Breast Cancer: The Treatment Decision
Guest: Dr. David Cole - Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. David Cole who is professor and chair of the department of surgery here at the Medical University of South Carolina. We are going to be talking, in this podcast, about surgical treatment options for breast cancer. Dr. Cole, in the old days certainly, radical mastectomy was the treatment of choice for women who were diagnosed with breast cancer. You approach it very differently now. When you have a patient referred to you who has a new diagnosis, what are some of the first steps that you take in evaluating that woman further?
Dr. David Cole: Well, the good news is that often we have the privilege of discovering cancers earlier and when they are smaller which gives everybody the opportunity to be far more effective in treatment of the cancer. At the end of the day, your outcomes, cosmetically, physically and emotionally, are improved. So, first issue is diagnosis because often times when I see a patient, they are not sent necessarily with the diagnosis of breast cancer. What they are sent with is an abnormal mammogram of breast mass and a lot of anxiety. So, usually the first issue is trying to resolve the question and I will get more specific.
Let’s say the question is a mammographic abnormality. Our first goal is to, as rapidly as possible, as part of the team we have in place, address the mammographic abnormality, get a diagnosis to determine whether it is cancer or not. Now, the good news is that the vast majority of women who present with a mammographic abnormality do not have breast cancer. Maybe only 15 percent of mammographic abnormalities represent a cancer or pre-cancer. But, for the other 85 percent, the more quickly we can remove that from their plate, the better. You know, we have a grateful patient that is happy not to have to worry about something more dire.
But then, on the 15 percent, now we can focus on the actual treatment of the breast cancer and we talk. My conversation is usually is centered on three things. First, what do we need to do to get rid of the cancer and minimize the chance of it coming back? In other words, how are we going to deal with the breast and where the cancer started? You know, in years past, as you mentioned, mastectomy was really the only option in terms of dealing with the breast. Thankfully, we have equal option which, to my mind, has major cosmetic advantage with equal outcomes, which is an adequate lumpectomy. Understand that lumpectomy needs to be paired with radiation to be equal to the standard of mastectomy. So, most times the conversation is, you need to understand as a patient, you have these options. But, if it is appropriate from a medical and surgical perspective, my bias would always be to pursue a lumpectomy. Remove the cancer so the pathologists are happy that the margins are negative. Then, we will talk about the options in terms of adjunctive or preventive radiation to the breast, to prevent an unnecessary risk of local recurrence.
So, that is one. Get rid of the cancer, makes intuitive sense. The second question is, and this is a bigger picture, what is the risk involved? There are a lot of terms used for that in doctor, physician terms: i.e. staging. You know, patients really want to know, what are the odds of my dying from this cancer, how dangerous is this? So, the three things that we look at, in today’s world, size of the tumor, and smaller is better. A 1 or 2 mm cancer is far less dangerous in terms of spreading than a 5 cm cancer. Markers on the tumor, currently estrogen and progesterone receptor and HER2 status, are things that we look at. Sort of like flavors of ice cream, they give you a relative flavor, or feel, for what you are dealing with. And then, importantly, does the cancer have evidence of spread to the regional lymph nodes? So, with those three pieces or information in place, assessing the risk, then we can go to the
third component which is addressing the risk.
So, if somebody has a greater risk, we are going to talk more about systemic therapy as a preventive measure, chemotherapy, estrogen blockade, or nothing, depending on what the details are. So, I tell most patients that the third component is something we need to think about but right now, we do not have enough information. We need to assess the lymph nodes surgically and see if there is any microscopic evidence of spread. We need to know, ultimately, the size and nature of the cancer that we are dealing with. Then, we will sit down and make rational decisions about what needs to be dealt with in terms of preventive strategies with the oncology member of the team. As an example, if you have a 95-year-old woman with a low-risk cancer, it makes zero sense to give chemotherapy. If you have a 27-year-old woman with a high-risk cancer, typically they are going to take the kitchen sink and throw it at her, in a positive preventive manner.
