Do Patients with Stage 1A Breast Cancer Need Chemotherapy After Surgery?

For breast cancer staged as 1A N0(i) M0 after complete surgical resection, the need for chemotherapy or targeted therapy depends on several factors, including the tumor's hormone receptor status (estrogen and progesterone receptors), HER2 status, and the patient's overall health and preferences. Typically, early-stage breast cancer with no lymph node involvement may not require chemotherapy, but adjuvant therapy could be considered based on the specific characteristics of the tumor. It is essential to discuss

Dear Doctor,
My friend, who is 48 years old, underwent a core needle biopsy of the left breast at Chang Gung Memorial Hospital on December 17, 2017.
The report indicated ductal carcinoma in situ (DCIS), with ER (0%), PR (0%), HER2 (strong +), and high grade.
Due to distance, she chose to seek treatment at Tzu Chi Hospital in Taichung, where she was re-diagnosed.
On January 5, 2018, she underwent a left total mastectomy, with a clinical stage of I and sentinel lymph node dissection.
The pathological staging was pT1mi(3)N0(i)(sn)M0, Stage p1A, with microinvasive invasive ductal carcinoma (miIDC) foci (3) + DCIS Grade II-III (intermediate to high) comedo + cribriform + papillary, EIC mi.cal (Tis, N) L0V0Pn0.
The sentinel lymph node showed isolated tumor cells (1/1), pN0(i).
The IHC molecular testing results were ER (0%), PR (0%), but there was no description of HER2.
I asked the doctor why there was no HER2 assessment at Tzu Chi when it was reported as strong + at Chang Gung.
The doctor explained that HER2 testing is generally not required for DCIS, and for IDC, the small amount of invasive cells may not allow for HER2 detection.
Currently, the doctor recommends regular follow-up visits without further treatment, suggesting that treatment would only be necessary if there is a recurrence.
However, I am concerned about the possibility of microscopic invasion in the sentinel lymph node, along with the grading of Grade II-III (intermediate to high).
Therefore, I would like to ask you:
1) Are there any additional treatment recommendations (such as chemotherapy or out-of-pocket targeted therapies) to reduce the risk of recurrence, or is regular follow-up sufficient?
2) What is the likelihood of recurrence for this pT1mi(3)N0(i) staging with high-grade cellular differentiation? If a recurrence occurs in the future, given that the left breast has been completely removed, how can we determine if the IHC molecular testing still shows ER (0%), PR (0%), and HER2 (+ or -)? Would it be necessary to perform another biopsy at the site of recurrence for confirmation and differentiation?
Thank you for taking the time to address my concerns!

LISA, 40~49 year old female. Ask Date: 2018/02/05

Dr. Lai Yicheng reply Oncology

Dear Miss LISA,
I have received your letter and appreciate the detailed information you provided.
Here is a summary of the findings:
1.
Your friend has Stage IA breast cancer, not in situ carcinoma.
2.
Tumor characteristics: the tumor measures ≤ 1 mm, with three foci.
3.
Lymph node involvement: sentinel lymph node measures ≤ 0.2 mm, with one lymph node showing invasion.
4.
Hormone receptor status: negative.
5.
HER2/neu status: positive.
6.
Histological grade: high grade.
Based on this information, although your friend has Stage IA breast cancer, she has three "unfavorable" prognostic factors: hormone receptor negativity, HER2/neu positivity, and high grade.
According to American breast cancer treatment guidelines, early-stage breast cancer patients with hormone receptor-negative and HER2-positive status, with tumors measuring ≤ 0.5 cm, including microscopic disease in axillary lymph nodes, may be considered for chemotherapy and targeted therapy.
My recommendation for your friend is to be proactive in her treatment since she is still young; please discuss this further with her physician.
Wishing her a speedy recovery.
Dr.
Lai Yi-Cheng
Department of Radiation Oncology
Changhua Hospital

Reply Date: 2018/02/05

More Info

When considering whether patients with Stage 1A breast cancer need chemotherapy after surgery, several factors must be taken into account, including the specific characteristics of the tumor, the patient's overall health, and the potential risks and benefits of chemotherapy.

In the case presented, the patient has been diagnosed with invasive ductal carcinoma (IDC) with microinvasion, characterized by high-grade features and negative hormone receptor status (ER and PR both at 0%). The HER2 status is also critical, as HER2-positive cancers tend to be more aggressive but can be targeted with specific therapies like trastuzumab (Herceptin). The presence of isolated tumor cells in the sentinel lymph node (pN0(i)) indicates a very early stage of lymphatic involvement, which complicates the decision-making process regarding adjuvant therapy.

