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Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ?

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Practicing since : 2002
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Hi, I am a 35 year old unmarried girl & also sexually inactive. I have been detected with Invasive Ductal Carcinoma, Grade II of Modified Bloom Richardson Variety. 5 out of 24 lymph nodes extracted show metastatic carcinoma. My very good doc has recommeded 7 cycles of chemo. my question is: is chemo the ONLY way forward or can medication or radiation address my situation ? await your advice. thanks
Posted Sat, 14 Apr 2012 in Breast Cancer
Answered by Dr. Robert Galamaga 5 hours later
Hello there,
My first question to you is - was your tumor tested for estrogen receptor, progesterone receptor or Her2-NEU receptor? I ask this because there are medical therapies which target these receptors to decrease the risk of recurrence of disease after chemotherapy. I certainly agree with chemotherapy which is usually for 6 to 8 cycles.

Radiation to the chest wall and regional lymph nodes is a consideration as well and I would encourage you to consult with a radiation oncologist who can discuss the benefits of this line of therapy in addition to chemotherapy.

Again regarding receptor status - the receptor status is important to determine because if you do have estrogen or progesterone receptor positive, we often recommend medical therapy for 5 years or more after the surgery.

I hope I have adequately addressed your concern here. I am available for your followups.
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Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 4 hours later
Thanks Doc. To answer your questions. My
ER : Positive (90%)
PR : Positive (90%)
Herceptin Test (HER2/NEU/C-ERB B2 - XXXXXXX Domain) : Negative (0)
Ki-67 Positive (18%)

So as i understand chemo therapy is the way to go, right ? So, How do i undestand possibilities of loco reginal recurrence? I reckon that if the percentage of something(?cant remember) is less than 15% then possibility of recurrence is low ? HOw do i validate that chemo WILL INDEED eliminate chances of recurrence or will i need additional therapies after that too ?
-should i opt for 4 sessions or 7 sessions. I do realise that 7 sessions may be stronger or should i go ahead with 7 sessions ?
- How will i know whether i need o go for Radio therapy or Hormone therapy after Chemo therapy ?

I have broken my Large query into smaller questions, to be able to undertsnad it comprehensively. SInce we are speaking only via mail, here are some facts you could need:i am a petite built person with a bust line of 32A. Weight 50 Kilos.

Eagerly await your revert.

Thanks V Much ! Pallavi
Answered by Dr. Robert Galamaga 1 hour later
Hello again,

I will address your followups.

Yes, your recurrence may be 15% or less and no one will tell you any chance is eliminated.

What we can due is diminish the likelihood of recurrence as much as possible with the chemo and other therapies such as hormonal therapy and or radiation. Locoregional recurrence just refers to the possibility that any remaining cancer cells in the region of the primary tumor would develop again into a tumor.

1) Chemotherapy - I would advocate a more aggressive 7 cycle course. You are young, fit and able to tolerate this and it will further decrease the chances that you would have residual cancer cells in your body.

2) Radiation therapy - This should be discussed with a radiation oncologist.
Let me give you a link which will further help you understand the consideration of radiation. This is an excellent resource and I encourage you to review their information. WWW.WWWW.WW I strongly urge you to obtain the opinion of a radiation oncologist regarding this and before you start chemo if possible.

3) Hormone receptor status. Having ER and PR receptor strongly positive is a good thing and you will likely start hormonal therapy in the form of tamoxifen or estrogen receptor drug which will again further diminish likelihood of recurrence. This therapy typically goes for 5 years or more.
You will absolutely need this therapy and your oncologist will discuss this with you.

Thank you for your followup question. I am available if you have additional queries.
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Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 4 days later
Hi Doc, my oncologist has recommended the following medicines for my Chemotherapy. Could nor read doctor'shandwriting well hence my quesion XXXXXXX against two names :)

Epizubie (?)
Cyoxan / Endoxon (?)

- what factors will tell me that i am progressing well with my chemo cycles ?
- What side effects of these drugs can i anticipate ?
- what are the key Dos & Donts, esp wrt diet as everyone is pshyching me out that i should constantly eat since chemo will weaken me. Family is dumping food in my mouth almost every hour (grrr...)
- any specific precautions that are MUST to take ?
- can i have a drink to celebrate my fight against the big C in beween chemo?

