Reading Room - To Chemo or Not to Chem: Evaluation of Risk of Recurrence in Stage II Patients
Posted: 15 Feb 2010 10:57 AM PST
Written by Kate Murphy.
Here’s a second article from C3 research advocate, Pam McAllister, based on information she learned at the 2010 GI Cancers Symposium in Orlando.
Pam’s experience with colorectal cancer research advocacy goes back more than a decade. She has been a patient advocate with several cancer cooperative groups and now chairs the Radiation Therapy Oncology Group (RTOG) Patient Advocacy Committee.
While most patients with stage II colon cancer are at low risk of recurrence, there are patients in this group who are at increased risk and who may need chemotherapy to reduce their risk.
The average stage II patient has an absolute benefit of only 1 or 2 percent from chemotherapy. In other words, the average Stage II patient will decrease risk of recurrence by only 1 or 2 percent it they have chemotherapy. And since chemotherapy has its own risks, it is important to identify those at increased risk whose potential benefit would be greater than average.
Currently a variety of factors are used to try to identify which stage II patients are at increased risk of recurrence.
One is the number of lymph nodes examined. Not only is examination of at least 8 to 12 nodes essential to accurate staging but the number of nodes removed is a strong prognostic indicator. In other words, people with more nodes removed do better than people with fewer. At the 2010 Gastrointestinal Cancer Symposium it was again confirmed that patients with 12 or more lymph nodes examined had a recurrence risk at 3 years about 5% lower than those with examined fewer nodes. It was further noted that the prognostic value of lymph node number was independent of the 12 gene recurrence score.
The 12 gene recurrence score (Oncotype DX Colon recently released by Genomic Health) reports patients as at high, medium or low risk of recurrence at 3 years. The recurrence scores range from an average risk of 12 % for low risk, 18% for medium risk to 22% for high risk.
Also frequently used to evaluate stage II tumors is lymphovascular invasion (the visualization of cancer cells in small vessels within the tumor), T stage (T3 versus T4), and the markers 18qLOH and MSI (microsatellite instability).
Microsatellite status has been shown to be a prognostic indicator in stage II colon cancer. Patients with pMMR (proficient mismatched repair) have worse outcomes than those who are deficient in mismatch repair (dMMR or MSI-H). The 5 year survival for patients who have pMMR is less than 75% in comparison with those who have dMMR (MSI-H) whose 5 year survival is greater than 90%. About 15% of patients have deficient mismatch repair (are MSI) and are a reduced risk of recurrence. A presentation at the ASCO Gastrointestinal Symposium indicated a need for physician education on the value of mismatch repair testing and use in treatment planning.
Those who have loss of heterozygosity at 18q, a place on a chromosome, (18qLOH) are at increased risk of recurrence.
Examination of these factors and others can assist patients and their physicians to decide whether or not to have chemotherapy. At this point, no single factor is adequate to guide treatment decisions. When many factors available are used together, though, sufficient information is available to assist physicians and their patients decide whether or not chemotherapy is warranted.
Since patients vary widely in the amount of decreased risk is necessary to justify the toxicity and expense of chemotherapy, the decision must be made on an individual basis. This will require better education of physicians so they can better inform their patients.
Comments
-
Hmm!
Thanks for this info on stage II.I understood *some* of it I am stage II and elected chemo. It was my choice as the onc. was ok with either choice. I was told that chemo would increase my chances of the cancer NOT recurring by about 7%.
I had 26 nodes taken during surgery and all were negative.Adenocarcinoma, low grade, ascending colon. Tumor was 7.5 x 4.6 cm and extended through wall into pericolic fat. 42 cm in all taken out. Had the DNA / microsatellite test ( which blue cross is balking on paying for )and it states " All markers are stable 100%. Results consistant with intact DNA mismatch repair function."
My question is what does this mean for me in reference to the article you published? Would I have been better off doing nothing? Or am I doing the right thing by winning as many marbles as I can? Anyone have any input?
-Pat0 -
Statistics?
Re:
"it was again confirmed that patients with 12 or more lymph nodes
examined had a recurrence risk at 3 years about 5% lower than those
with examined fewer nodes."
Those statistics are a bit skewed.
To get an accurate staging, twenty or more nodes should be removed;
less than that does not provide enough data for an accurate count.
A patient that has more than four infected nodes, is staged higher
than one with less than four infected nodes, and that changes
the staging and prognosis.
