Let's do the chemo mañana...
November 26, 2009 10:23 AM   Subscribe

In cancer treatment, how much does delaying chemo by a couple of weeks exacerbate recurrance risk?

My mother has breast cancer. Based on the biopsy report, it's fairly aggressive, hormone-receptor negative, and had spread to the lymph nodes in her armpit on the same side as the breast with the tumor. She had the tumors removed last week, and is recovering well from the surgery.

She lives in a relatively small city, and the first opportunity to see a local oncologist is on Dec 15, which seems like a long time away. However, there are some larger cities nearby where she could probably see someone sooner. I'm thinking that she could get a recommendation for a chemo regime from further away, then receive the treatment in her home town. However, for reasons I don't understand, her surgeon is resistant to this idea. Money is not the issue: she is loaded. I'm wondering how hard I should push on this. Is delaying the chemo by a couple of weeks likely to substantially increase the risk that the cancer will recur? I would have thought by doing the chemo while the metastases were still small, you could reduce the risk of a chemo-resistance mutation, because there would be fewer cancer cells to explore the space of possible mutations. (I will be asking the surgeon this, too, of course, but I'm looking for an unbiased view. Any pointers to research papers bearing on this question would be particularly welcome.)

Ideally this would be her responsibility, but she can't seem to think about it clearly because there is a big elephant lumbering through the room with "CANCER=DEATH" inscribed in large gothic script on both its flanks, and she won't go near it. She affects a child-like faith in the good intentions and skills of her surgeon, and any time I try to talk about the risks or the personal responsibility to verify that the treatment makes sense, she freaks out or retreats into assertions about the surgeon's skill and positive outlook. (Despite the fact that he has told me that statistically, she's in pretty bad shape.) So I feel like the responsibility's on me, to a certain extent, and I can't communicate effectively with her on the issue. Doesn't help that I'm on a different continent...

The surgeon says that based on the pathology results so far from the analysis of the main tumor, he believes that the tumor is HER2 positive, but we don't have the results for the HER2 lab test back, yet. There were no obvious metastases in a full-body scan, and he said he found no evidence that the cancer had colonized the exteriors of the lymph nodes, which he says is a good sign.
posted by Estragon to Health & Fitness (9 answers total)
Generally in my city, breast cancer tumors are treated with chemo first and then radiation. For whatever reason (and it was incidental to my treatment) I had radiation first and then chemo. I had my surgery in February, started the radiation in May, and then started chemo in July. For my type of breast cancer I was told that the chemo increased survival rates by 6%. I don't remember what information I was given regarding recurrence. It was 8 years ago during which time I've been fine.

My experience, and my conditions may have been wildly different from your mum's, was that a couple of weeks delay would make no appreciable difference. My cancer was aggressive, pre-menopausal, hormone receptor positive, but my lymph nodes were clear.
posted by angiep at 12:10 PM on November 26, 2009

My guess is that no one can tell you for sure. It's all a matter of probabilities. Sooner is better than later, and the more aggressive the cancer, the more urgent the treatment. On the other hand, the chemo regime, if it's anything like what friends of mine have gone through, is going to last six months to a year, so a two-week delay is not major relative to the length of the treatment itself. The treatment will wear her down considerably as it goes along. My suggestion would be to use the two weeks to help her recover as fully as possible from the surgical procedure and to regain as much strength as possible for the chemo. Attitude is important, and if she's happy with the surgeon ("childlike" or otherwise), you should probably not jeopardize that by trying to get her to a different surgeon she doesn't know, is farther away from, and might not be happy with.
posted by beagle at 12:11 PM on November 26, 2009

Thanks to both of you for the advice. It looks as though there's no clear advantage to earlier treatment over these timescales, anyway.
posted by Estragon at 12:17 PM on November 26, 2009

I am a scientist that's not studied cancer directly but I've learned a lot along the way through classes and whatnot. If I was your mother, I personally would not delay.

More importantly, I would be getting at least one other opinion aside from just this surgeon, and that opinion would be from a cancer center affiliated with a big, well-known, research university.

Best of luck to you.
posted by sickinthehead at 3:20 PM on November 26, 2009

Wait for the Oncologist visit: he/she will have all the tests results by then and be better able to devise the correct treatment.
In my lab we do FISH (fluorescent in situ hybridization) for HER2. (mostly we test patients whose results are not clearly negative or positive by immunostaining)

This is the time line:

1. from Surgery to Pathology, just a few hours
2. from Pathology to our lab, anything from 2,3 days to two weeks
3. in our lab, a minimum of 3 days ( the test itself takes 2 days) to 7 days

There are other tests performed on tumors and leukemias, specifically cytogenetics and molecular, that take even longer. While you might be able to see a specialist in a larger city sooner, keep in mind that the transfer of medical records to a specialist not in the surgeon loop might also delay treatment. Do ask for a second opinion if you feel any bad vibes in regard to the treatment.

Feel free to Me-mail me if you have specific questions.
posted by francesca too at 4:22 PM on November 26, 2009

The American Cancer Society has navigators you can talk to on the phone or online during certain weekday hours. They are really good at answering questions like this, and should be able to help you find someone for a second opinion and/or a quicker appointment, or ease your mind about the wait. This page has all the contact info, and though the URL sort of appears to be be region-specific, the information is valid for people all over the U.S.
posted by vytae at 9:30 PM on November 26, 2009

I used to work at ACS. The online navigators are a region specific resource. You need to call 800-227-2345. That number is open and staffed always-- 24/7/365. You can call them right now, even. They will not be able to answer this question right away because it's too specific and hypothetical in nature, so they will have to send this question to be researched. The person who actually researches it has medical training and will have to call you back in 1-5 business days.
I will tell you that this question is nearly impossible to give you a very concrete answer. IANAD, but I will tell you that it is very common for people to wait this long before starting chemo. However, it is never a bad idea to get a second opinion, so there's no reason not to get her an appointment with a doctor in the city. They will want as much of her path reports as possible, so whatever you can get should be sent over. The first doctor will almost certainly be totally cool with this, as most doctors understand the importance of second opinions in making treatment decisions.
posted by ishotjr at 9:48 PM on November 26, 2009

Thank you all for your information and suggestions. The ACS sounds like a valuable resource.
posted by Estragon at 5:36 AM on November 27, 2009

I'm an almost-three-year cancer survivor. For me, BreastCancer.Org was an invaluable resource. It is run by an oncologist - there are articles, fora, all kinds of info.

My timeline went: surgery (lumpectomy) in February; chemo April-September: radiation, October. IANAD and IANYD, but my understanding is that the type of breast cancer where immediate chemo does make a difference is the highly aggressive inflammatory breast cancer (the kind that killed Molly Ivins). If it's not inflammatory you can take a few weeks to research and decide treatment, so a couple weeks' delay in chemo won't make a difference.

Best of luck to your mom. MeMail me if you want to talk more.
posted by Rosie M. Banks at 3:09 PM on November 27, 2009 [1 favorite]

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