Expert Tips for Choosing Your Treatment


"The choice between lumpectomy and mastectomy depends on location, size, and appearance."(DEBORAH L. TOPPMEYER)

Deborah L. Toppmeyer, MD, specializes in medical oncology and directs the New Jersey Comprehensive Breast Care Center at the Cancer Institute of New Jersey.

Q: How much time do I have to decide about treatment?

A: Waiting a couple of weeks after your diagnosis to decide what kind of surgery to have (and whether you want reconstruction, if that's an option) won't make a difference for the cancer's growth. It may be as much as six weeks after that before you're able to schedule the surgery. The key thing is not rush into any sort of treatment decision.

Q: What are some key decisions I'll have to make?

A: After a cancer diagnosis, the first question is what type of surgery will you have—a lumpectomy (with sentinel node biopsy) or a mastectomy. There is absolutely no difference in survival rates, but everything from the stage of your cancer to the size of your breast may figure into this decision. The next question for mastectomy candidates is: Do you want breast reconstruction, and if so do you want it immediately after the surgery or later on? You also may need to decide whether to have chemotherapy to kill any cancer cells that may have been left behind.

Q: What do the different stages of breast cancer mean for my treatment options?

A: There are four stages reflecting how advanced the tumor is. In stage I, the tumor is less than two centimeters across and the cancer hasn't spread to your lymph nodes. Stage II could involve a larger tumor with no lymph nodes or a small tumor with a few lymph nodes. Once the tumor has spread outside the breast and lymph nodes, it becomes stage IV. At stage II or III, we usually recommend chemo plus hormone therapy and Herceptin, if appropriate, and radiation if the patient has a lumpectomy or lymph nodes are involved. But your treatment options depend on more than the stage.

Next Page: Avoiding a mastectomy

[ pagebreak ] Q: Is it possible to avoid a mastectomy if my tumor is more advanced than stage I?

A: Absolutely, because the decision is not based purely on the size of the tumor. The choice between lumpectomy and mastectomy depends on where the cancer is located; how much tissue will be sacrificed to remove it; and how your appearance will be affected afterwards. If a woman has a very small breast and a large tumor, for instance, she may be better served with a mastectomy and reconstruction. We often use chemotherapy to shrink a tumor in order to make it more easily removeable by surgery.

Q: Do all women with breast cancer have to have surgery?

A: Yes, unless the breast cancer has spread to other parts of your body. Studies have looked at using radiation to target very tiny tumors without having to perform surgery, but that's very experimental.

Q: What are the chances I'll need chemo? If I need chemo, will I be able to choose the least toxic options?

A: Seventy percent of women diagnosed with breast cancer have an early-stage tumor, and of those about 50% are recommended for chemotherapy. Chemo is perceived as being toxic, but the goal is to kill any cancer cells that have escaped from the primary tumor. We have better supportive therapy these days, such as anti-nausea medication and meds to stimulate white blood cell count. Chemo has evolved to offer a wider spectrum of choices, but certain agents are better for some kinds of tumors than others. It's not just a matter of picking the least toxic—you want to work with the regimen that will prevent your cancer, with its particular molecular characteristics, from coming back.

Q: What are common side effects of chemotherapy? Do some women not take chemo because of side effects?

A: You may experience nausea, hair loss, and/or a decrease in blood counts, but the side effects depend on the chemotherapy regimen. Certain drugs have easier side effects, but you want the treatment that is most effective for the particular characteristics of your cancer.

Q: Will chemotherapy make me infertile?

A: Certain chemotherapy drugs are more likely like to cause infertility than others—and age is also a factor. The older you are, the greater the likelihood that a chemo drug will induce menopause. But generally speaking, chemo moves up your menopause by about five years.

Next Page: Complementary therapies

[ pagebreak ] Q: I've heard complementary therapies can help with side effects. Is that true?

A: Nothing has been shown in clinical trials to relieve the side effects of chemotherapy. But some people report benefits from therapies such as Reiki, massage, and acupuncture.

Q: Which drugs will help reduce my risk of cancer in the future?

A: If you have hormone-positive breast cancer, you can take tamoxifen or an aromatase inhibitor to reduce the risk that the cancer will come back. Some patients choose not to take them because of side effects, but I find the benefits far outweigh the risks. These don't come into play until you've completed other treatments; you'll generally continue on them for about five years.

Q: When is it a good idea to seek a second opinion?

A: I recommend getting a second opinion when you're diagnosed. And I would encourage patients to consider getting an evaluation at a National Cancer Institute comprehensive cancer center, where there's also information about clinical trials available to them.

Q: Should I participate in a clinical trial?

A: I recommend clinical trials because they give patients access to cutting-edge treatments. People have misconceptions about clinical trials—these are not placebo trials where somebody gets an active drug and somebody else doesn't get anything. Your treatment is always as good as the standard of care.

Q: What does it mean for my treatment if I'm "triple-negative"?

A: If you're triple-negative, your cancer tests negative for estrogen receptors, progesterone receptors, and HER2/neu—which means you can't take hormone therapy or Herceptin so don't have as many treatment options. About 15% of breast cancer is triple-negative.