Chemo? or no?

My stepdaughter's story:

Hodgkins 18 years ago, treated with surgical staging, splenectomy,
radiation to max. No recurrence.

Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs
say C. was caused by radiation therapy for Hodgkins.

Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
Stage One.

Question: is chemo indicated? She can't do radiation. What decides? Any
science here?

Thanks,
Anxious Stepdad

"pk" <laptop@hoptechno.com> wrote in message
news:480fc3a1$0$48229$815e3792@news.qwest.net...
> My stepdaughter's story:
>
> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
> radiation to max. No recurrence.
>
> Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
> Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs say
> C. was caused by radiation therapy for Hodgkins.
>
> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
> Stage One.
>
> Question: is chemo indicated? She can't do radiation. What decides? Any
> science here?
>
> Thanks,
> Anxious Stepdad

The oncologist is the one to decide. Yes there is science, but fortunately
but unfortunately for your step daughter her case is rare . Good news early
stage Breast Cancer and radiation is usually not given after mastectomy.

"pk" <laptop@hoptechno.com> wrote in message
news:480fc3a1$0$48229$815e3792@news.qwest.net...
> My stepdaughter's story:
>
> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
> radiation to max. No recurrence.
>
> Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
> Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs say
> C. was caused by radiation therapy for Hodgkins.
>
> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
> Stage One.
>
> Question: is chemo indicated? She can't do radiation. What decides? Any
> science here?
>
> Thanks,
> Anxious Stepdad

That is not always an easy thing to decide. There are different ways to
present the relevant statistics. When presented as improvement over the
present state, the argument might run something like this (statistics are
guesses):

With no further treatment, your chances of no recurrence are 95%.
Chemotherapy will cut the risk of recurrence by half--you should do it.

50% improvement looks impressive, but that means merely a 2.5% improvement
in the probability of getting by without recurrence. Balanced against that
is the discomfort of chemo and perhaps complications of chemo. Her age
might affect her decision. The ER/PR status might make the starting odds
worse (or perhaps better, but I think morelikely worse). If the probability
of no recurrence is 50% instead of 95%, a 50% improvement would take her
from 50% to 75% and that looks, to me at least, a whole lot more attractive.

The 95% and 50% were numbers given my wife, who had a slightly larger
primary but with ER+ and PR+, about 10 years ago. She declined, based in
part on the experience of an aunt who accepted chemo and radiation after
removal of a very large primary but died after several years of a somewhat
miserable fight. The oncologist remarked that he had seenonly three other
women decline, all, like my wife, physician's wives. My wife is doing well
so far, but that doesn't prove much of anything. I don't know the right
answer for your stepdaughter; I wish to suggest only that she ponder
whatever numbers are given her carefully.

Sandy L wrote:
> "pk" <laptop@hoptechno.com> wrote in message
> news:480fc3a1$0$48229$815e3792@news.qwest.net...
>> My stepdaughter's story:
>>
>> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
>> radiation to max. No recurrence.
>>
>> Breast cancer left side this year discovered via mammogram. DCIS/IDC,
>> ER Negative, PR Negative and HER2 Negative. Clear bone scan, lungs.
>> Docs say C. was caused by radiation therapy for Hodgkins.
>>
>> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm
>> tumor. Stage One.
>>
>> Question: is chemo indicated? She can't do radiation. What decides?
>> Any science here?
>>
>> Thanks,
>> Anxious Stepdad
>
> That is not always an easy thing to decide. There are different ways to
> present the relevant statistics. When presented as improvement over the
> present state, the argument might run something like this (statistics
> are guesses):
>
> With no further treatment, your chances of no recurrence are 95%.
> Chemotherapy will cut the risk of recurrence by half--you should do it.
>
> 50% improvement looks impressive, but that means merely a 2.5%
> improvement in the probability of getting by without recurrence.
> Balanced against that is the discomfort of chemo and perhaps
> complications of chemo. Her age might affect her decision. The ER/PR
> status might make the starting odds worse (or perhaps better, but I
> think morelikely worse). If the probability of no recurrence is 50%
> instead of 95%, a 50% improvement would take her from 50% to 75% and
> that looks, to me at least, a whole lot more attractive.
>
> The 95% and 50% were numbers given my wife, who had a slightly larger
> primary but with ER+ and PR+, about 10 years ago. She declined, based
> in part on the experience of an aunt who accepted chemo and radiation
> after removal of a very large primary but died after several years of a
> somewhat miserable fight. The oncologist remarked that he had seenonly
> three other women decline, all, like my wife, physician's wives. My
> wife is doing well so far, but that doesn't prove much of anything. I
> don't know the right answer for your stepdaughter; I wish to suggest
> only that she ponder whatever numbers are given her carefully.
>

Thanks, Doc. Fascinating that only refusals were MDs. I am anxious to
review stats also. She is not a numbers person, so it may be uphill to
give her a reason to avoid a lot of grief for so little potential
benefit. Everyone talks in percentages when absolute numbers are what
count as you so succinctly pointed out.

