Early Breast Cancer Not Needing Chemotherapy?

Screen Shot 2018-06-19 at 10.46.38 PM.png
Article in BBC News

One of my patient was rather up-to-date because she was asking if she can forgo/ do without (adjuvant) chemotherapy since her breast cancer is just stage 1, triple negative. She told me that she read from the Internet that chemotherapy can be omitted for early breast cancer, and hers was just stage 1.

Adjuvant treatment is the additional treatment given after primary surgical treatment to increase the chance of cure.

I do believe cancer patients these days are more well informed regarding treatment options as they follow keenly news regarding their disease.

However, news headlines can be misleading if they didn’t read the actual full journal article or discuss with their oncologist.

Below is the article which the news above was based on.

Screen Shot 2018-06-19 at 10.40.17 PM
Article of interest today from NEJM (6/ 2018)

So, does all early breast cancer not requiring adjuvant chemotherapy?

No. Absolutely NOT true.

  • Firstly, a 21-gene assay test, Oncotype DX, need to be performed.
  • Cost around RM14,000 per person
  • For ER positive breast cancer only (so my patient with triple negative breast cancer is not suitable)
  • Results is in the form of scoring; Recurrence Score (RS) from 0 to 100.
    • RS 0-10 (low risk recurrence)
    • RS 11-25 (intermediate)
    • RS 26 and above (high)
    • High RS predict chemotherapy benefit
Screen Shot 2018-06-19 at 11.20.38 PM.png
Oncotype DX sample report

In conclusion, hormonal therapy alone (not needing chemotherapy) is **as effective as chemo-hormonal therapy only for:

  • ER positive breast cancer and
  • HER2 negative and
  • Lymph node negative/ not involved and
  • Recurrence score (RS) 25 and below

** patients who are <50 years old still benefit from chemo-hormonal therapy.

So, generalising that early breast cancer not needing chemotherapy is not correct.

Do patients need to spend so much money to do the test just to know that they do not need adjuvant chemotherapy after surgery?

There is simpler and cheaper (actually, it’s free) method. See below:

Screen Shot 2018-06-19 at 11.34.00 PM.png
MOH CPG Management of Breast Cancer (2010): Risk stratification (low, intermediate, high)
Screen Shot 2018-06-19 at 11.34.46 PM.png
MOH CPG Management of Breast Cancer (2010): Indications for adjuvant chemotherapy for early breast cancer

Does it mean that the Oncotype DX test is not important? When should it be done?

Instead of doing the 21-gene assay (Oncotype DX) test to see if patients DO NOT NEED adjuvant chemotherapy, I have a different take on this.

If patient can afford the Oncotype DX test (which is very expensive), I will do it on low risk patients (ER positive, HER2 negative, lymph nodes not involved, Grade 1, less than 2cm) to see if they NEED adjuvant chemotherapy.

  • If Oncotype DX recurrence score > 25, adjuvant chemotherapy is indicated

As you can see from the table below, there is survival benefit for patients who undergo adjuvant chemotherapy.

I do not want to see patients of mine miss the survival benefit of adjuvant chemotherapy, unless these low risk patient’s Oncotype DX Recurrence Score (RS) is 25 and below (low and intermediate RS).

Screen Shot 2018-06-19 at 11.32.27 PM.png
MOH CPG Management of Breast Cancer (2010): Benefits of adjuvant chemotherapy – improve survival

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