Oncology (General Cancer)/Breast Cancer Mets to Brain
QUESTION: Hi Dr Higby,
You have been of tremendous help to me in the past and I hope you can answer a couple of questions for me.First, just a little background regarding my wife. She is 45 and was diagnosed
in 12/08 with HER-2+ , ER+, PR+ breast cancer that was believed to be stage 4 due to hilar lymph node involvement. She responded well to chemo, but in 6/10 had a local recurrence which led to double mastectomy. At that point, the oncologist stopped herceptin treatment since she progressed while on it. She had
a seizure in 11/11 that led to a brain MRI, showing what they thought might be a meningioma at the time but following scans showed it most likely to be metastasis. The neurosurgeon and oncologist agreed to remove it, and they did in June, completely removing the metastatic tumor with good margins. She then had cyberknife surgery with good results. The CT scan was clear at that time, and the oncologist decided to wait before giving chemo or pills. I wrote to you at that time, and you said his plan is rational, but you would advise gentle therapy. With our most recent brain MRI, a small 4mm tumor was found in the frontal lobe. A CT scan showed no evidence of disease elsewhere. The surgeon, radiation oncologist and oncologist all agreed cyberknife was a good option at this point. However, now the oncologist has prescribed aromasin. I have a few questions,and I appreciate your knowledge as always:
1) I know you recommended aromasin/tykerb initially after the first brain met was found, but why do you think the oncologist is recommending aromasin now and not then? I know you can't speak for him, but is it because he even moreso expects cancer to pop up elsewhere due to the new met?
2) I don't want to create more fear for my wife when meeting with these doctors, but I would expect more mets to pop up soon in the brain, is that correct? They did say they will do follow up MRI 1 month after cyberknife, then every 3 months thereafter. Would they most likely save whole brain radiation in the event of multiple mets? They say they don't want to do that now because of the possible dementia.
3) One positive I see is still no disease elsewhere in her body. Does this give her prognosis a little better outlook? Realistically, how much time could one expect in her situation? She is always asking me for a range based on what I read(which is usually about 1-2 years), but her doctors don't want to give her one, I think because they know she is a bit depressed and want her to keep fighting.
Thanks as always for your help, it is truly appreciated.
ANSWER: Recurrence in the brain after initial treatment with surgery and cyberknife therapy is not a good sign. Such patients generally don't do well, even though there may be no metastases elsewhere. Some breast cancer cells thrive in brain tissue but don't do well in other parts of the body. I would expect her to have more brain mets in the future. Aromisin may delay the recurrences but would probably not eliminate the possibility. As for why your oncologist didn't start before, all I can say is that he may have reasoned as follows: If that tumor was the only one in the body and it's been killed by the treatment, she is cured and won't need additional therapy, so why give it? On the other hand, if something recurs, then aromasin (and maybe tykerb) would give her another shot at control. That's rational. My own approach might have been to initiate what I feel would be a gentle and tolerable therapy, and that might have delayed the recurrence. If she recurred with a little tumor known only through the MRI, that's great, but sometimes they recur in an area that is "eloquent" and even with treatment there is residual neurologic damage. So it's six of one, half dozen of the other.
I think a range of 1-2 years is realistic, although I might not be so optimistic. Hope this helps.
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QUESTION: This does help, thank you. Just one more quick follow up please. What kind of results have you seen with cyberknife? The oncologist and radiation oncologist seemed confident it would take care of the tumor, which we thought to mean would get rid of it, at least as far as a scan could show. However, when we met with the surgeon separately, he said it might not be likely to completely take care of it, and that just arresting it's development and keeping it the same size would still be considered a success.He said it could even grow a bit due to being inflammed from cyberknife. What would be your expectations? Are breast cancers more reactive to cyberknife then some others? Thanks again.
cyberknife therapy involves giving a very focused dose of radiation to a tumor; in this way a much higher dose can be given, with less damage to the surrounding tissue. This is especially good for brain lesions. The problem with diseases like breast cancer is that we usually only see the tip of the iceberg, and most likely other spots will pop up as time goes on. However, in the areas treated by the cyberknife, the tumors should not recur. Obviously you can only treat the brain with cyberknife therapy up to a certain point, because you do destroy some brain tissue when you use this modality. So she should get rid of the tumors that can be seen. However, it's unlikely that this will cure her, but I'd try anyway. Hope this helps.