She also wants to have more kids (has 2 now) and this may make a difference.

AS

"pkmn" <news@ezweddingplanner.com> wrote in message
news:48114ac2$0$48222$815e3792@news.qwest.net...
>
>
> Sandy L wrote:
>> "pk" <laptop@hoptechno.com> wrote in message
>> news:480fc3a1$0$48229$815e3792@news.qwest.net...
>>> My stepdaughter's story:
>>>
>>> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
>>> radiation to max. No recurrence.
>>>
>>> Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
>>> Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs
>>> say C. was caused by radiation therapy for Hodgkins.
>>>
>>> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
>>> Stage One.
>>>
>>> Question: is chemo indicated? She can't do radiation. What decides? Any
>>> science here?
>>>
>>> Thanks,
>>> Anxious Stepdad
>>
>> That is not always an easy thing to decide. There are different ways to
>> present the relevant statistics. When presented as improvement over the
>> present state, the argument might run something like this (statistics are
>> guesses):
>>
>> With no further treatment, your chances of no recurrence are 95%.
>> Chemotherapy will cut the risk of recurrence by half--you should do it.
>>
>> 50% improvement looks impressive, but that means merely a 2.5%
>> improvement in the probability of getting by without recurrence.
>> Balanced against that is the discomfort of chemo and perhaps
>> complications of chemo. Her age might affect her decision. The ER/PR
>> status might make the starting odds worse (or perhaps better, but I think
>> morelikely worse). If the probability of no recurrence is 50% instead of
>> 95%, a 50% improvement would take her from 50% to 75% and that looks, to
>> me at least, a whole lot more attractive.
>>
>> The 95% and 50% were numbers given my wife, who had a slightly larger
>> primary but with ER+ and PR+, about 10 years ago. She declined, based in
>> part on the experience of an aunt who accepted chemo and radiation after
>> removal of a very large primary but died after several years of a
>> somewhat miserable fight. The oncologist remarked that he had seenonly
>> three other women decline, all, like my wife, physician's wives. My wife
>> is doing well so far, but that doesn't prove much of anything. I don't
>> know the right answer for your stepdaughter; I wish to suggest only that
>> she ponder whatever numbers are given her carefully.
>>
>
> Thanks, Doc. Fascinating that only refusals were MDs. I am anxious to
> review stats also. She is not a numbers person, so it may be uphill to
> give her a reason to avoid a lot of grief for so little potential benefit.
> Everyone talks in percentages when absolute numbers are what count as you
> so succinctly pointed out.
>
> She also wants to have more kids (has 2 now) and this may make a
> difference.
>
> AS

Her desire for children would make her quite a bit younger than my wife, who
was 57 at the time. I think the odds are not so good for younger women.
Again,, the oncologist will have current numbers. If she wishes, having
someone else along to listen and take notes may be helpful. There is
inevitably anxiety at this stage.

On Apr 23, 6:18*pm, pk <lap...@hoptechno.com> wrote:
> My stepdaughter's story:
>
> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
> radiation to max. No recurrence.
>
> Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
> Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs
> say C. was caused by radiation therapy for Hodgkins.
>
> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
> Stage One.
>
> Question: is chemo indicated? She can't do radiation. What decides? Any
> science here?
>
> Thanks,
> Anxious Stepdad

I am facing a similar decision soon. In addition to the info you
mentioned, you might want to find out
- if there is any mention of how aggressive the tumor appeared. Terms
like "highly differentiated" are more alarming, I think, than
"moderately differentiated", for example.
- how much margin (shortest distance between an edge of the tumor and
an edge of the tissue removed) was there? More than 1cm is, I think,
considered very good.
- was there any other suspicious or cancerous tissue in the tissue
removed?

