Talk About Treatment Options -- Marisa Weiss, MD
Every good story includes a brave choice made by the hero. Your survivor story will be no different! Take the first step by exploring your treatment choices. Marisa Weiss, MD, discussed the options, from surgery to radiation to bodywide treatments, and how to make the best decision for you.
By Marisa Weiss
The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome back WebMD University Dr. Weiss, and welcome, members. Tonight we're talking about treatment options.
Member: I had a biopsy for microcalcification. The path report came back as "unable to rule out ductal carcinoma in situ." My physician wants me to start tamoxifen and possibly radiation. I am unsure what to do since I don't have a definitive diagnosis. What do you think? We sent the path slides to another pathologist and his came back "favoring the diagnosis of carcinoma in situ," with still nothing definite. My physician is sending it to a pathologist who specializes in breast tissue. He said my case was "unusual" because of catching it early. I want to treat aggressively if it is cancer, but I sure don't want to go through all that if its normal breast changes. Help!
Weiss: Your question is very interesting. The breast is a gland, made up of lobules that make the milk and ducts that drain the milk. The cells that make up the structures can get excited and hyperactive. Sometimes they can grow in an unusual way. The type of overgrowth is called atypical ductal hyperplasia. If the cells take one more step further and misbehave more, they can "cross the line" and make too many cells that go from unusual over to clearly abnormal. This second type of process is called ductal carcinoma in situ. The difference between the first process, "ADH," and "DCIS" is a matter of expert judgment.
In your situation, you are caught between these two diagnoses. Only an experienced breast cancer pathologist can resolve and firmly establish the diagnosis. It sounds like your doctor is taking the right steps to resolve this. It is important for you to make sure that the whole area on mammography that was worrisome has been completely removed. In your situation, it would be good to get a mammogram after the last surgery, to make sure that all of the calcifications have been removed.
Moving forward, the purpose of any additional treatment like radiation to the remainder of the breast tissue and Tamoxifen is to reduce your risk of ever developing an evasive breast cancer in the future. What you have been diagnosed with is considered a "pre-invasive cancer." It is important for you to communicate with your doctor that you want to be as aggressive as possible within the realm of what is reasonable. In addition, if you have a significant family history of breast cancer, together with the changes noted in your breast, you may choose to be extra cautious. Good luck with this.
Member: What is the most current treatment following a lumpectomy?
Weiss: In general, today's standard of care is to treat the whole breast. For early stage breast cancer, with one site of disease that has been removed, you can be equally well treated by lumpectomy and radiation to the rest of the breast as you would by mastectomy, which treats the whole breast by removing it. There are some treatment protocols that look at lumpectomy alone for women with a wide clear margin of resection (like 1 centimeter or greater). Some studies also add Tamoxifen. Some studies may offer radiation only to the site of the disease. All of these approaches are still considered experimental.
Member: I have just been diagnosed with breast cancer. I am also 18 weeks pregnant, I want to keep the baby, what should I do?
Weiss: You are in a difficult situation. At the same time that you are trying to create a new life you have to fight for your own. The appropriate treatment for a woman who is pregnant with breast cancer depends on a number of factors:
First are the stage and extent and nature of the disease. If you have a large breast cancer with significant lymph node involvement, your doctor will want to initiate aggressive treatment right away. You may need chemotherapy sooner than later, under those circumstances. It is considered unsafe to give chemotherapy during the phases of pregnancy.
If you have metastatic disease, the need to initiate systemic treatment becomes more urgent. The type of treatment required depends on specific kind of cancer that you might be diagnosed with. If you are diagnosed with early stage breast cancer while pregnant, surgery is usually initiated to include removal of the breast mass and the underarm lymph node. If chemotherapy were required, doctors would usually wait until later in your pregnancy before starting it. Under no circumstances would radiation therapy be given to a pregnant woman.
Other factors need to be taken into consideration include your age, how precious this pregnancy is to you, and whether or not it would be better to have an abortion given the situation you might be in. Of course these complicated and anguishing decisions require a lot of careful thought and compassionate care from a team of breast cancer experts along with your obstetrician.
Member: If borders are clear around grade 3 breast cancer, why are the nodes removed and has cancer been known to spread outside the area into nodes if borders are clear?
Weiss: The margins of resection, that is whether or not cancer is present along the edge of the breast tissue that has been removed, is entirely separate from and unrelated to lymph node involvement. That is there is no connection between the two tumor characteristics. It is important to evaluate lymph nodes because whether they are involved or not has a significant impact on your outlook and on treatment choices that are best for you.
