What comes next?

Alittleknowledgeisdangerous

Age: 73. Health: excellent. Arthritis and osteopenia but no heart, lung or other systemic problems. Active, not overweight. I expect to be around another 20 years.

My right breast, small to begin with, has had some reductions: I had LCIS and lumpectomy five years ago. Also, two incisional biopsies that look like lumpectomies twenty years ago. (Surgeon was suspicious even though pathology was negative, so he suggested going back in and taking a chunk. I trusted that surgeon more than I trusted an unknown pathologist and think he was probably correct because laterthe LCIS was in the same spot.)

This week: Core biopsy shows DCIS. Small. Tomorrow I see surgeon. What options do you think she will offer? Am I being overreactive by investigating mastectomies?—I see in my research that mastectomy is an option after two lumpectomies, but have I had two lumpectomies? I have no interest in reconstruction. Also no interest in hormone therapy as I could not tolerate Aromasin and am concerned about side effects of other estrogen inhibitors.

countdooku

I don't think you're being over-reactive at all. I'm going through almost the same choice myself, although I am interested in reconstruction (I'm 46). I wrote down a ton of questions that I had for the breast surgeon before I met with her late last week. There's no way I could have remembered all of them!

Hang in there, sister!

AliceBastable

A friend who is about 82 had a lumpectomy a few years ago, and with a small recurrence late this winter, she opted for a mastectomy without reconstruction. She's doing fine.

Beesie

"I see in my research that mastectomy is an option after two lumpectomies, but have I had two lumpectomies?"

I don't think what you read is relevant to your situation. If someone has a lumpectomy and the surgical margins aren't clear, and then has re-excision surgery (effectively another lumpectomy) and again the surgical margins aren't clear, at that point although another re-excision could be attempted, usually a mastectomy (MX) will be recommended.

A MX is also recommended in situations where a patient has had a previous diagnosis of breast cancer and had a lumpectomy + radiation, because rads is normally done after a lumpectomy and rads can't be done twice on the same area.

MXs are also recommended when the area of DCIS or invasive cancer is large. When I had approx. 7+ cm of DCIS in two areas of my breast (plus a microinvasion of IDC), a MX was the only viable surgical option. For women who have invasive cancer, sometimes chemo is done prior to surgery to shrink the tumor, in which case a lumpectomy might be feasible, but chemo is never given for pure DCIS, so this is not an option for women who have large areas of DCIS.

All that said, every patient has the option to have a mastectomy (and even a bilateral mastectomy, i.e. both breasts), whether they've had surgery before or not, and even if the size of the cancer appears to be small. A lumpectomy might be recommended by the surgeon, but it's the patient's choice.

Given that you have DCIS (a pre-invasive diagnosis) and given your age, the question is whether a lumpectomy alone will be considered a reasonable option, allowing you to avoid both rads and endocrine therapy without the need to have a MX. If your DCIS is small and lower grade (grade 1 or at most grade 2), this could be an approach to consider. My mother was 80 when diagnosed. She had a 1cm grade 1 invasive cancer, had surgery, then a re-excision to widen the surgical margins, and that's it. Rads and endocrine therapy were discussed but not pushed, and she decided against both those treatments. She's now 94.

Of course if your preference is to have the MX (or a BMX), that is an option, but with a small area of DCIS, a simple lumpectomy might also be an option. This approach is being taken more and more with DCIS given the concern in the medical community that DCIS is often over-treated. The choice is yours.

countdooku

I also think it's a very individual decision where what works for 1 person might not necessarily be what the next person would choose.