My First Post

I had the same questions about radiation and endocrine therapy after my lumpectomy path results came back with clean margins. The reason is that even with negative nodes and clear margins, one can never be sure that there are no residual “micrometastases” in either the breast or elsewhere in the body, to continue growing and become either a new tumor or distant metastases. So there are two types of postoperative “adjuvant” treatments: local and systemic. Unless you are well past 70, and had extremely small DCIS, if you had a lumpectomy you will almost certainly be advised to have radiation, as “local” therapy. It is designed to directly destroy those micromets most likely to remain after your tumor was removed: the ones still hiding out in your breast. Depending on how aggressive your tumor, its size and location and your age, you might be offered a shorter course of higher intensity partial-breast radiation, to just the tumor cavity and a small margin around it. Radiation is usually not given if you had a mastectomy--but it’s still administered if there were positive lymph nodes and/or tumor cells found on or near the chest wall.

You might also (probably most of us almost certainly) have some micromets that made it past your lymph nodes and into your body. Therapy to kill them is called “systemic.” If your tumor had a certain profile that indicated it was likely to be aggressive, and/or your OncotypeDX (if needed & offered) score confirms it, then you will be urged to have chemo--since cytotoxic (cell-poisoning) drugs given as chemo are most effective in killing those fast-dividing (and thus aggressively-growing) cells. If your tumor’s profile indicated it was slow-growing and was positive for estrogen & progesterone receptors, and/or your OncotypeDX (if needed & offered) indicated it was non-aggressive, you would be advised to go on endocrine therapy. Hormone-receptor-positive tumor cells are too slow-growing to be vulnerable to chemo drugs, and the risks to you from chemo would outweigh the benefits. These tumor cells feed on estrogen. So instead of “slash/burn/poison” of surgery/radiation/chemo, your treatment plan would be “slash/burn/starve”--by depriving tumor cells of estrogen they would starve to death. Why, if these cells are so slow-growing and non-aggressive in the first place, would you even need to kill them in the first place? Because, given enough time untreated, they could still grow and spread to your bones and organs, eventually killing you. It’d just take a long time. And some tumor cells, even if hormone-receptor-positive, have more aggressive features (e.g., Grade 3, spread to more than a couple of lymph nodes, large size, HER2 positive), you would get chemo first to kill the most aggressive cells, then radiation to kill what’s hiding out in your breast, and finally endocrine therapy (5-10 yrs) to starve the slow-growing stragglers to death before they can become a tumor and spread.

Endocrine therapy will depend on how close to menopause you are (or if you’re past it). If you’re not done with menopause yet, you’d get Tamoxifen and maybe some other drug to shut your ovaries down permanently or temporarily. If you’re postmenopausal, you won’t need anything to suppress your ovaries; and instead of Tamoxifen--which blocks access to the estrogen receptors--you’d get an aromatase inhibitor, which neutralizes the enzyme that helps your fat cells and adrenal glands convert the hormones they make into estrogen. There are other considerations your doctor will explain more fully. It’s still your call, but you need to know why certain treatments are recommended for you so you can make an informed rather than just a visceral decision.

Glad you are finding the support you need, MyWalk! Please keep us posted on your path report when you receive it. We're all here for you!

--The Mods