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Just Diagnosed

Overview
When a woman is informed that she has just been diagnosed with breast cancer, she typically goes into a state of mental shock. She might think: "You've made a mistake"; "Why me?”; And, "Am I going to live?" These are just a few of the common thoughts that spin through a woman's mind. Since every woman is unique, the approach to guiding a woman through the process of understanding her diagnosis and her treatment options must be individualized. However, experience has taught us that there are a series of helpful steps that minimize the stress in the journey from just being diagnosed to the successful completion of treatment.

When we first opened our center 21 years ago, we prided ourselves on our ability to provide newly diagnosed breast cancer patients with immediate and comprehensive explanations about their breast cancer. We soon learned that most women were not ready to absorb these intricate details in the first days after being diagnosed. We still see the patient and her family immediately following diagnosis, and attempt to answer all questions. Now, however, a major focus of the initial discussion is to ensure that the patient is emotionally prepared to go forward with the process.

Within 48 hours of being diagnosed, most women are ready to focus on their treatment options. Before reviewing these options, it is essential that a woman has a clear understanding of her cancer diagnosis. The first question that must be answered: “Is my cancer invasive or non-invasive?” With non-invasive cancers, the initial focus of the discussion is whether or not the breast can be saved (in most cases, it can). The amount of time required to eventually make a decision is less of an issue, since these cancers are almost always curable.

With invasive cancers time is an issue; however, the process should not be rushed. It is essential that a woman take the time to fully understand the nature of her cancer, as well as all her treatment options. It is also essential that the treatment team have time to study the various clinical issues so that the most accurate treatment recommendations can be made. At the center, all newly diagnosed breast cancer patients are presented to a treatment conference in which a mammographer re-reviews the mammograms, a pathologist re-reviews the slides, and a surgeon presents the history and clinical findings. Based on these findings, the team formulates a treatment plan.

Initial Treatment Options

Breast conserving surgery (lumpectomy + irradiation)
Mastectomy (with or without immediate reconstruction)
Chemotherapy first (to reduce the size of a larger tumor), followed by surgery.

Breast conservation :
For most women, breast conservation will be the treatment of choice since it is less traumatic, and the survival results are identical to survival rates with mastectomy. However, not all women are candidates for breast conservation, and some women prefer mastectomy. We believe women should be given the facts and encouraged to make their own choices.

Women considering breast conservation must have a clear understanding of the issue of '”margins". The goal in breast conservation is to remove the tumor, along with a surrounding rim of normal tissue. Obtaining clear margins all around the tumor edges can be a challenge. Although the surgeon attempts to take out the entire tumor at the time of the initial surgery, in some cases the tumor cells (which are not visible during the surgery) are found by the pathologist to extend to the edge (margin) of the lumpectomy specimen, and a second operation is required. Fortunately, the vast majority of women who initially choose breast conservation will ultimately achieve a good to excellent cosmetic result. Long-term survival is equal to that with mastectomy.

Mastectomy :
Some women are either not candidates for breast conservation or choose mastectomy for personal reasons. Women considering mastectomy should be given the option of immediate reconstruction. Some women, however, are not good candidates for immediate reconstruction because of an underlying medical condition, such as diabetes. For these women there is still the option of delayed reconstruction, and this option should be taken into consideration at the time the initial mastectomy

Chemotherapy first (Neoadjuvant therapy) :
Giving chemotherapy first (neoadjuvant therapy) is becoming a more common option. In the past, chemotherapy was given before surgery in situations where the tumor was too large to permit a mastectomy. The chemotherapy was given first to shrink the tumor so that a mastectomy could be successfully performed. It is now becoming common practice to give chemotherapy first to shrink the tumors so that less tissue is taken at the time of the lumpectomy, which leads to improved cosmetic results. We have had extensive experience with this approach and have now saved hundreds of breasts that in the past would have required a mastectomy

Additional Treatment Options

Radiation Therapy :
A 6-8 week course of irradiation therapy will be recommended for women undergoing lumpectomy (radiation therapy may be safely avoided in selected women with small, non-invasive cancers). The purpose of radiation is to eliminate any remaining cancer cells in the breast following lumpectomy, and it is very effective in lowering the rate of cancer recurrence in the breast. There is now an alternative to standard radiation therapy which can be accomplished in just 5 days. Radiation is painless and takes only a few minutes to perform. It is much like a simple chest x-ray in that a beam of energy goes through the breast without the patient being aware that anything is happening. With breast irradiation, the energy beam is much stronger then the energy for a chest x-ray. The most common side effect of breast irradiation is redness to the skin. There is no hair loss or nausea with breast irradiation as there is with chemotherapy.

Most women undergoing mastectomy will not require post-operative irradiation.

Lymph nodes and Sentinel Node Biopsy :
Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are lima bean shaped structures that vary in size from that of a pea to the size of a marble. A primary function of a lymph node is to filter unwanted materials from the body, and this includes cancer cells. In fact, if breast cancer cells break off from the main tumor, the first place they are likely to go is to the lymph nodes under the arm (i.e. the axillary lymph nodes). One of the most important indicators of prognosis is the status of the axillary lymph nodes (i.e. no nodes involved good means prognosis; the more nodes involved, the worse the prognosis). For this reason, it was standard therapy in the past to remove all of the lymph nodes under the arm at the time of the removal of the breast cancer to determine prognosis.

It is now standard practice to remove only the first draining lymph node (sentinel lymph node) at this time of the lumpectomy or mastectomy, and have it examined under the microscope. If the lymph node is free of cancer cells, no other lymph nodes are removed. By limiting the number of nodes removed, recovery is accelerated and the risk of complications (such as lymphedema) are minimized.

What is my prognosis?
One of the first questions a woman asks after learning she has breast cancer is :
"Am I going to live?" Or, in other words, " What is my prognosis?" When a woman asks her physician this basic question, she is often frustrated with the vagueness of the response. The problem is that the treating physician does not have enough information following the initial biopsy to make an accurate prediction of survival. Until the tumor and lymph nodes have been removed and analyzed, an accurate prediction of survival is not possible.

The most important predictors of survival are the size of the invasive component of the tumor, and the status of the regional lymph nodes. When there is no invasive tumor present (i.e. only ductal carcinoma in-situ, or DCIS), the survival rate is 100%. When the invasive tumor is less than 11 mm in diameter and the nodes are negative, the 10-year survival approaches 95%, and if you make it to ten years, consider yourself cured.

As the tumor enlarges and the number of involved lymph nodes increases, the potential for cure is reduced. However, dramatic improvements have been made in the medical treatment of breast cancer (i.e. chemotherapy and hormone therapy), and many new treatments are on the horizon. There is now reason for optimism in even the most advanced cases. To calculate your own prognosis, refer to the following web site: http://www.mayoclinic.com/calcs.

The time that elapses before a woman is informed about the details of her prognosis is typically 7-14 days after the removal of the tumor and the under arm lymph node(s). It usually takes this long to analyze the tumor and to receive a pathology report on the various tumor markers that also influence prognosis (see link to understanding your pathology report). A woman and her family will usually have a detailed consultation with the oncologist to discuss her prognosis, and more importantly, what steps should be taken to maximize her chances of survival. After this detailed discussion, a woman chooses the option that is best for her.