October 28, 2008
DR BLOUIN
Abnormal mammogram, biopsy shows lobular cancer
Lobular – 2nd most common breast cancer [20%], harder to diagnose because it infiltrates the tissue, 2nd behind ductal breast cancer, lobular has higher incidence of being on both sides, huge majority of people today are cured, have to figure out what is best for Dianne to get it cured, Dianne has family history, genetic testing – small number of patients have abnormality that increases risk significantly like 68%, braca 1 or braca 2 tests, gene mutations, 1st degree and 2nd degree relatives, consider breast mri because Dianne’s is lobular and could have chance of something going on in other side, need to know that before making plans for surgery, biomarkers to determine how hers may behave, nothing you could have done caused this, across the board 1 in 8 women get it, not fair, no rhyme nor reason, good news is found it when she did, studies show that hormone replacement therapy increase risk but more so with combined hormone, premphase being one of them, estrogen and progesterone, did it cause it do not think so, numbers are small that HRT combined could act as fertilizer and make grow faster, real controversial,
As a surgeon my job is to get rid of cancer on chest wall and give best chance of not coming back, that’s what radiation drs do with radiation treatment, the medical oncologist the ones that give chemo when it is indicated are the ones that evaluate your chance or risk of developing recurring disease or disease to another site down the road, it is an educated guess and the way they make that determination is how big the tumor is, what it looks like under the microscope, they give it a grade 1 2 or 3, what your estrogen receptors, progesterone, and her2 that are the biomarkers which they test on the cancer cells themselves. Then we look at lymph nodes. I can tell you right now that your biomarkers are very favorable – your estrogen receptor is positive, your estrogen is positive, and your her2 is negative, and that is what I want. That is best situation of the 3 and those are the 3 that they check. Option # 1 is a lumpectomy and taking the cancer out and a rim of normal tissue around it and that is followed by radiation and they go together. I you have a lumpectomy and say I do not want radiation, then you compromise your pure rate of death. The other option is a mastectomy, you take off all your breast, do not the muscles anymore. Those are the options to get rid of the cancer. The survival is the same. In both situations I need to evaluate your lymph nodes. So what we do is a sentinel node biopsy. Now we are able to identify, 98% of the time, the node that would be positive, if any are. We do that by injecting a blue dye, a radioactive material, then we make a small separate incision from a lumpectomy under your arm and we look for blue nodes to radioactive nodes - we have a Geiger counter. We find those and we get them to look at them during surgery to see if they see any cancer cells. They are pretty accurate but not 100%. If any nodes are positive, then I would take more nodes. But those that we identify are negative, and then I do not do anything else. Occasionally a week later they will come back and say we have looked and looked at these and then we may have to go back………………….they do not check the total lymph system but only check the nodes that are at risk for harboring breast metastatic disease. So, you have lymph nodes everywhere as far as your defense system. They seem to drain certain areas. All most all of the breast 80-90% cancers drain to the axcilla, what we are trying to come up with is a profile to determine if you need chemotherapy or not. I know that you need local control. You can get local control by a lumpectomy followed by radiation or by having a mastectomy. Radiation is not required after a mastectomy except in a few unusual situations. 1 is when you have a huge 5 cm tumor, which you do not. And the other is when you have 4 or more nodes that are positive in your arm, the axcilla, which I would really be blown away if you did. Radiation takes about 6 ½ weeks. The therapy is done mon – fri for 6 ½ weeks, but you lay on a table, get your treatment and come home. It does not hurt. Effect is tiredness and you will be worn out. The surgery itself is an outpatient and you will be put to sleep, and you will go home. You will have an incision in your breast over the breast cancer and an incision under your arm. A mastectomy is done under general anesthesia as well, and you can consider reconstruction or not at the same time. If you are bound to have your breast taken off; stay in hospital 1 or 2 nights and then go home. And you do not have to follow with radiation. Chemo is not determined by what procedure you have, but determined by the information we obtain during surgery. We get the same information with each procedure, size of tumor, what it looks like under a microscope, grade of tumor, we already have our estrogen receptors, and then whether any nodes would be positive. Dianne asked about braslo grade. Some people use Nottingham and some use braslo. You are a grade 2. 1, 2, 3. 