None of this will make the answer obvious, but it may help you and
your daughter reach a conclusion you can be comfortable with.

sarahz@rocketmail.com wrote:
> On Apr 23, 6:18 pm, pk <lap...@hoptechno.com> wrote:
>> My stepdaughter's story:
>>
>> Hodgkins 18 years ago, treated with surgical staging, splenectomy,
>> radiation to max. No recurrence.
>>
>> Breast cancer left side this year discovered via mammogram. DCIS/IDC, ER
>> Negative, PR Negative and HER2 Negative. Clear bone scan, lungs. Docs
>> say C. was caused by radiation therapy for Hodgkins.
>>
>> Mastectomy, bilateral 2 days ago. Negative sentinal node. 1.5 cm tumor.
>> Stage One.
>>
>> Question: is chemo indicated? She can't do radiation. What decides? Any
>> science here?
>>
>> Thanks,
>> Anxious Stepdad
>
> I am facing a similar decision soon. In addition to the info you
> mentioned, you might want to find out
> - if there is any mention of how aggressive the tumor appeared. Terms
> like "highly differentiated" are more alarming, I think, than
> "moderately differentiated", for example.
> - how much margin (shortest distance between an edge of the tumor and
> an edge of the tissue removed) was there? More than 1cm is, I think,
> considered very good.
> - was there any other suspicious or cancerous tissue in the tissue
> removed?
>
> None of this will make the answer obvious, but it may help you and
> your daughter reach a conclusion you can be comfortable with.
>
>
>
>
"Highly differentiated" is good, "poorly differentiated" is bad.

The more mutated a cancer cell line becomes, the more the cells become
unrecognisable as their original type. Differentiation is the process
by which universal stem cells turn into specific body tissue cells, so
if a cancer cell is said to be poorly differentiated, then it doesn't
look much like a healthy tissue cell (ie a breast cell in the case of
b.c.).

Highly aggressive cancers tend to be associated with cells that have
lost much of their form.

The decision whether or not to use chemotherapy is obviously a personal
one, but one that should be very much informed by the oncologist's
expert opinion. In favour of it are the lack of excess hormone
receptors, and the patient's age: younger people have a lot more life to
lose. When we say for example a 5% reduction in mortality risk, it's 5%
of a lot more life expectancy for a 40 year old than it is for an 80
year old. Against are the general undesirability of doing it, and the
fairly early tumour stage.

If the oncologist is equivocal, then on the whole if it were me I think
I'd bite the bullet and do it. But I'd follow the expert's opinion
first, and if not confident in it, get a second opinion.


Tim Jackson

"Tim Jackson" <tim@tim-jackson.co.uk> wrote in message
news:fvCdnYO5trWeI4fVnZ2dnUVZ8sqjnZ2d@plusnet...
>>
> "Highly differentiated" is good, "poorly differentiated" is bad.
>
> The more mutated a cancer cell line becomes, the more the cells become
> unrecognisable as their original type. Differentiation is the process by
> which universal stem cells turn into specific body tissue cells, so if a
> cancer cell is said to be poorly differentiated, then it doesn't look much
> like a healthy tissue cell (ie a breast cell in the case of b.c.).

Does that apply to other cancers, Tim?

Thanks for all this,

Mary

Mary Fisher wrote:
> "Tim Jackson" <tim@tim-jackson.co.uk> wrote in message
> news:fvCdnYO5trWeI4fVnZ2dnUVZ8sqjnZ2d@plusnet...
>> "Highly differentiated" is good, "poorly differentiated" is bad.
>>
>> The more mutated a cancer cell line becomes, the more the cells become
>> unrecognisable as their original type. Differentiation is the process by
>> which universal stem cells turn into specific body tissue cells, so if a
>> cancer cell is said to be poorly differentiated, then it doesn't look much
>> like a healthy tissue cell (ie a breast cell in the case of b.c.).
>
> Does that apply to other cancers, Tim?
>
> Thanks for all this,
>
> Mary
>
>
Yes

Thanks for all for the thoughtful responses. We have new information.

The pathology after the dbl mastectomy showed the single tumor as grade
3/9 indicating maximum aggressiveness (I am told). 2 sentinel lymph
nodes showed nothing. All Hormone receptors are negative. Thus, we are
told the stage is 1C. So AC is the recommended Chemo therapy. 8 sessions
every 2 weeks for 4 months.

The next step prescribed is MUGA baseline cuz AC can hurt heart. Also CT
Scan on Chest, Abdomen and Pelvis.

Now this girl has had 'maximum lifetime radiation' with her prior
Hodgkins therapy. And she has had Cervical cancer.

The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is
done - otherwise 10-20%.

What real advantage is there to chemo? If she has heart problems is
there some other suite of probabilities? What are the probabilities of
chemo problems that take her out of the set.

