let's review the facts:

(1) According to a Journal report of the American Society of Clinical Oncology, 85% of patients don't benefit from chemo; and according to a talk this summer given by the head of the International Genome Consortium (Bob Pennie), the number is actually 90% of patients do not benefit;

(2) that the standard "cookie cutter" dispense of chemo is 8 cycles and the cost of the 8 cycles is 2x the cost of the Oncotype DX test;

(3) that the medications prescribed to help mitigate the nasty little side-effects of chemo can run up to 1/2 of the cost of the Oncotype DX test; and

4) that these same nasty little side-effects can create long term health issues that have the potential of running up unimaginable costs for both the insurance company as well as...oh yeah...the one with the cancer.

The silver lining to this disconnected thinking is that the Oncotype DX lab has its own in-house appeal division to deal with the idiocracy of the insurance company. The lab, Genomics in California, offers a free-of-charge 3-tier appeal process because they deal with this reactive thinking all the time.

Those who want to maintain the current health care status quo would point to the lab's "enlightened service" as an example of how the market system works. I.e, a need was identified and the market forces filled it!

Sigh...in my world, this mental myopia is a cancer in and of itself.

And what about the promoted adjuvant treatemtns...like, Tam-toxic-fen?

Tamoxifen is a "Selective Estrogen Receptor Modulator" intended to be prescribed to women with DCIS (ductal carcinoma in situ) -- a non-invasive disease, and which is reportedly 99% curable without Tamoxifen. This "wonder drug" has been proven to quickly cause thickening of the uterus - a precursor to uterine cancer. Indeed, Tamoxifen increases the risk of two types of cancer that can develop in the uterus: endometrial cancer, which arises in the lining of the uterus; and uterine sarcoma, which arises in the muscular wall of the uterus. In the initial trials of Tamoxifen in the 1970s, a significant amount of women died, not of their breast cancer, but of endometrial (uterine) cancer. Like all cancers, endometrial cancer and uterine sarcoma are potentially life-threatening. As such, the World Health Organization thought it prudent to list Tamoxifen as a "cancer-causing" drug. In addition, the Med-Pros appear to gloss over not only the 2x higher rates of endometrial cancer in women with breast cancer, but also the increased rates in blood clot diseases (pulmonary embolism, deep vein thrombosis, strokes) and cataracts caused by the drug.

Indeed, in most of the NCI (National Cancer Institute) study results that I have reviewed, there did not appear to be any statistically significant difference in the chance of dying whether or not a woman took Tamoxifen. Nor, did there appear to be a difference in breast cancer deaths overall. There are projections of long-term improvements in survival, but they are only projections. According to the National Women's Health Network's analysis of the Tamoxifen claims, if you take out unknown, unrelated, or non-GYN cancers, the exact same number of women appear to have died in both test groups. It is also known that minority women were not well represented in this study, in spite of efforts to do so. So whatever the final results may be, they may not apply to all women.

Across the pond, in Britain's reputable Lancet medical journal, a European study showed that when Tamoxifen was taken for the standard cookie cutter 5-years, the risk of uterine cancer increased by 6.9%, and, the developed cancer was of a more deadly strain. Benraadt , Coenbergh W et al. Risk of endometrial cancer after tamoxifen treatment of …FE Van Leeuwen - … Risk of endometrial cancer after tamoxifen treatment

According to the University of Virginia School of Medicine, risk factors for endometrial cancers include: "being treated with tamoxifen for breast cancer, age 40 or over, personal history of breast cancer...."

Estronaut's assessment of Tamoxifen as a prophylactic drug play out similarly: "Taking Tamoxifen preventively simply trades one disease for another, one cause of death for another. The disease a woman trades for may be worse beyond the absolute numbers. Blood clots can cause immediate death and permanent disability. With breast cancer there is the possibility of cure or at more years of life."

So where does this translate into my situation?

First and foremost, given my lack of family history and health risks, I am in the less than 1% grouping already when it comes to my diagnosis of Invasive Lobular Carcinoma. So, again, the statistical significance of a more than 1% risk factor is not lost on me.

Second, I am in a "complex" subset grouping because of my age in developing ILC and due to the large size of my tumor (6.2 cm).

Third, although ILC can be slow to metastasize to the ovaries, my tumor markedly increased in size from diagnosis on July 8, 2009 to surgery on August 21, 2009. Ovarian cancer, while not in the classification of endometrial cancer, is in close enough physiological proximity that it gives me pause.

Lastly, thus far, I have yet to be presented with any tangible facts or reason to ingest Tamoxifen, or any other chemical for that matter, other than the size of my tumor...which was surgically removed with the rest of my left breast.

Consequently, as a woman diagnosed with ILC, if I were to ingest Tamoxifen for the standard 5 year plan, from where I sit I have a greater risk of developing uterine cancer as my blood payment for the "cure." The ICBC's solution to such a dilemma (actually told to me on two separate occasions -- with a straight-face no less) ... a prophylactic hysterectomy!

AHH!...now that is an enlightened market-based solution!