1. Need for Additional Treatment: The recommendation for chemotherapy or targeted therapy after surgery often depends on the tumor's biological characteristics and the risk of recurrence. In this case, the patient's high-grade tumor and the presence of microinvasion suggest a higher risk of recurrence compared to lower-grade tumors. However, the absence of lymph node metastasis (pN0) and the fact that the tumor is classified as Stage 1A may lead some oncologists to recommend observation rather than aggressive treatment. The decision to pursue chemotherapy or targeted therapy should be made collaboratively with the oncologist, considering the patient's preferences, potential side effects, and the latest clinical guidelines.

2. Recurrence Risk: The recurrence risk for a patient with pT1mi (microinvasive) and high-grade IDC can vary. Generally, high-grade tumors have a higher likelihood of recurrence compared to low-grade tumors. Studies suggest that the recurrence rate for high-grade tumors can be significant, especially within the first five years post-treatment. The isolated tumor cells in the sentinel lymph node may also indicate a slightly elevated risk, but the overall prognosis remains favorable for Stage 1A breast cancer, especially with appropriate follow-up.

3. Monitoring for Recurrence: After a breast cancer diagnosis and treatment, regular follow-up appointments are essential. If the cancer were to recur, it is crucial to perform a biopsy of the new lesion to determine its receptor status accurately. This would involve repeating immunohistochemistry (IHC) tests to assess ER, PR, and HER2 status, as these can change over time. The recurrence may present differently, and the treatment plan would be adjusted based on the new tumor characteristics.

In conclusion, while the current recommendation is to monitor the patient with regular follow-ups, it is essential to have an open dialogue with the healthcare team about the potential benefits of chemotherapy or targeted therapy, especially given the tumor's high-grade nature and the isolated tumor cells in the lymph node. Each case is unique, and treatment decisions should be personalized based on the patient's specific circumstances and preferences. Regular monitoring and prompt evaluation of any new symptoms or changes are crucial for managing the risk of recurrence effectively.

Similar Q&A

Do I Need Chemotherapy After Stage 1 Breast Cancer Surgery?

I have stage I breast cancer, have already undergone surgery, and my cancer markers are normal. Do I still need to undergo chemotherapy?

Dr. Lai Yicheng reply Oncology
Dear Ms. Cola, Thank you for your letter. The treatment for breast cancer depends on the degree of cellular differentiation indicated in your pathology report, which may lead to different approaches and treatment plans. Since I have not reviewed your pathology report, I cannot p...

Do I Need Chemotherapy for Early Stage Breast Cancer?

Stage I breast cancer, partial mastectomy, PR negative, ER positive (90%), Her-2/neu protein: without overexpression (score 1+), Ki-67: ~15% labeling index, 50 years old, perimenopausal, tumor size less than 1 cm (0.8 x 0.7 x 0.6), nuclear grade: 3, no lymph node metastasis. Is c...

Dr. Lai Yicheng reply Oncology
Dear Ms. Wu, Breast cancer treatment primarily involves surgical intervention, with radiation therapy, chemotherapy, and hormone therapy as adjuncts. For Stage I: when the tumor is less than two centimeters and has not metastasized beyond the breast, surgical removal of the br...

Understanding the Necessity of Chemotherapy and Targeted Therapy for Early-Stage Breast Cancer

Hello Doctor: I would like to ask about my sister, who has stage I breast cancer. She has already undergone a mastectomy and axillary lymph node dissection, and tests show that the cancer cells have not spread. However, there is a risk of recurrence, and the doctor has recommende...

Dr. Lai Yicheng reply Oncology
Hello, Miss: Thank you for your inquiry. In response, it was mentioned that your sister is in stage I of breast cancer and has undergone a total mastectomy and axillary lymph node dissection. For a detailed assessment, we will need to review your pathology report. If necessary, p...

Understanding the Decision Against Chemotherapy After Breast Cancer Surgery

The physician believes that chemotherapy is not necessary after the right mastectomy because the tumor extent is minimal at 0.1 cm and the tumor grade is intermediate (Grade 2). Although the pathology report shows that both estrogen receptor (ER) and progesterone receptor (PR) ar...

Dr. Zhou Jiazhen reply Breast and Thyroid
Dear Mei, 1. Have you undergone chemotherapy or other treatments prior to the surgery? This is important because there is a residual tumor of 0.1 cm. If not, please provide the size of the tumor, whether there is lymph node metastasis, and the stage of the tumor. 2. HER-2-neu: ...