Met w BS and now have Qs?

Hi MCBeach, sometimes the "top" surgeons don't have the best bedside manner. I certainly had that experience with a plastic surgeon who was the chairperson of the plastic surgery department of one of the most well-known cancer hospitals in the country. I understand why your surgeon said that the grade doesn't matter, although it's not really correct. Probably what he means by that, is that with the current standard of care (which is changing), the treatment is the same for low, intermediate and high grade DCIS: either the lumpectomy, rads, tax (or other hormonals) or the mastectomy. So what he may be saying is that knowing the grade doesn't change the treatment plan. If you read through the threads on bc.org, you will see that the tide is turning, in that some women with LOW GRADE DCIS may not need to do the radiation, and RARELY, they may not need the lumpectomy, if everything is removed with wide margins during the biopsy. If you have high grade DCIS, you usually do need to do the radiation, although according to NCCN guidelines, the hormonal therapy (for hormone receptor positive DCIS) is still considered optional. So, high grade DCIS is a higher risk condition, with a greater likelihood of becoming invasive. With regard to the 4mm and 6mm area, it seems that he DIDN'T READ THE PATH REPORT carefully. Of course, DCIS can appear in areas with calcs and areas without calcs. Now, how could a well-known and well reputed surgeon miss something on a path report--VERY EASILY. Look, he sees many patients each day, and he may not be as careful as he should be. That doesn't excuse it! Sometimes, you have to point things out to them, so you need to know the reports yourself (if you have them in advance).

Now, I agree that you should have a surgeon who is technically top notch. I also think it does help if they are careful and accurate, and it's even better if they do have a kind bedside manner. You need to have an ongoing relationship with this person. I don't know if you can switch surgeons at this hospital. At mine, it's actually difficult to switch practitioners, but possible. It's a thought anyway. About the lx vs. mx issue with the implants, that's best discussed with a plastic surgeon. Do you have a consultation with a plastic surgeon?

As usual, Beesie, you have a truly extraordinary ability to understand and respond to the nuances of every post. I hadn't realized that MC might be thinking that the current implant would still be used. Obviously, breast reconstruction is totally different. A good question is, if a lumpectomy is done, do they remove the current implant for the surgery and keep it out?

You also have the issue of the effects of radiation on an implant. I would think that a plastic surgery consult is a good idea under these circumstances regardless of what choice is made for the type of surgery.

Let us know how it goes.

MCbeach, I had breast implants for a couple of years before I was diagnosed with Stage I breast cancer in 2008. My cancer was high on my left side, maybe 1:00 if you were looking at me. My implant was under my chest muscle and did not need to be removed during my lumpectomy surgery, and it took my surgeon several tries to get clean margins. My doc said the implant would give my heart protection against the radiation. I went through radiation fine, there was no issue with the breast tissue or the implant feeling different or having any problems afterward. With such as small DCIS, I think a lumpectomy and radiation would be the kindest thing for you and your body. I LOVED my radiation treatments, did not have any skin problems, just fatigue. BTW I tried to talk to a plastic surgeon before my lumpectomy and he told me he would see me AFTER the lumpectomy and if there was any need for additional surgery, it would be after my cancer surgery and treatment. Just sharing that so if you hear the same thing, you won't feel "brushed off." You said you would be happy to toss away your pretty boobs if necessary .... you have the right to have a chest that you feel good about and doesn't make you feel ashamed. Just because you have DCIS doesn't mean you have to give up a pretty pair. Good luck to you.

I was recently diagnosed, finally met with the BS and am also confused on a few things. I have DCIS low grade, but multiple different calcification areas about 3.5cm apart and a hematoma from my biopsy. The area is large compared to the size of my breast, so I am considering a mx and reconstruction. 1) I don't understand why the Mx would include removing the armpit nodes if by definition my cancer is 'insitu' and I had a PEM and MRI which showed exactly where the cancer was. She said with the partial & radiation option they would Not do the node biopsy so why would the mastectomy be any different? Has anyone else been told the same thing or understand the logic behind this? its not like they are not performing a real function and without risk. 2) If I am brave enough to choose the Mx (logically, it makes a lot of sense to me in my situation, but I am struggling with the decision) I would be a candidate for the nipple/skin sparring mx and would seek a direct to implant reconstruction using alloderm (instead of the expander and months of delay, and reopening of healed tissue, etc) but my BS said this decision is made during surgery??? I am fit, I do not desire the implants to be any bigger than my real boobs, what could be the reason I would have to have the surgery with this as an unknown? Did anyone have the direct to implant plan with alloderm sling holding the implants, but wake up to find they had expanders instead? I meet for a consult with the plastic surgeon next week. Thanks so much for any wisdom and light you can share.

