Breast Cancer Questions To Ask The Doctor (cont.)
In this Article
Should I start chemotherapy before surgery?
The classical concept of breast-cancer treatment has been a
sequence of tumor-removing surgery followed by chemotherapy and/or
radiation therapy. The goal of surgery and radiation therapy is to
destroy
or remove the primary cancer. Follow-up chemotherapy is designed to
eliminate any cancer cells, as yet undetectable, at remote sites.
Recently, there have been new findings suggesting a potential
benefit in some patients when chemotherapy is started before
surgery. However, initial chemotherapy (neoadjuvant
chemotherapy) should primarily be considered in patients with larger
tumors and
those with strong evidence of lymph-node involvement at the time of
initial diagnosis.
If you are enrolled in a clinical trial, the advantages and disadvantages of all protocols should have been explained to you, giving you the opportunity to make an informed decision.
If I am advised to have a mastectomy, what are the risks and
benefits of immediate breast reconstruction?
If a mastectomy is necessary, immediate reconstruction offers
a great psychological benefit to most women. However, as is often
the case in medicine, there are trade-off risks which must be
considered. If the
reconstruction is done during the same surgery as the mastectomy
(immediate reconstruction), the final results of the pathology tests
on the removed tumor and tissue is not yet known and
will not be known for at least a day or two.
There are sometimes findings on the final pathology report which
make chest-wall radiation advisable in order to reduce the risk of
local recurrence. If a prosthesis for the breast has been implanted,
the radiation treatment will still work, but the radiation may
significantly compromise the cosmetic appearance of the prosthesis.
There may also be healing problems which delay chemotherapy,
potentially increasing the risk of breast-cancer recurrence. These
and
other factors should be discussed and carefully considered before
committing to immediate breast reconstruction.
Should my lymph nodes be removed?
Lymph nodes are small glandular structures that filter
tissue fluids. They filter out and ultimately try to provide an
immune
response to particles and proteins which appear foreign to them.
There are thousands of these nodes scattered in groups throughout the
body. Each cluster is more or less responsible for the drainage of a
particular region of the body.
The lymph nodes under the arm (axillary nodes) are the dominant
drainage recipients from the breast. When cancerous cells break free
from a breast cancer, they may travel through the lymph tubes
(vessels) to
the lymph nodes. There, the cancerous cells may establish a
secondary growth
site.
The presence of cancerous cells in the lymph nodes proves that cancer
cells
have traveled away from the primary breast tumor. Therefore, the
presence or absence of cancer cells in these regional nodes is an
important indicator of the future risk of recurrence. This
information
is
often important in making decisions about whether to use chemotherapy
and what type of chemotherapy should be employed.
Unfortunately, removal of the lymph nodes also carries a potential
risk of lymphedema, a condition that may cause the arm to swell.
Lymphedema can occur early after surgery or many
years later. It can be a difficult and disabling condition. Here
again, there are trade-offs in risk. When more lymph nodes are
removed,
more accurate the information about tumor spread is obtained and the
chance
for tumor recurrence is less. But there is a greater incidence of lymphedema.
There are alternatives to standard lymph-node removal
(called axillary node dissection). These alternatives should be considered in
each patient's situation. They include
- replacing standard axillary-node removal with sentinel node
biopsy (explained below);
- not doing lymph-node removal in patients who will receive
chemotherapy anyway based on other information; and
- not doing lymph-node removal in patients with very small or
"favorable" tumors.
Again, these alternatives must be selectively applied with the
benefits and risks carefully evaluated.
Next: What is a sentinel lymph node biopsy, and what are its benefits
and risks? »
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