*ICBC, Inc. - Industrial Complex of Breast Cancer, Incorporated, a phrase coined by me to encompass the anomaly of the profit making industry that shrouds the study and treatment of breast cancer.

PSA - Oncotype DX Test for Breast Cancer

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Living with breast cancer is challenging for millions of women today. Some new ways of evaluating the likelihood that breast cancer will recur may allow doctors to determine who might benefit most from chemotherapy and other treatments.

With any cancer, the tumor cells divide uncontrollably. Cancer cells can then invade nearby tissues and spread through the bloodstream and lymphatic system to other parts of the body (called metastasizing). To kill cancer cells, doctors have routinely given patients with breast cancer the standard prescription: tumor removal via mastectomy or sometimes lumpectomy, usually followed by radiation and chemotherapy.

Until now, doctors have not been able to tell which women are at higher risk for breast cancer recurrence. Rather than take chances, every patient received the standard course of chemotherapy, which often has toxic side effects for many patients.

As we've learned more about cancer, researchers now realize that not all women with early breast cancer, including stage I and II, lymph node-negative breast cancer, actually benefit from adjuvant systemic therapy, which refers to chemotherapy, hormone therapy, and/or the drug trastuzumab (Herceptin).

Not All Breast Cancer Is the Same

More researchers are now thinking that not all breast cancers should be treated the same. Through findings from breast cancer clinical trials, scientists are discovering they can do a risk analysis of each woman's particular cancer and then base the outcome of breast cancer therapy (and specific type of therapy) upon the estimated risk of breast cancer recurrence.

Using a tool called the Recurrence Score, scientists are learning to quantify the likelihood of breast cancer recurrence in women with node-negative, estrogen receptor-positive (ER+) breast cancer and also predict the extent of chemotherapy benefit. While chemotherapy is necessary for some types of breast cancer, it may not be necessary for other types. And that's where the Oncotype DX test comes into play.

Breast Cancer and Oncotype DX

Oncotype DX is a diagnostic test that assesses the tumor tissue and estimates the likelihood that invasive breast cancer will return, or recur after treatment. By analyzing the expression pattern of certain genes in breast tumors, the Oncotype DX test can more precisely estimate a woman's risk of cancer recurrence when compared with the standard assessments doctors normally use to evaluate the risk of cancer returning.

The Oncotype DX screening test is performed on each tumor sample to get the Recurrence Score. The Oncotype DX test scores the breast tumor on 21 different genes involved in breast cancer and gives a Recurrence Score, or a number between 0 and 100 that shows a the chance of the breast cancer returning within 10 years of the original diagnosis.

The Recurrence Score is then categorized into one of three groups: low, intermediate, or high risk. For example, if a tumor has a Recurrence Score over 31, a high-risk score, this means there's a greater chance that the breast cancer will return. If a tumor gets a Recurrence Score of 18 or less, a low-risk score, this signals a lower chance that the breast cancer will return.
Using the Recurrence Score as a measure of risk, researchers now acknowledge a correlation between the score and the type of cancer treatment that is required. For example, with a low Recurrence Score, hormone therapy alone may successfully treat the woman's cancer. Alternately, a high Recurrence Score indicates a greater chance of the breast cancer returning, so the patient may benefit from adjuvant systemic therapy, including chemotherapy.

Who Might Benefit From the Oncotype DX Test?

The Oncotype DX test is recommended for breast cancer patients who are newly diagnosed, node-negative, estrogen receptor-positive, stage I or II, and who will be treated with tamoxifen, a selective estrogen-receptor modulator (SERM). Early findings from prospective trials indicate that a low Recurrence Score may determine which patients with ER+, node-negative breast cancer do not need chemotherapy.

The TAILORx TRIAL for Breast Cancer

More clinical trials are ongoing testing the Oncotype DX test. A groundbreaking clinical trial known as TAILORx is using the Oncotype DX test to see if some of the genes involved in breast cancer recurrence can also determine the need for chemotherapy -- and, more importantly, who will do better without it.The eventual results will help doctors recommend therapy that's based on the unique characteristics of each breast cancer tumor so they can maximize both effectiveness and safety in breast cancer treatment.

Use of the Oncotype DX test is limited to women with estrogen receptor-positive, node-negative breast cancer to help doctors determine if they can avoid the toxicity of chemotherapy if they have a low Recurrence Score. If women still want to undergo chemotherapy, that's a choice they can make with their oncologists.

Future Trends in Breast Cancer Treatment

In the near future, scientists predict the Recurrence Score may be used on other types of cancer, thus aiding doctors in prescribing individualized treatment that is safe and effective for cancer patients. A web-based tool called Adjuvant! Online allows doctors to incorporate the Recurrence Score from an Oncotype DX test to determine the benefit of chemotherapy in women with node-negative, ER-positive breast cancer. Using data from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute, and from the year 2000 analysis of the Early Breast Cancer Trialists Collaborative Group (EBCTCG) findings, along with a proprietary formula, Adjuvant! Online can assist doctors in estimating each patient's prognosis and the benefit of adjuvant systemic treatment.

Reprinted from Web