If they take 20+ nodes and only find 3 infected, that individual will
have a much better chance at survival, since the staging is truly accurate,
rather than the questionable "3 out of 10" attempt at diagnosis, that
may have totally missed the other infected nodes.
If they just took 10 nodes from me, they might have only found 3
infected nodes, and would have given me a much better staging and
prognosis... even though more infected nodes were actually in my
system and could cause a recurrence later.
While taking more than 20 nodes and finding 7 infected made my
prognosis more bleak sounding, it was the more accurate finding,
and provided a more accurate staging.
(Did I 'splain that right? I just washed my hair and can't do a thing with my head)
John0 -
Time will tell I supposeJaylo969 said:Hmm!
Thanks for this info on stage II.I understood *some* of it I am stage II and elected chemo. It was my choice as the onc. was ok with either choice. I was told that chemo would increase my chances of the cancer NOT recurring by about 7%.
I had 26 nodes taken during surgery and all were negative.Adenocarcinoma, low grade, ascending colon. Tumor was 7.5 x 4.6 cm and extended through wall into pericolic fat. 42 cm in all taken out. Had the DNA / microsatellite test ( which blue cross is balking on paying for )and it states " All markers are stable 100%. Results consistant with intact DNA mismatch repair function."
My question is what does this mean for me in reference to the article you published? Would I have been better off doing nothing? Or am I doing the right thing by winning as many marbles as I can? Anyone have any input?
-Pat
Even then, who is to say what kept the cancer away which hopefully will be your case. There are so many ways to deal with cancer as there are types of cancer. Personally, I would have taken the chemo too. That's my input on it.
-phil0 -
Thank youPhillieG said:Time will tell I suppose
Even then, who is to say what kept the cancer away which hopefully will be your case. There are so many ways to deal with cancer as there are types of cancer. Personally, I would have taken the chemo too. That's my input on it.
-phil
That helps to encourage me. Getting ready to leave out for my 6th with a numb hand, numb feet and 27 degree weather/ snow on the ground in the heart of dixie...LOL.
This too will pass...
Have a good day!
-Pat0 -
Pat -Jaylo969 said:Hmm!
Thanks for this info on stage II.I understood *some* of it I am stage II and elected chemo. It was my choice as the onc. was ok with either choice. I was told that chemo would increase my chances of the cancer NOT recurring by about 7%.
I had 26 nodes taken during surgery and all were negative.Adenocarcinoma, low grade, ascending colon. Tumor was 7.5 x 4.6 cm and extended through wall into pericolic fat. 42 cm in all taken out. Had the DNA / microsatellite test ( which blue cross is balking on paying for )and it states " All markers are stable 100%. Results consistant with intact DNA mismatch repair function."
My question is what does this mean for me in reference to the article you published? Would I have been better off doing nothing? Or am I doing the right thing by winning as many marbles as I can? Anyone have any input?
-Pat
Prior to finding out I had stage 3c (or 4, depending on onco) colon cancer,
all my "markers" were fine, and there had been absolutely no indications of
cancer anyplace in my simply marvelous body.
Cancer cells are difficult (if not impossible) to locate, when they're only
single cells; It's when they grow into masses, that they can be located.
Chemotherapy works by killing any cell that grows faster than the normal cells
that surround it, but chemo kills more good cells than the bad ones, regardless.
For that reason (for some people), using chemo, if it isn't going to help all
that much, can be the worse choice. Doing so will kill our good immune system
cells, and leave our body more vulnerable to diseases, infections, and the
progression of cancer.
Chemotherapy compounds are all well known carcinogenic substances,
and the frequency of "second cancers", or cancers caused by the chemo
drugs themselves, are very frequent.
Sometimes we can do ourselves more harm by not letting our
own body fight for itself. We can easily lose the battle with cancer,
by simply not being able to survive the battle with chemotherapy
and radiation.
Just sayin'......
John.0 -
Well, looks like my oncologistJohn23 said:Pat -
Prior to finding out I had stage 3c (or 4, depending on onco) colon cancer,
all my "markers" were fine, and there had been absolutely no indications of
cancer anyplace in my simply marvelous body.
Cancer cells are difficult (if not impossible) to locate, when they're only
single cells; It's when they grow into masses, that they can be located.
Chemotherapy works by killing any cell that grows faster than the normal cells
that surround it, but chemo kills more good cells than the bad ones, regardless.
For that reason (for some people), using chemo, if it isn't going to help all
that much, can be the worse choice. Doing so will kill our good immune system
cells, and leave our body more vulnerable to diseases, infections, and the
progression of cancer.