Thanks a on in advance !

Rgds, Pallavi
Answered by Dr. Robert Galamaga 4 hours later
Hello again,

To address your followups:
In order to assess your progress your doctor will monitor your kidney function, electrolytes and blood counts. I am sure you will do fine. Occasionally the chemo is held for a day or two if blood counts dip a bit but generally the chemo is well tolerated.

You can anticipate the followuing side effects - but again every patient will tolerate the drugs differently: A bit of nausea and perhaps some vomiting - the doctor should give you some medicines to help prevent and treat this. Some hair loss can also be seen. Fatigue is expected - especially later in the course of therapy, but your body will recover after you complete your treatments.

Eat a well balanced diet and stay well hydrated. I would avoid taking lots of herbals or supplements and just take what your doctor recommends for now. Go for walks and keep active as well. Theres no reason for you to lay in bed while being treated!

As far as something you MUST do: Remain positive! Your positive thinking is as important as any chemotherapy we provide. You must stay in contact with good support like friends and family. They will help you fight this cancer! You must also tell your doctor if you aren't feeling well or if you have more nausea or vomiting or diarrhea etc. Sometimes patients are afraid to bother us - but believe me, your oncologist wants to know these things if they are happening!

You can absolutely celebrate with a drink to celebrate your brave fight between cycles, a fight I sincerely believe you can win!! I am sure you will do well XXXXXXX

I wish you again all the best and continued good health and positive thinking.
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Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 8 hours later
Thanks v much doc.

I am keeping as positive a head as is possible and will take the big C by its horns.
I will be moving my bsse for a few months to a city where my family is which means my medical and ratiation oncologist will be different from my surgeon.I will take the prescription from my surgeon to the medical onco. How often and regulary should I have the two speak to eachother ? And more importantly what should they be dicussing about my progress between my chemos' ?
- I guess I should also XXXXXXX & with the Radiation oncologist befre I start my chemo to set up a schedule etc or meeting AFTER chemo is over is a better idea ?
- how hoes hormone therapy work ? How does having ER & PR positive make it a good thing ?

Thanks again, XXXXXXX
Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 5 hours later
DOC, one more thing.

A doctor recommended BRCA Test I & 2 that i should get done ? My oncologist has no recommended. Do you think i should ? Also if you recommend that i do, is there also a preferred time i.e. bfre chemo starts or any such time.

Is it also related to ER/PR positive ?


Rgds, Pallavi

Answered by Dr. Robert Galamaga 18 hours later
Hello again,
I would try to see the rad onc specialist sooner rather than later. I think it's a good idea to have all the specialists familiar with your situation before you go forward. He or she can then tell you if they would like to see you after the chemo or not. Your specialists should communicate with each other via written correspondence with each visit you have. That way they are all up to date with what is going on with you. They will discuss your progress and if any changes need to be made.

Having ER or PR makes it a good thing because these represent targets for the hormonal meds. The hormonal med will attach to the ER or PR receptor on remaining tumor cells and cause them to shrink away and die. If you did not have the ER or PR then the hormonal med wouldnt work on your tumor. The hormonal med is very tolerable as well which makes it even better.

I think having BRCA testing is a reasonable idea but it is unlikely to be positive since you have ER/PR positive cancer. It is more likely to be positive in a case where ER and PR are negative. It doesnt matter if u have it before or after your treatment - you can get it done anytime.
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Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 35 days later
Hi Doc, how are you ?

I have already undergone two rounds of Chemo & have 6 more to go. My Med Onco has put me on Dose Dense, so i get my therapy on the 22nd day or the 1st day of the 3rd week. My 1st 4 therapies are with a mix of Adriaycin & Endoxan (Cyclophosphamide). the remaining four therapies will be with another medicine. One one day after the chemo i am being administered Nupeg 6 mg or peg-Grafeel.

Guess the above sounds like a fien regimen ? your comments!

