Should My 67-Year-Old Mother with 1cm Breast Cancer Undergo Chemotherapy?

Q: Should My 67-Year-Old Mother with 1cm Breast Cancer Undergo Chemotherapy?

Hello Ms. <br>Lai： Whether adjuvant chemotherapy is needed after breast cancer surgery primarily depends on the tumor size. <br>For example, if the tumor is larger than 1 cm or there is axillary lymph node metastasis, adjuvant chemotherapy is recommended. <br>Here, it is importan

Breast cancer measuring 1 cm without metastasis, uncertain whether to undergo chemotherapy?

Dear Dr.
Lai,
My mother is currently 67 years old and has hypertension.
She is continuously taking medications including Clonidine, Bisoprolol, and Amlodipine.
She also has bone spur issues and poor leg strength.
In July, a black spot was detected in her left breast, and a biopsy confirmed it to be a malignant tumor.
The tumor was surgically removed in August, and lymph node testing was performed.
The current results indicate that the tumor is 1 cm in size and has not metastasized.
The subsequent treatment plan includes radiation therapy along with hormone therapy, and there is no need for targeted therapy.

However, we are quite hesitant regarding chemotherapy.
The doctor mentioned that 1 cm is the critical point, where the decision to proceed or not is ambiguous, and advised the family to consider it carefully.
Since we are not well-informed about this matter, we are quite uncertain ourselves.
We hope Dr.
Lai can provide advice on whether chemotherapy should be pursued.
Our family will discuss this further.
Thank you very much!
ER: Positive (93% tumor cells with nuclear staining) (Ab: Novocastra, clone 6F11)
PR: Positive (94% tumor cells with nuclear staining) (Ab: Novocastra, clone 16)
Her-2/Neu: Negative (0 scored by 2013 CAP guideline) (Ab: Zeta, clone SP3)
Ki-67: 18% nuclear staining (Ab: Gemened, clone GM001)
E-cadherin: Done.

Lai Xiaojie, 30~39 year old female. Ask Date: 2018/08/30

Dr. Lai Yicheng reply Oncology

Hello Ms.
Lai: Whether adjuvant chemotherapy is needed after breast cancer surgery primarily depends on the tumor size.
For example, if the tumor is larger than 1 cm or there is axillary lymph node metastasis, adjuvant chemotherapy is recommended.
Here, it is important to explain the concept of sentinel lymph nodes, which is that "lymphatic drainage is sequential." Therefore, in cases where there is no suspicion of lymph node metastasis during clinical examination, the physician can first inject a dye or use isotopes to locate the first one or two lymph nodes in the patient's lymphatic drainage pathway, and then these lymph nodes can be sent for examination to check for evidence of cancer metastasis.
If the closest lymph nodes to the tumor show no cancer metastasis, we consider the remaining lymph nodes to be healthy and surgery to remove them is not necessary.
If the sentinel lymph nodes are confirmed to have cancer metastasis, further axillary lymph node dissection surgery is required.
It should be noted that although we explain surgical treatment in terms of tumor and lymph nodes, these procedures are performed simultaneously.

In recent years, clinical findings have shown that a small number of breast cancer patients with tumors smaller than 1 cm and no axillary lymph node metastasis may experience recurrence and metastasis that threatens life 2 to 3 years, or even 5 years after surgery.
Therefore, there is a tendency to use more testing and analysis to assess the risk of breast cancer recurrence, including hormone receptors, HER-2/neu, tumor differentiation grade, Ki-67 proliferation index, and whether cancer cells invade lymphatic vessels or microvessels, to determine whether adjuvant chemotherapy should be recommended.
Hormone receptors include ER and PR, while HER-2/neu refers to human epidermal growth factor receptor 2; if positive, it is considered to have a higher risk of recurrence and treatment resistance, necessitating the addition of targeted therapy against HER2 beyond traditional chemotherapy.
Tumor differentiation grade typically indicates grade 1 as well-differentiated cells, grade 2 as moderately differentiated, and grade 3 as poorly differentiated.
Ki-67 is a tumor proliferation index; a higher value indicates a faster rate of tumor cell division and growth.
Second or third-grade differentiation, a higher proliferation index, HER2 overexpression, and invasion of lymphatic or microvessels all represent a potentially higher risk of recurrence.