From a surgical perspective, then, that really translates into, what about the nodes? If we have dealt with the cancer, what about the lymph nodes? And, again, in a changing world, it adds to the complexity but, I think, in a very positive manner. Not too many years ago, we would remove all of the lymph nodes, full axial lymph node dissection, send them to pathology, let them take a look and, tell us, is there cancer there or not? The downside is that is a fairly big procedure. It can have long-term consequences in terms of chronic swelling, decreased range of motion, pain and so forth. But, we now understand that there is a, for a particular place in the body, in this case the breast, a first node of drainage, like a gatekeeper. The term we use is _____ lymph node. That is a predictor of the remainder of the remainder of the lymph nodes. So, we will focus on identifying that _____ node, asking the pathologist, is there evidence of cancer here?
If it is negative, we know within about a 95 percent certainty that the rest of the nodes are negative. We do not have to do anything further. We have a lower impact surgery, better answers.
Dr. Linda Austin: Just to clarify, that would be the most likely place for the cancer to have spread, if indeed it has spread beyond the area where it started?
Dr. David Cole: Yes, with the caveat, the most likely, in today’s world, that we can get our fingers on. You know, there are a lot of molecular diagnostics that come into play that I honestly hope that in a more sophisticated world, in the near future, we can draw blood and answer that question. But, right now, I think the most apt predictor is the node status. Therefore, we need to look at that, currently, to ask the question.
Dr. Linda Austin: Now, you gave the example of two women at two extremes, one, a 95-year-old woman with very low-risk cancer, the other, a 25-year-old woman with decades of life ahead of her, with a high-risk cancer, where you would advise her to be much more aggressive. Of course, many women are in between those two extremes which I think can be a blessing and a curse. There is a lot more discretion or judgment that comes into play and the woman, herself, needs to be more educated about what the options are. It is not quite so cut and dry. What advice would you give a woman in that kind of shades-of-gray area about how to learn more about what her options are, what questions she should ask a surgeon, how should she think about the choices facing her?
Dr. David Cole: Well, that is a great question. I think it is something we are all sort of faced with daily. One, my first goal, actually, is to inform the patient. I hope that I do two things functionally. One is to provide some clear guidance on what the priorities are and, also, to try to inform the patient so they can understand a very confusing situation that they did not want or anticipate as to what they need to be thinking about. Then, hopefully, make timely decisions so we can move on. Diffuse anxiety without any end points is, if nothing else, difficult to manage. So, family, friends, internet, second opinions are all good. But, you have to be careful and you have to look at the source. For example, family and friends, there are a lot of well-intentioned women who will provide their experience to a patient and just confuse her based on old information or misinformation. What was good 20 years ago for Aunt Nellie is not the standard of care now. So, I try to get patients focused on understanding, in simplest terms, what the issues are and then encourage them. We provide resources in clinic and the nurses provide literature. There are wonderful websites. The National Cancer Institute (NCI), for example, has treatment guidelines and so forth for patients who have questions.
Dr. Linda Austin: American Cancer Society, I think, also has a very good website. You also said something important which is, you would not be offended by a patient saying he/she wants to get a second opinion. You might even help that patient in pursuing a second opinion.
Dr. David Cole: Oh, I would encourage it. I think, at the end of the day, maybe even more so in the world of cancer and cancer care, it is important that the patient has an understanding of what is required and, I think, a comfort with the people that are taking care of them. So, if, for whatever reason, it is just not quite right, for better or for worse, I would say, please, go and get another opinion. Either form a comfort level so we can take care of you, or find where [else] that comfort level is with an informed decision. I would always encourage patients. In fact, most times, if I sense any sort of hesitancy, in terms of, oh there is a lot being thrown at me and I do not know, I will back up and say, take some time to think about this. Also, if we can provide any sort of option for a second opinion, or people to talk to, I am glad to do that. In today’s confusing world of management of cancer patients, the first step is to make sure that you have an informed patient that, hopefully, is making appropriate decisions.
Dr. Linda Austin: Dr. Cole, thank you so much for talking with us today.
Dr. David Cole: Thanks.
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