One of the most irritating things about breast cancer is the lack of certainty around treatment. I mean, you break your leg, you go to the hospital, they set it, put on a cast, give you a pair of crutches, and off you go. Got a sore throat? If the strep test is positive, you’re sent out the door with a prescription for antibiotics. The only thing you need to decide on is CVS or Rite Aid.
But if you’re diagnosed with breast cancer, the path is never straight. Right out of the starting gate, you’re given an option: lumpectomy, or mastectomy? Decide. The oncologist and surgeon could suddenly pass for professional poker players, their faces revealing nothing. Do you save your breast and roll the dice with a lumpectomy, hope if they get clean margins that they’re REALLY clean, and then trust that radiation mops up any surviving cancer cells? Or do you opt for a mastectomy, get rid of all the cancer by getting rid of all the breast tissue" and lose your breast in the process? Tough decision.
And then there’s chemo. This one is sometimes a bit easier; if cancer has traveled to your lymph nodes – even a single node – chemo’s almost a given. But if you’re node negative, but you’re stage II, intermediate grade" in other words, right on the edge of probably needing chemo, but maybe not – decision time. Do you want to go through chemo – lose your hair, and run the risk of a horde of other side effects – in order to lower your risk of recurrence by a small amount, say, 4%? How lucky do you feel? Tough decision.
Well, for those of you sitting squarely on the fence trying to decide the chemo issue, help may be available. A test called Oncotype DX has gradually been making its way into the marketplace, and it appears to be quite reliable in assessing your chance of recurrence. Here’s how it works: RNA is extracted from your tumor, and then analyzed to determine the level of expression of each of 21 specific genes.
The results of the analysis determine the likelihood of breast cancer recurrence within 10 years of your initial diagnosis. You’re assigned a recurrence risk of low, medium, or high. And in ongoing clinical trials, it’s been determined that 6.8% of women with an Oncotype DX recurrence score of "low" did in fact see a recurrence; 14.3% of women with a "medium" score had a recurrence; and 30.5% of women who scored "high" had a recurrence.
Obviously, if you have this test and end up with a high score – your chance of recurrence is about 1 in 3 – you’ll be thinking seriously about chemotherapy. But if your score is low, and your recurrence risk is only about 1 in 14, you may be willing to forego the chemo and take that chance. And if your score is in the middle? One in seven chance. Again – how lucky do you feel? Sometimes you just HAVE to roll the dice
Note that this test is appropriate ONLY for women with a specific prognosis: early-stage (node-negative OR node-positive), estrogen-receptive breast cancer that will eventually be treated with tamoxifen or an aromatase inhibitor. But that particular group is a large one; and if you’re in it, and are trying to make a chemo decision right now, ask your doctor about Oncotype DX.
Understand that there may be other factors with your particular situation that influence the chemo/no-chemo decision heavily; your doctor will tell you if that’s the case. But if, after everyone’s best efforts at assessing your situation, it still comes down to "Do I REALLY need chemo?" – you might opt for the test. (After checking your insurance, of course. It’s quite expensive-about $3,500-and while it’s covered under Medicare, not all private insurance plans pay for it.)
PJ Hamel is senior digital content editor and food writer at King Arthur Flour, and a James Beard award-winning author. A 16-year breast cancer survivor, her passion is helping women through this devastating disease. She manages a large and active online survivor support network based at her local hospital and shares her wisdom and experience with the greater community via HealthCentral.com.