I am getting blood tests & liver & Kidney function tests on the 7th day of the chemo & one day bfre the day of chemo. Does the frequency of the tests sound fine. the other question i had for you is what are the specific things one should look for in the blood tests : And most importantly which specific white blood cells as there are 5 types of White blood cells ? i guess neurophils is the key ones ? What role does haemoglobin play in ensuring that the patient is ready for the dose fo therapy ?

i am have a tonic to up my HB count but it makes me very gassy. are there any specific food items i MUST have & can include in my diet & ensure that my HB stays at desired levels ?

Lastly, i noiced that you are a hematologist - is that the same or close to a med oncologist ? just wondering :-)

overall i am holding up fine so far. Thanks in advance for your answers :-)

rgds, Pallavi
Answered by Dr. Robert Galamaga 7 hours later
Hello again! It's great to hear from you and learn of your progress.

It sounds very much like your oncologist is treating you with an excellent standard regimen again with curative intent. I am glad to hear you are receiving the neupogen as well as this will decrease the likelihood of your white blood cell count remaining low for extended periods. This is an excellent regimen.

The blood tests that are being done are very similar to how we monitor things in my clinic. In the blood tests they are making sure your liver and kidney functions remain adequate, As for the blood count, you are correct - the neutrophil is the key cell as we regard this as the primary defense against infections. Hemoglobin may be affected by your chemo and your oncologist is just making sure that it doesn't drop too low which would make you feel tired, subsequently making additional chemo more difficult to tolerate. On rare occasions, we might delay chemo by a few days if the counts are a bit low.

As for the diet - foods XXXXXXX in iron and vitamin B would be recommended. XXXXXXX leafy vegetables and red meat are good sources of this. If you are vegetarian, sometimes we have the patient take a multivitamin or an iron supplement as well. A good balanced diet is really usually all you need.

As for the term hematologist in my case, I am trained in hematology and oncology so am sometimes referred to as hematologist, oncologist or hemato-oncologist.

It sounds like you are holding up very well. This is fantastic news. I encourage you to remain optimistic - positive thinking is as important as any medication!! I am confident you will do extremely well XXXXXXX

Best regards and again it was great to hear from you and learn of your progress.
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Follow-up: Invasive Ductal Carcinoma, 5 out of 24 lymph nodes extracted, chemotherapy the right option ? 24 hours later
thanks for your encouraging words doc. i have trivialised the big C in my mind & my mantra which is working quite well is One day at a Time.

So now a few more questions :) One of my doctor friends suggested that I should start on some Folvite (folic acid) which i have. In addition he also suggested the following:
- Proton Pump Inhibitors - drugs like femera & Tomoxicin
- Anti Oxidants - Co Q
- Non Steroidal Pain Killers - Mex Pro & NH2

Pain killer i can understand, Hwr for PPI & Anti oxidant my question is should i start taking these daily ? is it okay to include them in my daily medication & if so in what what quantities ?

In addition i am developing some sort of brown stains in between my teethe & on teh edged near the gums. I know that people react differently to chemo therpay and i also plan to go see a dentist. But is that something you have seen in your experience ? aand if Yes then is there something i can do already to mitigate the staining. (i end up scrubbing my teeth almost wth a vengenance each time i brush :)

Lastly, what cna i have for a mild cold. Very Little running nose and a slight sore throat ?

Thanks again as usual :)

Answered by Dr. Robert Galamaga 1 hour later
Hello there.

I see no problem with the folic acid supplement - you can take that safely with no problem.
As for the PPI therapy - omeprazole or Prilosec is a good one - if you are having symptoms of acid reflux. In the absence of symptoms, I see no need just yet for these.

CoQ10 is fine, But i would wait until after chemo is done to start this medication. We are not entirely sure if this medication has any impact in how the chemo works.

So, I would not recommend CoQ10 just yet and the PPI only if you have acid reflux symptoms.

As for the staining of gums I have seen this in a limited number of patients. It is not worrisome to me and I suspect it may even resolve after treatment is done. I think it is a good idea to consult with your dentist as well regarding this. Good dental hygiene - brushing thrice daily and perhaps a mouthwash as well would be all I recommend along those lines. I would advise against brushing too vigorously as that may cause bleeding and inflammation of the gums.

For the mild cold, supportive care with some good hydration, tylenol cold and sinus preparation and some extra rest at home are what I would advise.

Always a pleasure XXXXXXX Have a great day.
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