Expert: Claes-Gustaf Nordquist, M.D. - 8/4/2009

Question
Dr. Nordquist:

I am 59 and in good health except for this breast cancer.

Stage 3a IDC (moderately differentiated)
Lack of insurance prevented treatment until tumor in breast was 8cm; and a half dozen visible swollen lymph nodes were in arm pit.   “looked” like inflammatory with hardening,  nipple pointing toward west instead of north, and peau d'orange, but told that it was invasive  not inflammatory.  
At diagnosis (8/21/08), these were results:
Estrogen receptor: 85.8% positive
Progesterone receptor: 68.6% Positive (though 4/14/09 surg path report says negative)
HER2 amplification: Negative (1.50)

Treatment 11/08-7/09:  
October-December 08:  4 rounds of Adriamycin/Cytoxan - CA27-29 went from 99 to 43; breast visibly less deformed, shrunken (was about ½ its normal size pre-chemo).  Was told that I didn’t need the next 4 cycles of Taxol (and given the side effects I dealt with on A/C, that I probably wouldn’t tolerate it).  Surgeon said I was resectable.  Took a couple months to re-grow the skin on my hands.  
4/14/09:  Mod radical w/axillary node dissection– Path report: Nottingham 7, tubules 3, nuclei 3, mitoses1 was clear margins (1cm); 6 of 11 nodes removed were malignant and residual cancer on chest wall.
5/26/09-7/13/09:  Radiation (the usual dose) 28 + 5 booster to scar.  
Femara since January 09 - 2.5mg/day

Current:
CA27-29 is 28 as of 7/22
CT scan of 7/28: Dr notes: “previous mastectomy” – 2 cm axilla lymph node “decreased in size.”

So, today, I have cancer in my armpit and don’t know what re chest wall but not sure that it matters much given the armpit status.  I was told that ‘radiation keeps working for a while’ though I don’t really understand how that could be.  

QUESTIONS:  
Assuming that radiation does keep working: how long should I wait to learn whether the remaining cancer is “gone” (near as one can tell).

If that cancer is STILL present after the above time interval – then what are the usual options?
If that cancer is NOT seen, I’m assuming AI is usual course of treatment.  Am I wrong about that?  

Is it possible that my progesterone receptors were 68.6% positive in 8/08 and negative in 4/09?  How does that result affect choice of hormone therapy at this point?  

I sincerely appreciate the time you take to address my concerns.  I have been quite frustrated in my efforts to determine what, if anything, to do or not do given the information I have been able to glean from a wide variety of resources.  Feels like I may have to relinquish my remaining sanity to deal with this breast cancer in an informed manner and “the system.”   
Gratefully,
PJ


Answer
Since it seems you already have hormonal treatment (Femara) I'll not go into that. But ask the pathologists to recheck your tumor hormonal receptors if possible. I do not think you should wait (waiting has certainly not benefited your treatment so far). Also ask your radiation therapist if there is any possibility of giving you high voltage electron radiation therapy to your chest wall and arm pit. So additional radiation therapy. If that is possible & meaningful depends on your previous radiation dose.