And is there any study done on 35 yo Females with history of rad treated
Hodgkins (with no recurrence) and cervical ca (2 yrs ago)? In other
words does chemo make statistical sense here? Any absolute numbers to
rely on? Any studies?

Thanks to all!!

Step-Dad - so worried!!


Tim Jackson wrote:
> Mary Fisher wrote:
>> "Tim Jackson" <tim@tim-jackson.co.uk> wrote in message
>> news:fvCdnYO5trWeI4fVnZ2dnUVZ8sqjnZ2d@plusnet...
>>> "Highly differentiated" is good, "poorly differentiated" is bad.
>>>
>>> The more mutated a cancer cell line becomes, the more the cells
>>> become unrecognisable as their original type. Differentiation is the
>>> process by which universal stem cells turn into specific body tissue
>>> cells, so if a cancer cell is said to be poorly differentiated, then
>>> it doesn't look much like a healthy tissue cell (ie a breast cell in
>>> the case of b.c.).
>>
>> Does that apply to other cancers, Tim?
>>
>> Thanks for all this,
>>
>> Mary
>>
>>
> Yes

pkmn wrote:
> Thanks for all for the thoughtful responses. We have new information.
>
> The pathology after the dbl mastectomy showed the single tumor as grade
> 3/9 indicating maximum aggressiveness (I am told). 2 sentinel lymph
> nodes showed nothing. All Hormone receptors are negative. Thus, we are
> told the stage is 1C. So AC is the recommended Chemo therapy. 8 sessions
> every 2 weeks for 4 months.
>
> The next step prescribed is MUGA baseline cuz AC can hurt heart. Also CT
> Scan on Chest, Abdomen and Pelvis.
>
> Now this girl has had 'maximum lifetime radiation' with her prior
> Hodgkins therapy. And she has had Cervical cancer.
>
> The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is
> done - otherwise 10-20%.
>
> What real advantage is there to chemo? If she has heart problems is
> there some other suite of probabilities? What are the probabilities of
> chemo problems that take her out of the set.
>
> And is there any study done on 35 yo Females with history of rad treated
> Hodgkins (with no recurrence) and cervical ca (2 yrs ago)? In other
> words does chemo make statistical sense here? Any absolute numbers to
> rely on? Any studies?
>
> Thanks to all!!
>
> Step-Dad - so worried!!
>
>
You seem to have answered your own question, the real advantage of chemo
is that it roughly halves the risk of a fatal recurrence. That seems to
me to make it a good thing. Generally the younger you are the more you
have to gain from chemo, simply because you have more to lose by dying.

Yes there it causes some loss of heart muscle, but this is of little
concern if the heart is initially healthy and is monitored. It isn't
often a problem.

I think you'd be lucky to find any statistics of 35 yr old breast cancer
patients with previous cancer history, they are pretty thin on the
ground because breast cancer is quite rare in that age group.

From the SEER database (http://seer.cancer.gov) the annual incidence of
breast cancer in under-50s is 0.0007, of cervical cancer is 0.0001 and
of Hodgkins lymphoma is .000025, so multiplying up the probabilities
there are probably no more than a dozen such cases in the whole USA. Of
course if this is a syndrome with some common underlying cause (eg
genetic or environmental) rather than random events, then the incidence
could be a lot higher.


Tim

Tim Jackson wrote:
> pkmn wrote:
>> Thanks for all for the thoughtful responses. We have new information.
>>
>> The pathology after the dbl mastectomy showed the single tumor as
>> grade 3/9 indicating maximum aggressiveness (I am told). 2 sentinel
>> lymph nodes showed nothing. All Hormone receptors are negative. Thus,
>> we are told the stage is 1C. So AC is the recommended Chemo therapy. 8
>> sessions every 2 weeks for 4 months.
>>
>> The next step prescribed is MUGA baseline cuz AC can hurt heart. Also
>> CT Scan on Chest, Abdomen and Pelvis.
>>
>> Now this girl has had 'maximum lifetime radiation' with her prior
>> Hodgkins therapy. And she has had Cervical cancer.
>>
>> The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is
>> done - otherwise 10-20%.
>>
>> What real advantage is there to chemo? If she has heart problems is
>> there some other suite of probabilities? What are the probabilities of
>> chemo problems that take her out of the set.
>>
>> And is there any study done on 35 yo Females with history of rad
>> treated Hodgkins (with no recurrence) and cervical ca (2 yrs ago)? In
>> other words does chemo make statistical sense here? Any absolute
>> numbers to rely on? Any studies?
>>
>> Thanks to all!!
>>
>>
>>
> You seem to have answered your own question, the real advantage of chemo
> is that it roughly halves the risk of a fatal recurrence. That seems to
> me to make it a good thing. Generally the younger you are the more you
> have to gain from chemo, simply because you have more to lose by dying.
>
> Yes there it causes some loss of heart muscle, but this is of little
> concern if the heart is initially healthy and is monitored. It isn't
> often a problem.
>
> I think you'd be lucky to find any statistics of 35 yr old breast cancer
> patients with previous cancer history, they are pretty thin on the
> ground because breast cancer is quite rare in that age group.
>
> From the SEER database (http://seer.cancer.gov) the annual incidence of
> breast cancer in under-50s is 0.0007, of cervical cancer is 0.0001 and
> of Hodgkins lymphoma is .000025, so multiplying up the probabilities
> there are probably no more than a dozen such cases in the whole USA. Of
> course if this is a syndrome with some common underlying cause (eg
> genetic or environmental) rather than random events, then the incidence
> could be a lot higher.
>
>
> Tim

