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January 2013 Ask the Expert: Making Treatment Decisions for the Newly Diagnosed

During the month of January, Living Beyond Breast Cancer expert Adam Brufsky, MD, PhD, answered your questions about making treatment decisions when you are newly diagnosed.

What is the best type of biopsy sample or slide to ask for in order to preserve tissue for use in clinical trials or genomic sequencing?

What can I expect of treatment, testing and follow-up care for early-stage, triple-negative breast cancer?

I had a mastectomy w/TRAM flap reconstruction after my third breast cancer adventure. I have the BRCA2 mutation. Logic says have the "real" breast removed to reduce my risk. Is reconstruction recommended for someone like me?

I was told that my tumor is HER2 negative, but when a different lab tested it they said it is HER2 positive. The lab said parts of my tumor are positive and parts are negative. What relevance might this have to my tumor grade? Could one part of the tumor get a higher score than another part?

Does tumor size make a difference as to whether surgery or chemo is done first?

Regarding overall survival, how does dose-dense versus having three agents every three weeks compare? For example, AC-T (dose-dense AC every two weeks then T every two weeks) versus TAC every three weeks.

What is the reason some cancer centers add 5-FU to ananthracycline/cytoxan/taxane and others do not?

Please explain what lymphovascular invasion is? If there is any lymphovascular invasion, does that mean that cancer cells could be only on the walls of the vessels, or does that mean cancer cells definitely got into the lymphatic or vascular system? Does the amount of LVI make any difference?

What is the possibility that post-surgery/axillary lymph node dissection manual lymphatic drainage or massage (for lymphedema) could spread any residual cancer cells into the lymph system if done prior to axillary radiation?

Is  vitamin D level becoming a standard baseline blood test for those with a new diagnosis of breast cancer? If not, why not?

If one’s pathology report only has ER, PR, HER2 status, can one currently request any additional tests (and which ones) that would help determine one’s chemo plan, especially for TNBC?

Question: What is the best type of biopsy sample or slide to ask for in order to preserve tissue for use in clinical trials or genomic sequencing?

Dr. Brufsky: The best sample that is easily obtainable is a paraffin (wax) block of the tumor preserved in the pathology lab. If there is any frozen tissue left (sometimes the surgeons will do a frozen section to be sure the margins of the biopsy are clear of cancer), that is even better, but a lot of pathology labs don’t have any frozen tissue left. Unstained slides of the cancer will also work for gene sequencing or clinical trials.

Question: What can I expect of treatment, testing and follow-up care for early-stage, triple-negative breast cancer? Are there certain things to keep in mind as I move forward? 

Dr. Brufsky: A lot depends on the stage of the triple-negative breast cancer (TNBC) and your age.

For follow-up: if you’re younger than 50 and you have dense breasts, a lot of doctors will recommend annual tomography or MRI in addition to mammogram. If you are young and have dense breasts and your cancer is stage I, this is enough imaging. Exams should be every four months for the first two years after diagnosis, every six months for the next two years, and then yearly after that. If your cancer is stage II or stage III, some oncologists will add a baseline CT or bone scan, or both.

For treatment: generally if you have a TNBC tumor larger than 1 cm you will probably get adjuvant chemotherapy regardless of node involvement. The type and length of chemo depends on the stage of the cancer. Whether or not you get radiation also depends on your age and the stage of the cancer. Generally, if TNBC is going to recur, it will be in the first two to three years.

Question: I had a mastectomy w/TRAM flap reconstruction after my third breast cancer adventure. I take anastrozole (Arimidex). I have finally had genetic testing, and I have the BRCA2 mutation. Logic says have the "real" breast removed to reduce my risk. Is reconstruction recommended for someone like me?

Dr. Brufsky: Yes, you can have reconstruction. Having a prophylactic mastectomy after three cancers in the opposite breast, as well as a BRCA2 mutation, is a reasonable thing to do. Reconstruction is always a very personal decision.

Question: Initially, I was told that my tumor is HER2 negative, but when a different lab tested it they said it is HER2 positive. The lab where I am being treated took another look at my case and said parts of my tumor are positive and parts are negative. Because they need to treat "the most aggressive part" of my cancer, I am now considered HER2 positive. What relevance might this have to my tumor grade? I have a score of 1 for mitotic rate, but did that score come from only one part of my tumor? Could another part get a higher score?

Dr. Brufsky: The part of the tumor that was HER2 positive may or may not be higher grade. The issue is whether to treat you with trastuzumab (Herceptin) and chemotherapy, given that a part of the tumor was HER2 positive. This question has not yet been resolved. My decision would rest on how big the entire tumor was, and whether there were positive lymph nodes.

Question: Please discuss chemo versus surgery first. Does [tumor] size make a difference as to which is done first?

Dr. Brufsky: Generally, if we think we are going to give chemo to someone after surgery, we will consider it before surgery as well. The reasons to do chemo before surgery are to (a) see if the cancer is responsive to the first chemo and change the chemo if it is not; (b) make surgery easier by shrinking the tumor and perhaps allowing a lumpectomy instead of a mastectomy; and (c) allow time to plan for surgery and reconstruction. 

Generally, we would think about using chemo first for larger tumors (over five cm), and especially for cancers that are triple-negative. However, many oncologists consider chemo upfront for smaller tumors as well.

Question: Regarding overall survival, how does dose-dense versus having three agents every three weeks compare? For example, AC-T (dose-dense AC every two weeks then T every two weeks) versus TAC every three weeks.

Dr. Brufsky: The survival rate is exactly the same, per a trial called NSABP B-38 that was recently published. We tend to use four cycles of AC (Adriamycin, Cytoxan) followed by paclitaxel (Taxol) for 12 weeks, which is a lot less toxic than the other two regimens and has similar disease-free and overall survival.

Question: What is the reason some cancer centers add 5-FU to ananthracycline/cytoxan/taxane and others do not?

Dr. Brufsky: Thereis no real reason – it’s just the way each individual center has been practicing. The addition of 5-FU really does not add much to AC in the adjuvant setting.

Question: Please explain what lymphovascular invasion is? If there is any lymphovascular invasion, does that mean that cancer cells could be only on the walls of the vessels, or does that mean cancer cells definitely got into the lymphatic or vascular system? Some articles refer to large amount of LVI or the number of slides LVI is seen in. Does the amount of LVI make any difference?

Dr. Brufsky: Lymphovascular invasion means that there are cancer cells in the lymphatic vessels. I personally do not use it as a test anymore, since we have sentinel node dissection to tell us whether the cancer has the ability to spread to distant sites. We used to use LVI to help us with this in node-negative breast cancer, but a lot of us do not use it anymore in an era where we have Oncotype DX.

Question: What is the possibility that post-surgery/axillary lymph node dissection manual lymphatic drainage or massage (for lymphedema) could spread any residual cancer cells into the lymph system if done prior to axillary radiation?

Dr. Brufsky: Next to zero. There is no evidence for this at all that I am aware of.

Question: Is vitamin D level becoming a standard baseline blood test for those with a new diagnosis of breast cancer? If not, why not?

Dr. Brufsky: Interesting question. We are not quite sure what the normal level of vitamin D should be right now, so while we all were very excited about this a few years ago, I think some of us are back to using it cautiously.

Question: If one’s pathology report only has ER, PR, HER2 status, can one currently request any additional tests (and which ones) that would help determine one’s chemo plan, especially for TNBC?

Dr. Brufsky: Currently there are no other tests that can help. Some think the androgen receptor may be a test to order, but it is not widely accepted. In the near future, I suspect genomic profiling will become popular if we can figure out how to use the data we get out of such a test.

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