Chemotherapy compounds are all well known carcinogenic substances,
and the frequency of "second cancers", or cancers caused by the chemo
drugs themselves, are very frequent.
Sometimes we can do ourselves more harm by not letting our
own body fight for itself. We can easily lose the battle with cancer,
by simply not being able to survive the battle with chemotherapy
and radiation.
Just sayin'......
John.
agrees with you to a point. Went in for my 6th Folfox treatment today and she says no more Folfox. The neuropathy is getting too intense and she fears permanent disability if we continue. I will start Xeloda in a week and have my port taken out as soon as it can be scheduled.
I have very mixed emotions about this but I do trust her as much /probably more than any other doctor I've ever had.I think my fear is this: I have fallen through the cracks with almost every doctor I've seen in my adult life for other issues. I research and find the very best, most highly recommended doctors and they have made me suffer needlessly.I guess I'll just have to hope and have confidence that all will be well this time and proceed onward and upward.
-Pat0 -
Oh Pat... I can so relate....Jaylo969 said:Thank you
That helps to encourage me. Getting ready to leave out for my 6th with a numb hand, numb feet and 27 degree weather/ snow on the ground in the heart of dixie...LOL.
This too will pass...
Have a good day!
-Pat
I sure did pick the wrong time year to get cancer. )
It was about 23 outside this morning and I touched the metal screen door to let the dog out and I thought I'd burned my hands.
I keep forgetting gloves.
Really, I'm biding my time until we have some good weather. I want 70s. Now. )0 -
I THINK LIKE YOU...THANKS FOR SHARING!John23 said:Pat -
Prior to finding out I had stage 3c (or 4, depending on onco) colon cancer,
all my "markers" were fine, and there had been absolutely no indications of
cancer anyplace in my simply marvelous body.
Cancer cells are difficult (if not impossible) to locate, when they're only
single cells; It's when they grow into masses, that they can be located.
Chemotherapy works by killing any cell that grows faster than the normal cells
that surround it, but chemo kills more good cells than the bad ones, regardless.
For that reason (for some people), using chemo, if it isn't going to help all
that much, can be the worse choice. Doing so will kill our good immune system
cells, and leave our body more vulnerable to diseases, infections, and the
progression of cancer.
Chemotherapy compounds are all well known carcinogenic substances,
and the frequency of "second cancers", or cancers caused by the chemo
drugs themselves, are very frequent.
Sometimes we can do ourselves more harm by not letting our
own body fight for itself. We can easily lose the battle with cancer,
by simply not being able to survive the battle with chemotherapy
and radiation.
Just sayin'......
John.
Hi John..
I'm facing the same LIFE DECISION today...Chemo is highly recommended by my surgeon and my oncologist. I had rectal surgery Dec 30th 09. Tumor was 2.9 in greatest dimension. 3 of 23 lymph nodes taken were metastatic adenocarcinoma. I had a low anterior resection. I'm currently reading a book "100 Questions and Answers about Colorectal Cancer" by Drs David S Bub and W Douglas Wong. It is full of information and has stated in a few places that LOW RECTAL CANCER GROWTH HAS HIGH REOCCURENCE in the Pelvic Area. I haven't read all the details yet but--I've been freaked out ever since so am starting to gather more info. Since I'm only 1-1/2 months into recovery from surgery--I'm trying not to ruminate about future happenings and let my recovery take a natural course. Just writing about this dilema to all of you makes me feel better. I just don't believe I'd survive the BATTLE WITH CHEMO/RADIATION due to my high intolerance of pain and my age. Also..I'm still anemic from the past condition and lost lots of weight. KEEP ON SHARING YOUR THOUGHTS! Thanks..
MaryJane0 -
tiny partial answer???Jaylo969 said:Hmm!
Thanks for this info on stage II.I understood *some* of it I am stage II and elected chemo. It was my choice as the onc. was ok with either choice. I was told that chemo would increase my chances of the cancer NOT recurring by about 7%.
I had 26 nodes taken during surgery and all were negative.Adenocarcinoma, low grade, ascending colon. Tumor was 7.5 x 4.6 cm and extended through wall into pericolic fat. 42 cm in all taken out. Had the DNA / microsatellite test ( which blue cross is balking on paying for )and it states " All markers are stable 100%. Results consistant with intact DNA mismatch repair function."
