Risks and Concerns for Breast Cancer Patients Undergoing Chemotherapy

Hormone receptor negative, HER2 positive, lymph node metastasis (T2N2M0 / Stage IIB)

Hello Dr.
Chen, my mother was diagnosed with stage II breast cancer (HER2+, with lymph node metastasis) last month.
She has undergone one round of chemotherapy, and 12-13 days after chemotherapy, she experienced a periodontal disease flare-up and is considering tooth extraction.
She has discussed postponing her second round of chemotherapy with her doctor.
Here are my questions:
1.
Is there a risk associated with tooth extraction after chemotherapy? Are there any precautions to take?
2.
During the diagnosis, lymph node metastasis was observed via ultrasound, and a fine needle aspiration biopsy was performed, but no sample was obtained.
Now a second sampling is needed.
Can a fine needle aspiration biopsy of the lymph node be performed after chemotherapy, and is there a risk that cancer cells in the lymph node may not be detectable?
3.
If chemotherapy is delayed, is there a possibility that the cancer cells will develop drug resistance?
4.
During the chemotherapy process, can cancer cells metastasize?
Thank you for taking the time to read and respond.

Kathy, 40~49 year old female. Ask Date: 2020/09/14

Dr. Chen Sirong reply Oncology

Kathy / 45 years old / Female
1.
Is there a risk associated with tooth extraction after chemotherapy? Are there any precautions?
A: There is a risk of infection.
It may be considered to suture the extraction site (usually, tooth extractions do not require sutures, allowing the wound to heal on its own), or to administer prophylactic antibiotics.
2.
During diagnosis, metastatic lymph nodes were observed via ultrasound, and a fine needle aspiration biopsy was performed, but no sample was obtained.
Now a second sampling is needed.
After chemotherapy, will a fine needle aspiration biopsy of the lymph nodes still be effective in detecting cancer cells?
A: This is a valid concern.
Possible reasons for not finding cancer cells include:
2.1 It may not be cancer at all, but rather inflammation; if nothing was obtained last time, it may not be obtained this time either.

2.2 If cancer cells fill the entire lymph node, it would be easy to obtain a sample, but in your case, the cancer cells may only occupy a small portion of the lymph node, and there is no guarantee that the malignant part will be sampled.

2.3 Cancer cells in the lymph nodes may die off completely within a week after chemotherapy (though this is unlikely).
3.
If chemotherapy is delayed, will cancer cells develop drug resistance?
A: This is a concern of yours, but regardless of whether there is a delay, cancer cells will attempt to develop drug resistance.
4.
Can cancer cells metastasize during the chemotherapy process?
A: If the drugs used are ineffective for the patient, then metastasis can certainly occur.
Wishing you a smooth treatment process,
Taoyuan Hospital, Dr.
Chen Sih-Rong

Reply Date: 2020/09/14

More Info

When it comes to understanding the risks and concerns for breast cancer patients undergoing chemotherapy, it is essential to consider various factors that can influence treatment outcomes and patient safety. Your mother's recent diagnosis of stage II breast cancer (HER2 positive with lymph node involvement) and her subsequent chemotherapy treatment raise several important questions regarding her care.

1. Risks of Tooth Extraction After Chemotherapy: Chemotherapy can significantly impact the immune system, making patients more susceptible to infections. If your mother is experiencing periodontal disease and requires a tooth extraction, it is crucial to consult with her oncologist and dentist. They may recommend postponing the extraction until her blood counts are stable, particularly her white blood cell count, which is vital for fighting infections. If the extraction is necessary, they may prescribe antibiotics to minimize the risk of infection and ensure proper healing. Additionally, maintaining good oral hygiene is essential during chemotherapy to prevent complications.

2. Lymph Node Biopsy After Chemotherapy: Performing a lymph node biopsy after chemotherapy can be challenging. Chemotherapy may shrink tumors, including those in lymph nodes, which could make it more difficult to obtain a sample that contains cancer cells. However, it is still possible to perform a fine needle aspiration or core needle biopsy. The oncologist will assess the situation and determine the best approach based on imaging studies and clinical findings. If cancer cells are present, they will be identified; if not, it may indicate a positive response to treatment.

3. Delay in Chemotherapy and Drug Resistance: Delaying chemotherapy can raise concerns about the potential for cancer cells to develop resistance to the drugs being used. However, the degree of risk associated with a delay depends on various factors, including the type of cancer, the specific chemotherapy regimen, and the duration of the delay. It is essential to discuss these concerns with her oncologist, who can provide a more tailored assessment based on her individual situation. In some cases, the benefits of addressing immediate health concerns (like dental issues) may outweigh the risks of delaying treatment.

4. Cancer Cell Metastasis During Chemotherapy: The concern about cancer cells metastasizing during chemotherapy is valid. While chemotherapy aims to kill cancer cells and reduce tumor size, there is always a risk that some cells may escape treatment and spread to other parts of the body. However, chemotherapy is designed to target rapidly dividing cells, which includes cancer cells. Regular monitoring through imaging and blood tests is essential to assess the effectiveness of treatment and detect any signs of metastasis early.

In conclusion, managing breast cancer treatment requires a multidisciplinary approach that considers the patient's overall health, treatment response, and any concurrent medical issues. Open communication with healthcare providers is crucial to address concerns and make informed decisions about treatment plans. Your mother's oncologist will be the best resource for personalized advice and guidance throughout her treatment journey.

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