Thanks Tim,

1) Syndrome: possible since dad had exposure to Dioxin in VietNam. And
there is a high correlation w/ dioxin and Hodgkins. Also, one doc said
that breast cancer in young radiation-treated Hodgkins survivors is a
virtual certainty. So we are not dealing with isolated probabilities
here. There should be some good data somewhere.

2) What is the meaning of maximum lifetime radiation dose (she was told
this) if yet more radiation is prescribed with CT Scan and MUGA scan
both of which involve yet more substantial rads? That is, what increased
risk does this promote?

3) The huge ranges, 10-20%, 20-30% stated do not inform me that risk of
recurrence (nobody modified this with 'fatal') is halved. So where do
these numbers come from? For example if the chance of recurrence w/
chemo is 19% and the chance w/o is 21%, then we are not talking about
halving at all. What science justifies these numbers? That is my
fundamental question here.

4) What is the probability of fatality due to chemo (or over-radiation)
alone? Should that not be considered separately?

Phil

pkmn wrote:
>
>
> Tim Jackson wrote:
>> pkmn wrote:
>>> Thanks for all for the thoughtful responses. We have new information.
>>>
>>> The pathology after the dbl mastectomy showed the single tumor as
>>> grade 3/9 indicating maximum aggressiveness (I am told). 2 sentinel
>>> lymph nodes showed nothing. All Hormone receptors are negative. Thus,
>>> we are told the stage is 1C. So AC is the recommended Chemo therapy.
>>> 8 sessions every 2 weeks for 4 months.
>>>
>>> The next step prescribed is MUGA baseline cuz AC can hurt heart. Also
>>> CT Scan on Chest, Abdomen and Pelvis.
>>>
>>> Now this girl has had 'maximum lifetime radiation' with her prior
>>> Hodgkins therapy. And she has had Cervical cancer.
>>>
>>> The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is
>>> done - otherwise 10-20%.
>>>
>>> What real advantage is there to chemo? If she has heart problems is
>>> there some other suite of probabilities? What are the probabilities
>>> of chemo problems that take her out of the set.
>>>
>>> And is there any study done on 35 yo Females with history of rad
>>> treated Hodgkins (with no recurrence) and cervical ca (2 yrs ago)? In
>>> other words does chemo make statistical sense here? Any absolute
>>> numbers to rely on? Any studies?
>>>
>>> Thanks to all!!
>>>
>>>
>>>
>> You seem to have answered your own question, the real advantage of
>> chemo is that it roughly halves the risk of a fatal recurrence. That
>> seems to me to make it a good thing. Generally the younger you are
>> the more you have to gain from chemo, simply because you have more to
>> lose by dying.
>>
>> Yes there it causes some loss of heart muscle, but this is of little
>> concern if the heart is initially healthy and is monitored. It isn't
>> often a problem.
>>
>> I think you'd be lucky to find any statistics of 35 yr old breast
>> cancer patients with previous cancer history, they are pretty thin on
>> the ground because breast cancer is quite rare in that age group.
>>
>> From the SEER database (http://seer.cancer.gov) the annual incidence
>> of breast cancer in under-50s is 0.0007, of cervical cancer is 0.0001
>> and of Hodgkins lymphoma is .000025, so multiplying up the
>> probabilities there are probably no more than a dozen such cases in
>> the whole USA. Of course if this is a syndrome with some common
>> underlying cause (eg genetic or environmental) rather than random
>> events, then the incidence could be a lot higher.
>>
>>
>> Tim
>
> Thanks Tim,
>
> 1) Syndrome: possible since dad had exposure to Dioxin in VietNam. And
> there is a high correlation w/ dioxin and Hodgkins. Also, one doc said
> that breast cancer in young radiation-treated Hodgkins survivors is a
> virtual certainty. So we are not dealing with isolated probabilities
> here. There should be some good data somewhere.
>
> 2) What is the meaning of maximum lifetime radiation dose (she was told
> this) if yet more radiation is prescribed with CT Scan and MUGA scan
> both of which involve yet more substantial rads? That is, what increased
> risk does this promote?
>
> 3) The huge ranges, 10-20%, 20-30% stated do not inform me that risk of
> recurrence (nobody modified this with 'fatal') is halved. So where do
> these numbers come from? For example if the chance of recurrence w/
> chemo is 19% and the chance w/o is 21%, then we are not talking about
> halving at all. What science justifies these numbers? That is my
> fundamental question here.
>
> 4) What is the probability of fatality due to chemo (or over-radiation)
> alone? Should that not be considered separately?
>
> Phil