1 is low grade, 2 is intermediate, 3 is high grade. Dianne asked if it is invasive. It is invasive and let me tell you what that means. If you do not have invasive, then you have in situ cancer. Invasive is the most common type. If you have in situ, it will be ductal. They are abnormal enough to be called cancer cells, they are sitting in situ the duct. As longas they are just sitting in that duct they are not harmful. At some pint they grow from the duct, as in your case, they were sitting in the lobule and started invading the surrounding tissue. Dianne asked if it could have gone through chest. It is rare that it would happen, a locally advanced disease. What we are looking for if it has spread to a lymph node. If it has spread to a lymph node, then you would get chemotherapy unless you just say I am not taking it. You would also get a lot of scans to make sure in no nodes. We are sitting here which looks like a favorable situation, the tumor is not huge, actually in stage 1 area, there were no abnormal lymph nodes that showed up on any of lymph nodes. It is a moderately differentiated, so it is not a bizarre breast cancer, and the estrogen receptors are positive progesterone positive and her2 negative. Her2 is the growth factor and we do not want it to be positive, we do not want it to be over expressed. . Estrogen positive tumors have a better outcome, #1. #2 they have therapeutic implications. Because that can base your treatment, the oncologist will recommend that you either go on tamoxifen or arimidex every day for 5 years which will reduce your recurrence rate huge, like 40-50%
The thing that you need to think about right now is, what are you most comfortable with. This is not an emergency. It is to you, but now is to decide what you really want to do. Because it takes 5 to 8 years before you can see it. It does not mean that you have been negligent, that is just biology. It just may not have shown up on anything, and so it is not like packman in there chopping away, which is probably what you think. We have time to get MRI and recommend strongly since you have lobular. Would you be comfortable with lumpectomy as opposed to a mastectomy? I would be if my MRI was ok. I like lumpectomy with radiation because it interferes less with your life. Except that you have that 6 ½ week period running out get your radiation. You wear your clothes normally. You are not hospitalized. You can function more normally in the midst of your therapy. If perchance you had a strange situation and had a positive node, which I would be surprised about, and you required chemo for some reason, you would get that upfront and then radiation. Dianne asked we decide what we are going to do, and then you get in there and then decide that I need breast taken off. People ask me that, and if I saw something blatant, I would go ahead and do it if you gave me permission to do it. However, I can tell you that is not going to happen because I cannot look at and tell. Only the microscope can tell me if my margins are clear. If my margins are not clear, we will go back. I will not compromise your life. We are talking about a cure here, and that is what we are planning on. We are going to say well we have breast cancer and we are going to make you feel better. We are planning to cure you. You will not believe this for a long time. Every time you exercise, get sore, wake up with a crick in your neck, cough, you will think it is cancer. That will get better. I promise. You will get over feeling that you will die, because you will not. You are at a higher risk of dying in car after talking to me. It is terrifying. I know that. I want you to leave knowing that we will have a very good plan and it will work. Now let’s get a MRI first.
Susan Love – the breast book...4th edition. She is a breast surgeon. Read just the part about cancer.
Dianne told her about Mexico and asked her opinion. She said no I have never seen it work. Now do I think wholelistic is important, healthy diet, exercise, low fat diet? Drink too much, never misses mammogram.
There are a lot of things that have scientific merit but right now unfortunately we have nothing to cure breast cancer without surgery.
We told her about Linda. Now your mind has been totally skewed to think that a mastectomy works better thank anything else. It doesn’t. There are no survival benefits to mastectomy. I tell people this is 1 time to set your emotions aside and listen to the facts. The facts are that have been proven over and over that there are no survival benefits to mastectomy. The recurrence rate is a little bit higher after lumpectomy. You have a breast there. The recurrence rate is about 4-6%. Meaning 94 to 96% of the people have no recurrence in that area. If you do have recurrence you would have to have mastectomy because you can not have radiation twice to the same breast. But if that happens, then you would have the same survival as if you started with as a mastectomy in the beginning. That has been proven over and over again. I see no point in going straight to a mastectomy unless you can not sleep at night. Now the MRI may tell us something differently. You may have spots here and there, you may have something in your other side, and we may say we need to look at this a little more closely. Or, you may say I really want to have some genetic counseling and see if I have high risk of that gene. If you had that gene I would support taking both breasts taken off. These are some things that you can think about while you are waiting to get your MRI.
Or you may just want to keep a closer look with MRI, etc. You may not even fall in risk because you do not have 1st degree relatives.
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