By Mukund Nadipuram, MD
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Today the treatment plan for women with breast cancer is tailored to each patient depending on certain test results. Tumors are examined by a pathologist to determine the type of breast cancer it is, as well as newer tests that could be helpful in tailoring treatment options.

One of the tests for identifying the specific type of breast cancer a woman has is whether the tumor is Estrogen Receptor(ER) positive or not. If a tumor is ER-positive, that means the tumor growth is fed or accelerated by estrogen. In many cases, a drug is used to suppress the estrogen production, (estrogen blockade) thereby preventing growth of the cancer cells. Other deciding factors for treatment include tumor size and axillary lymph node involvement. Approximately 25,000 women were diagnosed with ER-positive breast cancer with negative axillary lymph nodes (no sign of spreading) in 2005. This type of breast cancer accounts for half of all breast cancers. Treatment guidelines recommend chemotherapy for all women whose tumors are 1 cm or larger, and for smaller tumors if some of the tissue tests indicate a less favorable long-term outcome.

Approximately 80% are treatable with ―hormonal therapy‖, such as the drugs Tamoxifen or Arimidex. Adding chemotherapy reduces the risk of recurrence; however the absolute benefit for the individual patient is small and ranges from 2 to 5%. Therefore, the vast majority of patients taking chemotherapy for ER-positive breast cancer with negative lymph nodes may be over treated, and may have benefited from hormone therapy alone.

Treatment recommendations have generally been based on several predictive features. There are tools that are currently available such as "adjuvant online", providing decision making help for clinicians and patients. Although such tools helps somewhat to make informed decisions, when faced with the choice, many patients and clinicians error on the side of over-treatment because of imprecise nature of predicting treatment benefit.

What is OncoType DX ?
A number of molecular diagnostic tests and prognostic molecular signatures have been evaluated which are also commercially available now.

OncoType DX is: 1. A currently standardized multigene, (21 genes/16 tumor genes, and 5 reference gene), study by molecular technique. 2. It is done utilizing the tumor tissue that is removed from the breast. 3. It more reliably predicts prognosis than standard clinical criteria in patients with ER-positive, node-negative breast cancer. 4. Its performance has been validated in a large population 
based study.

How is OncoType DX resulted?
The assay (or analysis) includes 16 tumor genes and 5 reference genes with the result expressed as a computed recurrence score. Less than 11 is a low risk. Between 11 and 25 is intermediate risk. Greater than 25 is high risk.

A National Surgical Adjuvant Breast and Bowel Project (NSABP) clinical trial indicated that only patients with an elevated recurrence score derived benefit from the chemotherapy. It is clear that patients with very low recurrence score do very well with hormonal therapy alone, and patients with very high recurrence score benefit from chemotherapy, but, there is still uncertainty as to whether chemotherapy is necessary for patients who have mid-range, (11 to 25 recurrence score), and who meet established clinical criteria for "adjuvant chemotherapy". Hence there is currently an ongoing clinical trial (TAILORx) to address this exact question.

OncoType DX represents a major step forward into the era of personalized medicine for breast cancer. By integrating a molecular diagnostic test into clinical decision making, patients and clinicians will be able to make more informed choices regarding the most appropriate treatment options. 

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by Debra (DJ) Corson

Seven was never my lucky number. I should have known it would be bad news when I was scheduled to learn the results of my biopsy for breast cancer on 7- 17-07.

To share my story, I have selected excerpts from my journal and ―updates‖ sent to friends and family.

Surgery
Our son asked me how I was doing as I was leaving for surgery. I said, ―I feel like this is the first day of feeling bad for months.‖ He said, “Mom, I believe this is the first day of you getting better.”

Chemo
Saturday—not great, but OK. Sunday—definitely not good. I better take something for this nausea thing…hum, I have three different meds for nausea, which one? This one can make you dizzy, this one is likely to cause a huge headache, this one makes you drowsy. Monday—THIS is BAD! Must not have taken the right thing for nausea … Food repulses me. I can’t watch TV because it is full of food commercials. I just want to get into a dark room, crawl into a ball, and sleep. It’s important for me to focus on the chemo as helping me get to better (not making me sick).

Losing my hair
It is always so windy at Hawkeye (Community College). When I walk across campus, I take $20. If my wig blows off, the accumulative effects of the chemo have me so worn down, I know I can’t run after it. With the 20 bucks, I’m hoping some passing student will run after it for the reward money.

From where we draw strength I’ve been playing the song Stand, by Rascal Flatts repeatedly. It helps me stay strong. The outpouring of support from friends is both overwhelming and humbling. All I can do is appreciate with my whole heart what has been done for me. Then, pay if forward because I can never pay it all back.

Finishing treatment
A celebration—my hair is growing back! I feel like a CHIA pet--just put some fertilized mud on my head, water it, and watch it grow! I’ll be glad when I have enough eyelashes to use mascara again. Wouldn’t you know, the wild hair on my chin is already back! I am in charge of my attitude, what I contribute to life, and how I treat my body. I am NOT in control of the outcome of this illness. I can hope for a miracle, but I cannot make one happen. And I am not a failure if one doesn’t happen.

My husband, who is in law enforcement, often talks about SMTs--Scars, Marks, and Tattoos. ​In his work, they are important for identification purposes. Breast cancer surgery, chemotherapy, and radiation gives survivors some SMTs of their own, but they aren’t just physical.

Our physical, emotional, and spiritual scars, marks, and tattoos serve as an important part of our identification: who are we today, and who we are becoming. 

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