Breast Cancer Treatment Options: Key Questions Answered

Breast cancer treatment issues?

I apologize for the inconvenience, but I would like to ask the doctor about my mother's breast cancer pathology report.
The report indicates the following: ER: positive (90%), PR: positive (90%), HER-2-neu (polyclonal): negative (1+), Ki-67 (MIB-1): 5%, type A invasive carcinoma with multiple foci, no special type (ductal), NBR grade 1, mpT1bN0(sn), margin negative.
Additionally, there is ductal carcinoma in situ (DCIS), low grade, with the upper margin focally involved.
The whole breast tissue was divided into 13 consecutive slices, from medial to lateral; the average thickness of each slice involved was 6 mm to the nearest upper margin (T19).
The DCIS margins were involved focally at the lateral margin (E1).

Regarding the regional lymph nodes, 5 sentinel and non-sentinel lymph nodes were received with no tumor found on frozen section.
The pathology report states that the 5 lymph nodes showed no infection or microscopic invasion, with the invasive cancer size ranging from 1 to 0.5 cm.
However, there was an additional finding of in situ carcinoma and specified changes of 20% - additional changes: sclerosing adenosis.
I would like to ask the doctor the following questions:
1.
Is the mention of multiple foci due to the additional finding of in situ carcinoma?
2.
Given the additional discovery of in situ carcinoma, the pathologist recommends a second surgery.
Would it be better to perform a total excision for the multiple foci, but the attending physician suggests partial excision?
3.
My mother underwent genetic testing, which showed no hereditary factors.
The attending physician recommends that after the second surgery, she undergoes one month of radiation therapy and take hormone therapy without chemotherapy.
Should I suggest adjuvant chemotherapy to my mother? I understand that hormone receptor-positive cases may not require chemotherapy, but adjuvant chemotherapy can reduce the recurrence rate.
I would like to know the doctor's advice on this matter.

Xiao Jia, 50~59 year old female. Ask Date: 2022/02/21

Dr. Yuan Tianmin reply Breast and Thyroid

In general, for breast cancer treatment, we try to avoid intervening in the treatment plan established with your primary physician.
However, considering your mother's condition, chemotherapy may not be necessary.
Regarding the issue of tumor margins, in addition to surgical resection, radiation therapy or simply monitoring the situation could also be viable options.
Ultimately, it will depend on the discussions you have with her primary physician.

Reply Date: 2022/02/21

More Info

Breast cancer treatment options can be complex and often depend on various factors, including the specific characteristics of the cancer, the patient's overall health, and personal preferences. Based on the pathology report you provided for your mother, it appears that she has a type of breast cancer that is hormone receptor-positive (ER and PR positive), HER2-negative, and has a low Ki-67 index, indicating a lower proliferation rate. This information is crucial for determining the most appropriate treatment plan.

1. Understanding Multifocality and Additional Findings: The term "multifocal" in the context of breast cancer indicates that there are multiple areas of invasive carcinoma present in the breast tissue. The presence of additional ductal carcinoma in situ (DCIS) suggests that there are non-invasive cancer cells in the breast, which can sometimes be associated with multifocal invasive cancer. The recommendation for a second surgery may be due to the need to ensure complete removal of all cancerous tissue, particularly since the margins of the DCIS were involved. It is essential to discuss with the treating physician whether a total mastectomy or a lumpectomy (partial removal) is more appropriate, considering the multifocal nature of the disease and the patient's preferences.

2. Surgical Decisions: The decision between total mastectomy and partial mastectomy often hinges on the extent of the disease, the patient's anatomy, and the desire to preserve breast tissue. If the cancer is multifocal and there are concerns about clear margins, a total mastectomy may be recommended to minimize the risk of recurrence. However, if the treating physician believes that a partial mastectomy with radiation therapy can adequately manage the cancer, this may be a viable option as well. It is crucial to have an open discussion with the surgical oncologist about the risks and benefits of each approach.

3. Genetic Testing and Treatment Recommendations: Since your mother underwent genetic testing and it was determined that there is no hereditary component to her breast cancer, this can influence treatment decisions. The absence of hereditary factors may suggest that her cancer is more sporadic, which is common. The recommendation for radiation therapy after surgery and the use of hormone therapy (such as tamoxifen or aromatase inhibitors) is standard for hormone receptor-positive breast cancer.
Regarding the question of whether to recommend adjuvant chemotherapy, it is essential to consider the specific characteristics of her cancer. For early-stage hormone receptor-positive breast cancer, especially with a low Ki-67 index and no lymph node involvement, chemotherapy may not be necessary. Studies have shown that many patients with early-stage hormone receptor-positive breast cancer can safely forgo chemotherapy and still have excellent outcomes when treated with hormone therapy and radiation. However, if there are concerns about recurrence or if the oncologist believes that chemotherapy could significantly reduce the risk of recurrence, it may be worth discussing further.

In summary, the treatment plan for your mother should be individualized based on her specific cancer characteristics, surgical options, and personal preferences. It is essential to maintain open communication with her healthcare team, including surgical oncologists, medical oncologists, and radiation oncologists, to ensure that all aspects of her care are considered and that she receives the most appropriate treatment for her situation. Additionally, seeking a second opinion can provide further clarity and reassurance regarding the treatment options available.

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