Additionally, family history and age must be considered; for instance, if maternal relatives such as mothers, aunts, or sisters have had breast cancer, the patient is in a high-risk group.
Breast cancer diagnosed under the age of 40 is considered young-onset breast cancer, which also carries a higher risk of recurrence.
The aforementioned predictive tools and risk factors must be assessed in conjunction with the patient's condition.
This is somewhat akin to fortune-telling, but it is done scientifically, based on data obtained from research to make predictions.
There are even new genetic tests that can be sent abroad to analyze various genes in tumor cells, such as OncoType Dx and MammaPrint, which provide scores to evaluate recurrence risk and suggest treatment recommendations based on those scores.

*Chemotherapy is not required if the patient meets the following conditions: the tumor is less than 2 cm, the cells are of low malignancy, hormone receptors are positive, HER2 receptor is negative, and tumor cells have not invaded the lymphatic or vascular system.
If the pathological type is mucinous, tubular, or typical medullary carcinoma, chemotherapy may not be needed for tumors under 3 cm.

*All breast cancer patients with hormone-positive cells are recommended to receive hormone therapy to reduce the recurrence rate.

Thank you for your inquiry.

Dr.
Yi-Cheng Lai, Department of Radiation Oncology, Changhua Hospital.

Reply Date: 2018/08/30

More Info

When considering whether your 67-year-old mother should undergo chemotherapy for her recently diagnosed breast cancer, there are several important factors to take into account. Based on the information provided, your mother has a 1 cm tumor that is ER-positive, PR-positive, and HER2-negative, with a Ki-67 index of 18%. The absence of lymph node involvement is also a significant factor in her prognosis.

Understanding the Treatment Landscape
1. Tumor Characteristics: The tumor size of 1 cm is indeed at a critical threshold where the decision to administer chemotherapy can be nuanced. The hormone receptor status (ER and PR positive) suggests that your mother’s cancer is likely to respond well to hormone therapy, which is a cornerstone of treatment for hormone receptor-positive breast cancer. HER2-negative status further indicates that targeted therapies like trastuzumab (Herceptin) are not applicable.

2. Ki-67 Index: The Ki-67 index of 18% indicates a moderate level of cell proliferation. While a higher Ki-67 percentage often correlates with a more aggressive tumor and a higher likelihood of recurrence, an 18% score is generally considered to be on the lower end of the spectrum. This suggests that the tumor may not be as aggressive as those with higher Ki-67 levels.

3. Age and Comorbidities: Your mother’s age and existing health conditions, such as hypertension and mobility issues, must also be considered. Chemotherapy can have significant side effects, particularly in older adults, and these can be exacerbated by pre-existing health conditions. The potential for increased morbidity from chemotherapy must be weighed against the potential benefits.

Recommendations
Given these factors, here are some recommendations:
1. Consultation with Oncologist: It is crucial to have a detailed discussion with her oncologist about the risks and benefits of chemotherapy in her specific case. The oncologist can provide insights based on the latest clinical guidelines and research, as well as her overall health status.

2. Consider Hormonal Therapy: Since her tumor is hormone receptor-positive, initiating hormonal therapy (such as tamoxifen or an aromatase inhibitor) is essential. This treatment can significantly reduce the risk of recurrence and is often recommended regardless of chemotherapy decisions.

3. Evaluate Chemotherapy Necessity: If the oncologist believes that the risk of recurrence is low due to the tumor's characteristics and the absence of lymph node involvement, they may suggest forgoing chemotherapy in favor of close monitoring and hormonal therapy. However, if there are concerns about the aggressiveness of the cancer or other risk factors, chemotherapy might still be recommended.

4. Second Opinion: If there is uncertainty or discomfort with the treatment plan, seeking a second opinion from another oncologist can provide additional perspectives and help in making an informed decision.

5. Monitoring and Follow-Up: Regardless of the treatment path chosen, regular follow-up appointments and monitoring will be essential to ensure that any changes in her condition are promptly addressed.

Conclusion
Ultimately, the decision regarding chemotherapy should be made collaboratively with her healthcare team, taking into account her specific cancer characteristics, overall health, and personal preferences. The goal is to ensure the best possible outcome while maintaining her quality of life. It’s commendable that you are actively seeking information and considering all options for your mother’s care.

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