Post-Chemotherapy Radiation Therapy for Triple-Negative Breast Cancer

Breast cancer treated with neoadjuvant chemotherapy followed by lumpectomy, currently undergoing radiation therapy (inquiry made on April 14, follow-up on previous case)?

Hello, (Old Case) A family member has a "triple-negative" left breast cancer measuring over 4 cm, and underwent "neoadjuvant chemotherapy (8 cycles)." By the "6th cycle, the ultrasound could no longer detect the tumor," but they completed a total of eight cycles of chemotherapy.
Afterward, a local excision surgery was performed, and one week later, the "pathology report stated that the cancer cells were dead." Three sentinel lymph nodes were removed, and there was no infection.
On the same day the pathology report was received, the family member was referred to a radiation oncologist for the first outpatient visit.
Since the family member had left breast cancer, the doctor recommended "out-of-pocket respiratory control" and hypofractionated radiation therapy (is this correct?).
A total of 16 sessions were completed (Old Question).

2.
Will the lymph nodes be irradiated? A: Actually, you did not provide whether the attending physician before chemotherapy thought there was an issue with the lymph nodes.
The principle is based on the diagnosis before chemotherapy, not on the absence of issues after chemotherapy.
{New Question} Initially, the family member underwent "ultrasound, mammography (standing compression of the breast), and biopsy." After one week, when reviewing the report, they asked the doctor, who said "the lymph nodes were not infected." Is the determination of "lymph node infection" based on "ultrasound examination" or is it based on "breast MRI" performed a few days later before hospitalization for the placement of a vascular access device? (Old Question)
3.
A family member heard from others that there was a patient A with an identical case.
After three sessions of radiation, during the second outpatient visit with the radiation oncologist, the doctor asked patient A if she wanted to increase to 20 sessions (the first visit stated only 16 sessions were needed) because the doctor mentioned treating the original bleeding site, but cancer cells were not clearly visible anymore, so they were unsure where to treat.
Is it possible for the number of radiation sessions to increase during the actual treatment process? / A: 16 +/- 4 sessions.
The initial decision to treat only the original tumor site was made by the physician and communicated to the patient, which is reasonable as long as the physician explains clearly and the family understands.
{New Question} The family member is about to complete 16 sessions of radiation therapy (with out-of-pocket respiratory control)...
The doctor did not mention the possibility of "adding 4 more sessions" and stated "only treating the original tumor site." Since the family member has "triple-negative" breast cancer and underwent chemotherapy followed by local excision, and the "pathology report stated that the cancer cells were dead," is adding 4 sessions absolutely necessary? (...concerns due to lack of understanding) {New Question} In clinical practice in Taiwan, are cases of breast cancer where neoadjuvant chemotherapy is performed and the tumor is no longer visible (cancer cells are dead) relatively rare? Thank you very much.

Miss Zhu, 50~59 year old female. Ask Date: 2022/04/20

Dr. Chen Sirong reply Oncology

Ms.
Chu / 52 years old / Female {New Inquiry} Initially, family members underwent "ultrasound, mammography (standing compression of the breast), and biopsy." After a week, they consulted the doctor, who said, "The lymph nodes are not infected." Whether the lymph nodes are infected is based on the "ultrasound examination" ...
or should we rely on the "breast CT scan" performed a few days later before hospitalization for the placement of the artificial blood vessel? A: The CT scan is the standard.
{New Inquiry} Family members are nearing the completion of 16 sessions of radiation therapy (with out-of-pocket respiratory control)...
The doctor did not mention the possibility of "adding 4 more sessions"....
"Only treating the original tumor site"...
since the family member has "triple-negative" breast cancer and underwent chemotherapy followed by local excision...
The pathology report states "cancer cells are dead"...
Is adding 4 more sessions absolutely necessary? (...
not understanding and feeling worried..) {New Inquiry} In international Taiwan, in clinical practice, is it relatively rare for breast cancer cases to undergo chemotherapy first and the tumor to disappear (cancer cells are dead)? A: Whether to proceed or not, if there are no severe side effects, I suggest you do not need to worry and respect the attending physician's opinion.
Wishing you a safe treatment at Taoyuan Hospital, Dr.
Chen Sih-Rong.

Reply Date: 2022/04/20

More Info

In the context of post-chemotherapy radiation therapy for triple-negative breast cancer (TNBC), it is essential to understand the rationale behind the treatment recommendations and the implications of the patient's specific circumstances. Your family member's case, where they underwent chemotherapy followed by surgery and were informed that the cancer cells were dead, presents a unique situation that requires careful consideration.

Importance of Radiation Therapy
For patients with TNBC, especially those with larger tumors or those who have undergone breast-conserving surgery, radiation therapy is often recommended as part of the standard treatment protocol. The primary goal of radiation therapy is to eliminate any remaining cancer cells in the breast and surrounding tissues, thereby reducing the risk of local recurrence. Even if the pathology report indicates that cancer cells are no longer detectable, radiation therapy can serve as a precautionary measure to ensure that any microscopic disease is addressed.

The Role of Lymph Nodes
Regarding the lymph nodes, the decision to include them in the radiation field typically depends on the initial assessment before chemotherapy. If the lymph nodes were not involved at the time of diagnosis (as indicated by imaging studies), the radiation oncologist may choose to focus solely on the breast tissue. However, if there was any suspicion of lymph node involvement prior to treatment, radiation to the axillary region may be considered to further mitigate the risk of recurrence.

Treatment Planning and Adjustments
The treatment plan for radiation therapy can be adjusted based on the patient's response to prior treatments. In your family member's case, if the initial plan was for 16 sessions and the oncologist has not mentioned extending this to 20 sessions, it is likely that the original plan was deemed sufficient based on the clinical evaluation and the pathology results. However, it is not uncommon for oncologists to reassess treatment plans based on ongoing evaluations. If there are concerns about the adequacy of the treatment, it is crucial to have an open discussion with the radiation oncologist.

Concerns About Additional Treatments
The apprehension about potentially needing additional radiation treatments (beyond the initially planned 16 sessions) is understandable. The decision to add more sessions would typically be based on clinical judgment, considering factors such as the size of the original tumor, the response to chemotherapy, and any new findings during treatment. If the oncologist has not indicated a need for additional treatments, it is likely that they believe the planned course is appropriate.

Conclusion
In summary, while the initial response to chemotherapy is promising, the recommendation for radiation therapy remains a critical component of the treatment plan for TNBC. It is essential to follow the oncologist's guidance and maintain open communication regarding any concerns about the treatment process. If there are lingering doubts or questions about the necessity of additional radiation sessions, it is advisable to seek clarification from the healthcare team. They can provide insights based on the latest clinical evidence and the specifics of your family member's case. Ultimately, the goal is to ensure the best possible outcome and minimize the risk of recurrence.

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