QuestionQUESTION: I am 58, brasilian was diagnosed with invasive ductal adenocarcinoma with axilliary lymph node metastasis in Sept of 2006. It was classified as Nottingham grade II (of III), histopathological grade II (Scarff, Bloom & Richardson), HER I (negative), 80% positive to both estrogen and progesterone. Lymph node fine needle biopsy found positive for methastasic adenoma.
between Sept and January had 6 FAC chemo sessions (3 week intervals), in Feb 2007 had a modified radical mastectomy of the left breast.
After the surgery pathologist found ductal methastasic carcinoma in two of seven lymph nodes.
Residual ductal infiltrating carcinoma, post chemo, not applicable histological grade (05X03mm) and presence of "in situ" ductal carcinoma focuses.
Immediately after I had four further sessions of chemo with taxoter (125mg in each session), last session was on May 15, 2007.
Questions:
1. should I have radiotherapy?
2. If positive what type of radio and how many sessions?
3. What do you think of linear vs.proton accelerators?
4.Can proton accelator therapy shorten the time of treatment?
5. Is it possible to avoid taking aromatase inhibitors? (I am past menopause)what are the risks of recurrence if I don't take those?
6.In my case, how can I evaluate the risks of recurrence?
7. What questions should I ask to the radiology Dr.?
8. What questions should I ask the clinical oncologist now after the end of chemo?
Thanks very much for your attention and help
ANSWER: Thank you for all this detailed information! 1. I started my cancer therapy career as a radiation therapist so I have a rather pro radiation therapy attitude generally. In your case we know that your cancer had - to some extent - spread to axillary lymph nodes. There is also some other lymph node stations (for example supraclavicular) to which there is lymph drainage from a breast. Even though you have been given chemo therapy I would for that reason - so not because of my professional origin per se - think it is best that you also accept radiation therapy. 2. Gamma radiation is suitable. The number of sessions depends on the number of stations treated and some other technicalities so that should be answered by the dr. in charge of your treatment.
It will probably be a treatment time that can be measured in weeks though. 3. In your case since gamma radiation would be the radiation of choice a linear accelerator (can produce both gamma radiation and electrons) or even an old fashioned cobalt60 source would be ok. Proton beams are not suitable for this kind of treatment. 4. As I have just stated proton beams are not a method of choice in your case, very different physical characteristics from what is needed in your case. 5. Even if you have entered menopause you may still have some ovarian estrogen production and there is always some from the adrenals too. Your cancer was hormone receptor positive so I think you should have some anti hormone therapy either aromatase inhibitors or Tamoxiphene (estrogen receptor blocker). Of these the aromatase inhibitors seem to be somewhat more effective. Such treatment will most probably lessen your risk of a relapse.
6. Cancer statistics - including relapse risks - deals with vast numbers of cases. You are a single case. It is difficult or impossible to use such statistical information in a single case. By following the advice above everything that is humanely possible to do is done in order to decrease your risks of a relapse. That is all that can be done at present. 7. You can ask about the treatment plan and schedule. 8. Well the best thing is probably to discuss the anti hormonal therapy. Good luck!
Well, you want to know why proton beams would not be suitable. To discuss that I would have to explain a huge amount of particle radiation physics. I'm doing this in my spare time and free of charge and every day I have a number of questions to answer. That means that unless I want to sit here all day - which I'm not prepared to do, since even if retired there are other things every day I both need and like to do - I have to be somewhat restrictive in the length of my replies. In short to produce proton beams you need huge extremely expensive electromagnetic accelerators. Such machines are few and far between. Here in my native Sweden with 9 million inhabitants we have only one (1) for medical use in the Gustav Werner Institute of the Department of Physics of and at the University of Uppsala about 60 kms north of Stockholm. However it is mostly not a matter of cost and availability though. It is mostly a matter of physics. A high energy proton beam (and it needs to be of high energy to have sufficient penetration power)has some rather strange physical properties. It has most of its effect in a very narrow area at a precise depth inside the irradiated target. This particular depth is mostly decided by the particular energy of this particular proton beam. This means that proton beams are best used in a kind of irradiation "surgery" where a rather SMALL area is destroyed completely by radiation. In your case a much larger area and volume must be irradiated in order to achieve the desired result. For this gamma rays and in some cases electrons (and in even more exotic applications neutrons) are better suited to do the job. Had you had a SMALL (less than 3 cms in diameter) benign brain tumour it would have been well suited for proton beam destruction. But your case is far from that situation! So you have unfortunately to take my word for it that the advice I gave you is the correct one and that shortness in explanations is not a sign of ignorance but rather of a lack of mostly time!
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QUESTION: Thanks very much for your answer, I now understand the issue and it makes a lot of sense. I do apologize for imposing on your time, and hope that you understand that this is a difficult situation to be in, sometimes very confusing, specially when there are many different points of view.
Thanks again, hope we will able to meet sometime on your vacation here in Rio
Anamaria
AnswerYou do not impose at all, I'm here to help - within my abilities and possibilities - but time does not permit me to be as extensive in my explanations as I perhaps would wish myself unfortunately! You are most welcome! I certainly do understand your difficult situation! Aha, you live in Rio! A most beautiful but unfortunately also dangerous city! One of the most beautiful - perhaps the most beautiful - cities I have ever seen! Only the inlet and harbour of Sydney in Australia of all the cities I have visited can compete (maybe also my native Stockholm but then only in a VERY GOOD summer)?! I have actually visited Rio 2 times, but in my youth - more or less - I was 32 and 33 years old. It was in 1977 and 1978 (one of the incentives for the visits was a Brazilian lady, then 25). In those days you could fly the Concorde of Air France between Paris and Rio, so I did on both occasions. I stayed in the Rio Intercontinental Hotel in Sao Conrado south of Ipanema. I did enjoy my visits very much! In those days I travelled a lot all over the World.
Now I'm retired after suffering a stroke and due to that I do not travel much anymore unfortunately.
I liked Rio much better than Buenos Aires by the way though some restaurants there were really outstanding!
