Crossroads !

[Vineets]

After the 18th chemo session followed up by Pet scan (attached in my previous post)the medical Onco has asked us to decide

- put my mothee on maintenance drug (herclone)

Or

- go for surgery of the affected areas (including liver and the nodes)

he also advised to take opinion of Onco surgeon. But would look forward from the group to take an informed call

[roxboxfox RadiationOncologist]

With chemotherapy alone, we normally would expect 12-15% fantastic response rate

With herceptin + chemotherapy ---- > Complete response is seen upto 40% and Partial or Good response is seen in upto 75-80% cases

With Perjeta + herceptin + chemo ----> Complete response is seen upto 60% and upto 90% partial or Complete response is seen.

Your mother had disease

1. Left breast

2. Left axillary nodes

2. Left supraclavicular nodes

3. Liver

4. Portal node

Wonder what surgical option exists here....... removing all these sites of metastatic disease. ! ! ! ! !

This will certainly not be Considered Standard Current Guidelines

Standard Guidelines would advocate to continue Herceptin till Progression

The average time for this progression is around 25-30 months

But we have seen exceptional cases where patient have remained in remission with treatment at even 8 years .....

The question is if Herceptin is so good, can we stop herceptin at some point...

Its a research question and no one knows the answer.

In UK as well, we did offer a small cohort of patients, an option of stopping Herceptin after 3-4-5-6 years of Herceptin treatment.... Most of them preferred to continue with herceptin, but few of them did agree to Stop Herceptin....

In that cohort majority of women 70%-80% had their cancers back in 6 months to 1 year

But a 20-30 % population, did not have their cancer back..... but these women lived in the constant fear of their cancer returning back... as these women had CT scans every 3 months.... These are non-traditional approaches for which no great evidence exists, and its a mutual discussion between oncologists and patients.

My management Plan

I would personally not offer option of Surgery Vs continuation of Herceptin

I would continue with Herceptin alone for at least 2-3 years... and then offer option in only those women in whom all cancer has disappeared.... whether to continue with Herceptin (Standard approach) OR Discontinue all options (remain under close follow up - The non traditional approach).....

Its a mutual call between the 2 parties.

(no one knows the right answer, as if the scan shows cancer is back...one would simply restart Herceptin once again).

The role for surgery is extremely debatable and is restricted ideally in patients with LIVER metastasis only ( with no portal node, no supraclav nodes, and it assumes locoregional disease has been handled already by surgical means)

I ll leave you with some food for thought from a report from France, where two patients with liver metastasis had their chemo and Herceptin and had complete response, and these pts agreed to stop herceptin and were cancer free...

Of course these are rare and exceptional and hence reported in literature as special reported case with the concluding remark of an unprecedented possibility of a cure-like state in exceptional cases.

But the chances of this happening really speaking is <1-2 % to be very honest and its good to be positive and equally realistic at the same time.

biomedcentral.com/1471-2407...

Best of luck !

Dr Rohit Malde MD, DNB, FRCR (UK)

Consultant Clinical + Radiation Oncologist