Member: By what percentage does Tamoxifen reduce the risk of invasive cancer in the other breast if you have already had cancer in one breast?
Weiss: Tamoxifen reduces the risk of your developing an invasive breast cancer in your other breast by about 50%. For example, if you had already had a breast cancer on one side your risk of developing breast cancer on the other side is about 1% per year. This means a 10% risk in ten years. Tamoxifen can reduce that risk by about 50%, bringing your risk down to about 5%.
Member: How can I have my doctor (ob-gyn) consider another form of medication treatment besides Tamoxifen? My cancer was caught very early and consisted of crystals that were totally encased. I had two surgeries and 33 radiation treatments. All of this was fairly easy to handle. Since I've been on Tamoxifen, in spite of Wellbutrin and Paxil, I continue to have horrible on-going hot flashes that alternate with periods when I am freezing. I have broken out with a rash that comes and goes all over my body. And I have gained 30 pounds that will not come off no matter how much/little I eat or exercise. I have spent my life (55 years) watching my weight to not be fat nor have my legs rub together. But guess what - all the medical people tell me to just relax and be happy! I want to try another medication that won't have me going through hell for the next three and a half years! Any suggestions?
Weiss: Excellent question and thank your for putting it so well. If you are 55 years old and beyond menopause, and if you are suffering from tamoxifen-related hot flashes, and if you only have intraductal cancer (non-invasive), then you can consider discontinuing the tamoxifen without finding another method of anti-estrogen treatment. This option may be open to you in this situation, because your outlook with non-invasive breast cancer is already so excellent. By adding tamoxifen, you are making an excellent prognosis just a little bit better.
This extra benefit may not be worth it to you if your quality of life is miserable. If, however, you are taking tamoxifen because of an invasive hormone-receptor positive breast cancer, your doctor may tell you that some form of anti-estrogen therapy is important for you. In this case, and if you are beyond menopause, then you can consider another medication called Arimidex.
No matter what you do, don't let your doctors condescend to you. You deserve to be taken care of with respect for your life and intelligence. If the tone of this conversation you have shared with us is how things generally go with that doctor, perhaps it's best to find someone else who you can relate to in a more respectful way.
Member: My mother was recently diagnosed with "category 1" breast cancer. No evidence of any spread (the sentinel node checked out negative.) Size of the tumor was less than one centimeter. She just had a lumpectomy. Doctor has indicated she might need to go through a regime of radiation therapy. But I understand that once you go through radiation, any subsequent chemotherapy is likely to be ineffective. Apparently the radiation prevents the chemicals from reaching the affected tissue. Is there any merit to this? Should treatment start first with chemo, then radiation, or does it really make a difference?
Weiss: It is completely false that radiation reduces the benefit you can get from chemotherapy. In fact, there is a definite synergism between breast radiation and chemotherapy. That is, the two treatments together reduce the risk of recurrence in the breast in a much more powerful way than either one alone or added together separately. The best sequence of treatment is very individual. These days, most women who need both radiation and chemotherapy, will have chemo first followed by radiation to the breast. In general, chemotherapy and radiation are not given together, at the same time.
Member: When will Iressa (or some other non-chemotherapy, molecular level treatment) be available for metastatic breast cancer? I have mets in the lungs. I'm doing well on Taxotere and Navelbine, but realize I can't stay on these forever. I know there has been excellent results with Iressa for lung cancer patients and would like to try it myself.
Weiss: We are just learning so much more about how breast cancers start, how they grow, and how we can target the problem areas specifically to prevent this type of cancer development and cancer growth. One example is a genetic abnormality (not an inherited type) called HER2. About 25% of breast cancers have an abnormal HER2 gene. There is a relatively new targeted therapy called Herceptin that targets the HER2 gene abnormality. For women with metastatic disease with HER2-positive cancers, Herceptin can be very effective.
HER2 has a sister gene called EGFR (epithelial growth factor receptor) that can be abnormal in both lung cancers and in breast cancers, as examples. Iressa is a new drug that targets the EGFR abnormality. It has mainly been tested in lung cancer patients. Studies are ongoing on Iressa in women with breast cancer. There are some other new medications that also address the EGFR abnormality. Results have not been as promising as we had hoped for.
Stay tuned and hang on because more of these types of treatments, and hopefully more effective ones, should be around the corner. Check out breastcancer.org and sign up for our email newsletters to get monthly research advances.
Member: Is there an advantage for the patient to have chemotherapy for breast cancer (CMF) on a weekly basis instead of the normal every-three-weeks basis? My doctor is recommending this, telling me that the side effects won't be nearly as bad with the reduced dosages.
