Breast Cancer Surgery and Post-Operative Treatment Options

Preoperative and postoperative treatment for breast cancer?

Hello Doctor,
My mother has been undergoing regular mammograms every six months and was diagnosed with breast cancer last week.
The tumor is located at the 9 o'clock position in the right breast, measuring 1.2 cm, and is a single tumor (the doctor mentioned that lymph nodes will be removed during surgery, and if there is infection, it would be classified as stage II).
All tests for ER, PR, and HER2 are positive.
The doctor stated that further treatment will depend on the complete pathology report after surgery, but it currently seems that chemotherapy, hormone therapy, and targeted therapy will be necessary.
I have a few questions for you:
1.
My mother has had many benign fibroadenomas in both breasts for many years (8-9 years), and she is concerned that these tumors may pose a risk in the future.
If cosmetic appearance is not a concern, would a total mastectomy be better than a partial mastectomy?
2.
I have seen many patient experiences where doctors arrange for abdominal ultrasounds, blood tests, and bone scans before surgery to confirm whether cancer cells have spread to other organs or bones.
However, the current hospital has not arranged for these tests and said to proceed directly to surgery.
Is this normal?
3.
Following up on the above, should we seek a second opinion from another hospital? If we choose to do so, it will inevitably delay the surgery, possibly by a month.
Would this be considered too long of a delay?
4.
Given that ER, PR, and HER2 are all positive, if hormone therapy, chemotherapy, and targeted therapy are administered, will this effectively reduce the recurrence rate? Or does the positive HER2 status inherently indicate a higher likelihood of recurrence?
Thank you for your response!

Niming, 20~29 year old female. Ask Date: 2016/12/07

Dr. Lai Yicheng reply Oncology

Dear Madam,
Thank you for your letter.
Here are my responses:
1.
If the malignant tumor is small, partial resection followed by adjuvant radiation therapy can be considered.
However, if your mother has multiple benign fibromas in both breasts as you described, total mastectomy may also be one of the options.
2.
The preoperative comprehensive examination to determine whether cancer cells have spread is generally based on clinical cancer staging.
For stage II or III breast cancer, a thorough examination is essential, including bone scans and brain MRI.
For early-stage cancer, the focus would be on blood tests for tumor markers, chest CT scans, and abdominal ultrasounds.
3.
If seeking a second opinion from another hospital delays treatment by more than one month, it is not advisable to transfer hospitals, as timely treatment is crucial in cancer care.
4.
If HER2 is positive (+++), targeted therapy can reduce the risk of recurrence or metastasis by one-third.
If HER2 is positive (++) further FISH testing is needed to confirm whether targeted therapy should be added.
If HER2 is positive (+), targeted therapy is not required.
If both ER and PR are positive, hormonal therapy for five years is necessary after the completion of chemotherapy.
Thank you for reaching out.

Sincerely,
Dr.
Lai Yi-Cheng
Department of Radiation Oncology
Changhua Hospital

Reply Date: 2016/12/07

More Info

Breast cancer diagnosis and treatment can be a complex journey, and it's understandable to have many questions regarding the best course of action for your mother. Based on the information provided, let's address your concerns systematically.

1. Surgical Options: Total vs. Partial Mastectomy: The decision between a total (mastectomy) and partial mastectomy (lumpectomy) often depends on various factors, including tumor size, location, and the presence of other breast conditions, such as benign fibromas in your mother's case. While a total mastectomy removes all breast tissue and may reduce the risk of recurrence, it is essential to consider the psychological and physical implications of such a decision. If the benign fibromas are not causing any issues and the primary concern is the malignant tumor, a partial mastectomy followed by radiation therapy could be a viable option. Ultimately, this decision should be made in consultation with her surgical oncologist, who can provide personalized advice based on her specific situation.

2. Preoperative Assessments: It is standard practice to conduct a series of preoperative assessments, including imaging studies (like abdominal ultrasound and bone scans) and blood tests, to evaluate whether cancer has spread beyond the breast. However, the necessity of these tests can vary based on the individual case and the surgeon's judgment. If your mother's healthcare team has deemed it unnecessary based on her clinical presentation, it may be acceptable. Nonetheless, if you feel uncertain, seeking a second opinion can provide additional reassurance.

3. Seeking a Second Opinion: If you are considering a second opinion, it is crucial to weigh the potential benefits against the delay in treatment. While it is understandable to want to ensure that all options are explored, a delay of a month could be significant, especially if the cancer is aggressive. Discussing this with her current healthcare team may provide clarity on the urgency of the situation and whether a second opinion is warranted.

4. Postoperative Treatment and Recurrence Risk: In cases where ER, PR, and HER2 are all positive, the treatment plan typically includes a combination of hormone therapy, chemotherapy, and targeted therapy (like trastuzumab for HER2-positive cancers). This multimodal approach aims to reduce the risk of recurrence significantly. While HER2-positive cancers can be more aggressive, the advancements in targeted therapies have improved outcomes for many patients. Therefore, following the recommended treatment plan can effectively lower the recurrence risk, even in HER2-positive cases.

In summary, your mother's treatment plan should be tailored to her specific diagnosis and personal circumstances. Open communication with her healthcare team is vital to ensure that all concerns are addressed and that she receives the most appropriate care. If you have further questions or need clarification, do not hesitate to reach out to her medical team or seek a second opinion if it provides peace of mind.

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