My question is what does this mean for me in reference to the article you published? Would I have been better off doing nothing? Or am I doing the right thing by winning as many marbles as I can? Anyone have any input?
-Pat
I do know that if you are microsatellite stable, you are in the majority of patients. I had the test too, and the first oncologist I went to said this is a bad marker -- it's the microsatellite instable people who have the best survival rates. I was really bummed to know I was in the "bad" microsatellite group. Kind of like the Starbelly Sneetches.
Then when I went for my second opinion visit to another oncologist, I told him I was bummed out because my marker tests came back that I'm microsatellite stable and I knew that was bad.
He said, "Well, yes, it's better to be microsatellite instability than stable because the lucky few that are MSI have higher survival rates, but did that other doctor also tell you that MOST colon cancer patients are microsatellite stable so you are well in with the majority????" He further said most patients aren't able to get the test unless they are in a clinical trial because insurers balk at paying for it (like you found out with BCBS), but if everyone got it, a huge majority of people would find out they were MS stable.
I had a kind of a good laugh about that in retrospect because it just goes to show you that information can be so subjective depending on how it is told to you, by whom, and what other info you get along with it (and how well you can understand its context). I'd gone around two or three weeks depressed that I had the "bad" marker result and then I found out so does most everyone else. It made it seem less horrible :-)
K10 -
0 out of 93PhillieG said:Interesting
Doesn't apply to me in that I am at Stage II squared but hopefully it can be of benefit to others.
I had 93 lymph nodes sectioned and I am 0 of 93...so with the info from this study - I am at a less risk of re-occurance?
I am KRAS mutation positive
Genetic testing was negitive
Stage ll June 09
have 2 more rounds of Folfox (10 completed - 9 with Oxiplatin)
completed 25 fractions of radiation with Xeloda
I need to research the Microsatellite status - this is new to me - if you have any additional info = could you please share?0 -
chemomaryjane said:I THINK LIKE YOU...THANKS FOR SHARING!
Hi John..
I'm facing the same LIFE DECISION today...Chemo is highly recommended by my surgeon and my oncologist. I had rectal surgery Dec 30th 09. Tumor was 2.9 in greatest dimension. 3 of 23 lymph nodes taken were metastatic adenocarcinoma. I had a low anterior resection. I'm currently reading a book "100 Questions and Answers about Colorectal Cancer" by Drs David S Bub and W Douglas Wong. It is full of information and has stated in a few places that LOW RECTAL CANCER GROWTH HAS HIGH REOCCURENCE in the Pelvic Area. I haven't read all the details yet but--I've been freaked out ever since so am starting to gather more info. Since I'm only 1-1/2 months into recovery from surgery--I'm trying not to ruminate about future happenings and let my recovery take a natural course. Just writing about this dilema to all of you makes me feel better. I just don't believe I'd survive the BATTLE WITH CHEMO/RADIATION due to my high intolerance of pain and my age. Also..I'm still anemic from the past condition and lost lots of weight. KEEP ON SHARING YOUR THOUGHTS! Thanks..
MaryJane
Hi MaryJane..
If chemo is highly recommended by your surgeon and your oncologist, do the chemo. The conventional treatments for low rectal cancer (what I had) take into account that this particular cancer has a high local recurrence rate. That why we rectal cancer patients ordinarily get radiation to kill off those residual cancer cells in the pelvis. After my LAR, I had chemoradiation; there was little pain, and I'm almost 68 -- are you much older than that? I can't guarantee it, but I think there is a good chance you'll do just fine.
--Greg0 -
MchappMchapp said:0 out of 93
I had 93 lymph nodes sectioned and I am 0 of 93...so with the info from this study - I am at a less risk of re-occurance?
I am KRAS mutation positive
Genetic testing was negitive
Stage ll June 09
have 2 more rounds of Folfox (10 completed - 9 with Oxiplatin)
completed 25 fractions of radiation with Xeloda
I need to research the Microsatellite status - this is new to me - if you have any additional info = could you please share?
I personally don't know very much about the microsatellite instability fragment analysis.What K1 posted made more sense to me than anything else I have heard. I was still in the hospital and very drugged up when they sent a portion of my tumor off to have the DNA testing. I do know that it was sent to Genzyme Labs in Los Angeles, Calif. and it has been under 'review' with my insurance for over a month. I just hope they will eventually pay some of the cost which was $2,200.00.
Maybe if you start another thread asking about this specifically more people will see it and pipe in.
Best wishes,
-Pat0
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