Hey McBeach:

Since you asked our opinion.. very concerned about some of this. True about BSs and bedside manner. But some of this doesn't sound right to my either. A new BS is in order as far as I'm concerned. Take it from someone who has had three Bss so far. See below...

I have DCIS grade 3. Was declared after a steriobiopsy. The micro cal area is 4mm. The pathology mentions DCIS in both the area of calcifications AND the area without calcifications.

I met my Breast Surgeon yesterady. He told me 2 things that doesn't seem to make sense.

1. "The grade of the DCIS doesn't matter". What??? I thought it did- Thoughts on this PLEASE??????

Of course the grade matters. It may not matter during excision. But it matters as far as treatment is concerned. I believe the grade is tied to rate of growth, isn't it?

2. "The DCIS is only 4mm". Not sure how this is so if it was positive in both areas and the calcification area alone was 4mm? The area take out on the non-calc portion of the biopsy was 6mm of DCIS so why would he think the total DCIS is only 4mm?

Not a doctor, but this is something that should be explained clearly for you. There does seem to be a discrepancy here.

I felt like he was trying to down play my situation, saying I am the PERFECT candidate for a lumpectomy.

Everyone is different. With two areas of DCIS I would consider BMX too. This is a decision which should be left up to the person with the breasts.

(which also doesn't make too much sense since I already have implants from an augmentation - he said that was not an issue w rads???)

How could that not affect rads at all? Can't believe this would be true.

Oh, and he told me btw you will have to take a little pill every day for a while.

This is how he referred to Tamoxifen? It sounds like he has an incredibly condescending tone. You sound pretty intelligent to me.

Later breezed over Tax... He did mention that he would support my decision either way (BMX or Lump+Rads+Tax)but mad me feel like I would be "overtreating" if I did the BMX.

These two statements the BS made are in conflict. You want a BS who supports your decision wholeheartedly (without referring to it as 'overtreating.'

I'd run if he was not at one of the best Cancer Hospitals in the Country and noted by many (Drs included) as one of the top Breast Cancer Surgeons. Is it that his bedside manner just sucks? Any one else have similar experiences? In the end, I'd rather him be skilled at surgery but WTH?

This is true. You want a BS who is skilled at cutting. If he is most skilled -- and no others are remotely close -- I'd go with him. But if you're at one of the best hospitals in the country, you have other choices.

We believe in you! Do whatever you want. Get a second opinion. Are you having an MO? You might want to talk to an MO as well. Sending you hugs.

Beesie, Thank you for all of the great info on the laypersons guide to DCIS, and for the SNB info above - that makes sense. Do you know if patients ever reject that portion of the mx treatment plan anyway? I feel the risks far outweigh the remote chance that cancer is anywhere but where my breast and node PEM scan indicated. Regarding the reconstruction, the BS said the decision was made "intra-operatively based on your chest wall and muscle and how the skin flap that I create looks." I guess I will really have to get clarification on this from the plastic surgeon. Thanks again Beesie! so very overwhelming navigating all of this: every time I feel I have made a step forward towards treatment, something knocks me two steps back.

I have read of people who chose to opt out of SNB during Mx for DCIS.

I too, wish that I could have had my Node marked during surgery, because I had pure DCIS after path report came in from my Mx.

In saying that, I was very compliant when my surgeon explained that if I had chosen to have a Lumpectomy and Rads, he wouldn't do a SNB, but that it would be very "remiss" of him not to do a SNB if I chose to have a Mx. I understood exactly what I could be facing, if I refused to have the SNB.

My Mother had BC in '94 and as was the norm in those days, had a Radical Mx and full Axillary clearance. She had moderate LE as a result of that and the irony was, that all those nodes were clear.

It is a highly emotive issue and can only be decided after careful consideration. I took what I considered to be the "safe road", for me, after my experience with my Mother. I certainly don't regret my decision to go ahead with it, even after getting a clear pathology report. It could just have easily gone the other way.

I am just very pleased that there may be another option, for people undergoing surgery now, with this node marking which wasn't there for me last December.

I wish you all the best with your decision!`