Weiss: In general, doctors are always trying to figure out how to give the greatest benefit from treatment with the fewest side effects. One approach to this is to give you the chemotherapy in lower doses but in greater frequency. For example, in your situation instead of six doses of CMF given over about six months, your doctor wants to divide up about the same dose and give it in smaller amounts, weekly. The two treatment approaches, CMF times six versus CMF weekly, have not been well tested against each other. Therefore we do not know if the two approaches are definitely equal. We know the most about monthly CMF. I would recommend that you get a second opinion from a breast cancer medical oncologist in order to help you make the best decision possible.
Member: I was diagnosed with breast cancer in 1996. The treatment I received was lumpectomy and radiation. Cancer has returned in the site of the lumpectomy. A breast surgeon has advised me that the recommended treatment for me at this point is a mastectomy. I could opt for another lumpectomy, but I run the risk of a spreading cancer, even though a needle biopsy and MRI of the breast only indicate interductal cancer at this time. I have suffered a great deal of scarring from previous surgeries that resulted in serious infections. I realize that a mastectomy will cause further scaring and discomfort from the scarring. I don't want to have such a radical surgery, but it seems to be the safest treatment. If there are any other options or opinions to share I would be grateful to hear them.
Weiss: The good news is that you seem to have been cured of your first breast cancer. This new breast cancer, depending on its location in the same breast, may very well be a new breast cancer, rather than a recurrence of the first. Regardless, an intraductal breast cancer is associated with an excellent prognosis. It is true that the standard of care over the years has been mastectomy for any type of breast cancer that is new or recurrent following lumpectomy and radiation. In general, we do not offer lumpectomy alone. But in your situation you may want to bend the rules, because only an intraductal breast cancer was identified (assuming wide clear margins were obtained), your MRI scan was clear (there was no evidence of other disease in the breast), and you have had difficulty in the past with healing after surgery.
Assuming that the tumor was small and contained and that in fact wide clear margins were obtained, and the MRI was read by an experienced radiologist, it may be reasonable to avoid mastectomy.
Realize that this is not considered "standard of care." If you have never had tamoxifen, you could consider taking tamoxifen after lumpectomy as an alternative approach. Whenever you bend or break the "rules," you may be taking on a potentially higher risk of recurrence. This increased risk in your situation is probably relatively low. Work closely with your doctors to figure what is best for you.
Member: How does Taxotere compare to Taxol?
Weiss: These two medications are very closely related. There are both considered quite effective. Only now are these two treatments being compared directly to each other in large clinical studies. Some doctors believe that Taxotere may be slightly more effective with a more acceptable group of side effects. These differences are relatively subtle. Talk to your own doctor about the choice between them in your individual situation.
Member: My mother is 74 years old and was recently diagnosed with a breast cancer for the second time in her life. This time appears it is more advanced and she has been given stage 4 status. While being prescribed only Arimidex for now, I am wondering if she would ever need chemotherapy or radiation. In other words, are prescription drugs such as tamoxifen and Arimidex able to keep this disease in check without ever needing radiation or chemo treatment? And if so, for how long and severity?
Weiss: For women who have breast cancer that has spread to other parts of the body beyond the breast and immediate lymph nodes, that is considered stage 4 disease, also called "metastatic" breast cancer. If hormone receptors (estrogen or progesterone) are present, then anti-estrogen therapy is usually the first treatment of choice. This is because they can provide significant benefits with minimal side effects.
For a woman beyond menopause, options include tamoxifen, Arimidex, Fenara, or Aromasin. Faslodex is a new medication in this group. For a woman before menopause, tamoxifen represents the mainstay form of treatment for metastatic hormone receptor positive breast cancer. Usually, one treatment is tried and is continued for as long as the tumor is responding. If there are signs of tumor progression, then your doctor is likely to shift from one type of anti-estrogen therapy to another. Eventually, if you stop responding to anti-estrogen therapy, then chemotherapy may be the next treatment of choice.
Moderator: Dr. Weiss, we are almost out of time. Do you have any final comments for us today?
Weiss: Thank you for having me. Please come and visit breastcancer.org.
And please participate in next Thursday's chat on breastcancer.org, together with WebMD, on complimentary medicine.
Moderator: We are out of time. Thanks to Marisa Weiss, MD, for joining us today. To learn more about breast cancer, read her book, Living Beyond Breast Cancer. Be sure to explore all the breast cancer info here at WebMD, including our message boards and live chats.
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