How is your statistics knowledge? Understand these ranges as
distributions: by 10-20% the oncologist means a distribution with a mean
around 15% and a standard deviation around 5%. It is important in this
business for the oncologist to emphasise that the standard deviation is
large, because people tend not to understand it. So looking at medians
he is talking about a reduction from something like 25% to something
like 15%. OK that's a bit less than half, but it's a reasonable
ball-park figure to thing of chemotherapy in the case of a medium-risk
cancer to be roughly halving the risk.

Justification of figures, well there have been papers published which
analyse the statistics retrospectively, plus there are clinical trials
of each treatment regime as it comes into use. This gives general risk
factors for certain categories of patient. But then it is up to the
skill and experience of the oncologist to place any individual patient
in the appropriate category, or to interpolate between them.

Nobody mentioned fatal? No they would rather not. But it is the fatal
ones we are interested in counting. Whether or not you include
treatable local recurrences, and distant metastases that go into
spontaneous long-term remission, doesn't make a lot of difference to the
results - all the risks move together.

Likewise the risk of fatality from chemo is small compared to the risk
of fatality from cancer, somewhere down under 1%, lower for young and
otherwise healthy patients. Of course it's significant, that's one
reason why for some patients it's better not to give chemo, but in the
25% bracket that really isn't a consideration.

Radiation limits: Radiotherapy is a much bigger dose than scans, so that
is the main concern. As for the risk factors, you'd best ask a
radiographer, I really don't know; but its obviously a progressive risk,
you don't suddenly hit a brick wall. It also depends which tissues are
being irradiated - different tissues have different tolerances and
different histories. It's a matter of making a risk-benefit judgement.


Tim

Tim Jackson wrote:
> pkmn wrote:
>>
>>
>> Tim Jackson wrote:
>>> pkmn wrote:
>>>> Thanks for all for the thoughtful responses. We have new information.
>>>>
>>>> The pathology after the dbl mastectomy showed the single tumor as
>>>> grade 3/9 indicating maximum aggressiveness (I am told). 2 sentinel
>>>> lymph nodes showed nothing. All Hormone receptors are negative.
>>>> Thus, we are told the stage is 1C. So AC is the recommended Chemo
>>>> therapy. 8 sessions every 2 weeks for 4 months.
>>>>
>>>> The next step prescribed is MUGA baseline cuz AC can hurt heart.
>>>> Also CT Scan on Chest, Abdomen and Pelvis.
>>>>
>>>> Now this girl has had 'maximum lifetime radiation' with her prior
>>>> Hodgkins therapy. And she has had Cervical cancer.
>>>>
>>>> The Oncologist says: Recurrence (2-3 years) is 20-30% if no chemo is
>>>> done - otherwise 10-20%.
>>>>
>>>> What real advantage is there to chemo? If she has heart problems is
>>>> there some other suite of probabilities? What are the probabilities
>>>> of chemo problems that take her out of the set.
>>>>
>>>> And is there any study done on 35 yo Females with history of rad
>>>> treated Hodgkins (with no recurrence) and cervical ca (2 yrs ago)?
>>>> In other words does chemo make statistical sense here? Any absolute
>>>> numbers to rely on? Any studies?
>>>>
>>>> Thanks to all!!
>>>>
>>>>
>>>>
>>> You seem to have answered your own question, the real advantage of
>>> chemo is that it roughly halves the risk of a fatal recurrence. That
>>> seems to me to make it a good thing. Generally the younger you are
>>> the more you have to gain from chemo, simply because you have more to
>>> lose by dying.
>>>
>>> Yes there it causes some loss of heart muscle, but this is of little
>>> concern if the heart is initially healthy and is monitored. It isn't
>>> often a problem.
>>>
>>> I think you'd be lucky to find any statistics of 35 yr old breast
>>> cancer patients with previous cancer history, they are pretty thin on
>>> the ground because breast cancer is quite rare in that age group.
>>>
>>> From the SEER database (http://seer.cancer.gov) the annual incidence
>>> of breast cancer in under-50s is 0.0007, of cervical cancer is 0.0001
>>> and of Hodgkins lymphoma is .000025, so multiplying up the
>>> probabilities there are probably no more than a dozen such cases in
>>> the whole USA. Of course if this is a syndrome with some common
>>> underlying cause (eg genetic or environmental) rather than random
>>> events, then the incidence could be a lot higher.
>>>
>>>
>>> Tim
>>
>> Thanks Tim,
>>
>> 1) Syndrome: possible since dad had exposure to Dioxin in VietNam. And
>> there is a high correlation w/ dioxin and Hodgkins. Also, one doc said
>> that breast cancer in young radiation-treated Hodgkins survivors is a
>> virtual certainty. So we are not dealing with isolated probabilities
>> here. There should be some good data somewhere.
>>
>> 2) What is the meaning of maximum lifetime radiation dose (she was
>> told this) if yet more radiation is prescribed with CT Scan and MUGA
>> scan both of which involve yet more substantial rads? That is, what
>> increased risk does this promote?
>>
>> 3) The huge ranges, 10-20%, 20-30% stated do not inform me that risk
>> of recurrence (nobody modified this with 'fatal') is halved. So where
>> do these numbers come from? For example if the chance of recurrence w/
>> chemo is 19% and the chance w/o is 21%, then we are not talking about
>> halving at all. What science justifies these numbers? That is my
>> fundamental question here.
>>
>> 4) What is the probability of fatality due to chemo (or
>> over-radiation) alone? Should that not be considered separately?
>>
>> Phil
>
> How is your statistics knowledge? Understand these ranges as
> distributions: by 10-20% the oncologist means a distribution with a mean
> around 15% and a standard deviation around 5%. It is important in this
> business for the oncologist to emphasise that the standard deviation is
> large, because people tend not to understand it. So looking at medians
> he is talking about a reduction from something like 25% to something
> like 15%. OK that's a bit less than half, but it's a reasonable
> ball-park figure to thing of chemotherapy in the case of a medium-risk
> cancer to be roughly halving the risk.
>
> Justification of figures, well there have been papers published which
> analyse the statistics retrospectively, plus there are clinical trials
> of each treatment regime as it comes into use. This gives general risk
> factors for certain categories of patient. But then it is up to the
> skill and experience of the oncologist to place any individual patient
> in the appropriate category, or to interpolate between them.
>
> Nobody mentioned fatal? No they would rather not. But it is the fatal
> ones we are interested in counting. Whether or not you include
> treatable local recurrences, and distant metastases that go into
> spontaneous long-term remission, doesn't make a lot of difference to the
> results - all the risks move together.
>
> Likewise the risk of fatality from chemo is small compared to the risk
> of fatality from cancer, somewhere down under 1%, lower for young and
> otherwise healthy patients. Of course it's significant, that's one
> reason why for some patients it's better not to give chemo, but in the
> 25% bracket that really isn't a consideration.
>
> Radiation limits: Radiotherapy is a much bigger dose than scans, so that
> is the main concern. As for the risk factors, you'd best ask a
> radiographer, I really don't know; but its obviously a progressive risk,
> you don't suddenly hit a brick wall. It also depends which tissues are
> being irradiated - different tissues have different tolerances and
> different histories. It's a matter of making a risk-benefit judgement.
>
>
> Tim

Thanks, Tim, much appreciated indeed.

I would like to see the data. I am always suspicious of numbers like 15%
and 25%. Nothing ever falls that neatly in statistics. My sense is that
these numbers are pretty much generated for patient consumption based on
WAGS and intended to assuage those who lean to quantification.

In my step-daughter's case, I suspect that with her history she is at
much higher risk of recurrence than someone her age with a similar dx
without prior Ca. And I wonder if that is factored in to the
oncologist's analysis, prescription and prognosis.

Phil

pkmn wrote:
>
> I would like to see the data. I am always suspicious of numbers like 15%
> and 25%. Nothing ever falls that neatly in statistics. My sense is that
> these numbers are pretty much generated for patient consumption based on
> WAGS and intended to assuage those who lean to quantification.
>
> In my step-daughter's case, I suspect that with her history she is at
> much higher risk of recurrence than someone her age with a similar dx
> without prior Ca. And I wonder if that is factored in to the
> oncologist's analysis, prescription and prognosis.
>

That's the whole point of giving wide ranges isn't it? They emphasise
that these are very rough figures. I don't see anything neat about
saying somewhere around 20-30%, this is just like the navigator laying
his hand flat on the chart and saying somewhere around here. It is an
acceptance that the answer is uncertain.

But unlike the navigator the oncologist will never make landfall and
pinpoint his position, he will only know what actually happened to that
individual, not what the precise probabilities were. But the
probability figure is an important factor in the risk benefit analysis
to determine treatment, and helpful for the individual to plan their lives.

The factors you mention are positive for chemotherapy, and little else,
so as he has already proposed doing that, there is probably little to
add even if he wanted to. I think he has included such factors in the
25% figure, that sounds rather high for a 'normal' 1.5cm stage 1.

A little story. When my wife was diagnosed with metastases, it was hard
to get the oncologist to give any sort of prognosis. We of course
wanted to plan for what remained of her life, although no-one had even
mentioned the word "terminal". I had to convince the man that I was
statistically literate and could understand that any median given might
have a geometric standard deviation of about 5, i.e. if he said 2 years
that means anything between 5 months and 10 years. So please could he
tell us, for patients with this sort of condition, what was the median
survival time? OK, he said, about 18 months.

So we borrowed a little money and booked a Christmas holiday to the
Canary Islands, something she'd always wanted to do, About 8 months
after we got back, she was bedridden, and six months after that she was
dead. Given the time it takes to organise things like holidays when
you've got school-age children, this statistical information even if
uncertain, is all you've got to go on to make significant decisions. I
wish the medical community could find an easier way of communicating it
to patients and their families.


Tim

Tim, thanks for hanging in with me and leading me here. You have been
extremely helpful to me and her mother.

Phil


Tim Jackson wrote:
> pkmn wrote:
>>
>> I would like to see the data. I am always suspicious of numbers like
>> 15% and 25%. Nothing ever falls that neatly in statistics. My sense is
>> that these numbers are pretty much generated for patient consumption
>> based on WAGS and intended to assuage those who lean to quantification.
>>
>> In my step-daughter's case, I suspect that with her history she is at
>> much higher risk of recurrence than someone her age with a similar dx
>> without prior Ca. And I wonder if that is factored in to the
>> oncologist's analysis, prescription and prognosis.
>>
>
> That's the whole point of giving wide ranges isn't it? They emphasise
> that these are very rough figures. I don't see anything neat about
> saying somewhere around 20-30%, this is just like the navigator laying
> his hand flat on the chart and saying somewhere around here. It is an
> acceptance that the answer is uncertain.
>
> But unlike the navigator the oncologist will never make landfall and
> pinpoint his position, he will only know what actually happened to that
> individual, not what the precise probabilities were. But the
> probability figure is an important factor in the risk benefit analysis
> to determine treatment, and helpful for the individual to plan their lives.
>
> The factors you mention are positive for chemotherapy, and little else,
> so as he has already proposed doing that, there is probably little to
> add even if he wanted to. I think he has included such factors in the
> 25% figure, that sounds rather high for a 'normal' 1.5cm stage 1.
>
> A little story. When my wife was diagnosed with metastases, it was hard
> to get the oncologist to give any sort of prognosis. We of course
> wanted to plan for what remained of her life, although no-one had even
> mentioned the word "terminal". I had to convince the man that I was
> statistically literate and could understand that any median given might
> have a geometric standard deviation of about 5, i.e. if he said 2 years
> that means anything between 5 months and 10 years. So please could he
> tell us, for patients with this sort of condition, what was the median
> survival time? OK, he said, about 18 months.
>
> So we borrowed a little money and booked a Christmas holiday to the
> Canary Islands, something she'd always wanted to do, About 8 months
> after we got back, she was bedridden, and six months after that she was
> dead. Given the time it takes to organise things like holidays when
> you've got school-age children, this statistical information even if
> uncertain, is all you've got to go on to make significant decisions. I
> wish the medical community could find an easier way of communicating it
> to patients and their families.
>
>
> Tim