Do I need radiation?

Hi pauli36:

Welcome. Here is some information for you.

"After a mammogram and ultra sound, it was found I had cancer in those areas. There was a calcified area on the top of the breast (left) and the surgeon suggested having a mastectomy plus removing 2 lymph nodes. He said due to the calcification of pre-cancerous cells, I would not need radiation or chemo due to having the mastectomy."

It is true that with a mastectomy, many patients will be able to avoid radiation. Unfortunately, in some patients, the post-surgical pathology does reveal findings that may appropriately lead to consideration of a course of post-mastectomy radiation.

Whether post-mastectomy radiation is considered or not depends on a variety of factors, such as lymph node status and the size of the surgical "margins", such as whether they are close or involved, and the type of cancer present at the margins (e.g., non-invasive DCIS and/or invasive disease).

"Margins" are a measurement of how close the disease in the surgically removed tissue is to the edge of the tissue that was removed. When the margin sizes are very small or involved, it means the cancer in the breast was located very close to the edge of tissue removed. This raises suspicion that all of the cancer cells might not have been removed and that there may have been more cancer cells nearby that were left behind in the breast, which may increase risk of recurrence. While a mastectomy removes most breast tissue, it is not possible to remove all breast tissue. Thus, local recurrence may occur even with mastectomy. Here is a link to an illustration of surgical margins on this site:

http://www.breastcancer.org/symptoms/diagnosis/margins

"I have searched and found reports that state that if the percentage is lower than 39, I do not need radiation or chemo."

I do not think there is one single simple rule like this that would apply to all types of breast cancers or that would apply equally to radiation and chemotherapy and hormone therapy. These therapies can have different purposes, address different types of risks, and have different risk/benefit profiles. Also, there are differences in recommended treatments based on whether the patient has non-invasive or invasive disease, and received lumpectomy versus mastectomy.

Radiation and surgery are local treatments.

Chemotherapy mainly reduces risk of distant recurrence.

Hormonal therapy (oral anti-hormonal or endocrine therapies, such as tamoxifen or an aromatase inhibitor) may have benefits in terms of both local or distant recurrence. Such anti-hormonal drugs are considered in patients with hormone receptor-positive disease.

"Next he said he sat me up with an appointment for a second opinion. This is because the cancer was in the nipple area. So, I thought that is fine - I can not turn down a second opinion, but was concerned as to why?"

The area of expertise of a "medical oncologist" ("MO") is in drugs for treating cancer, such as chemotherapy, HER2-targeted therapy, and anti-hormonal therapy.

In contrast, radiation is the area of expertise of Radiation Oncologists ("RO"), and not medical oncologists. That is why your MO sent you to consult with a Radiation Oncologist about the possibility of post-mastectomy radiation. Technically, it was an initial consultation with an RO. In any case, that was a good move. Some patients have to beg for such a referral.

It sounds like there may be some concern arising from the size of the [anterior] margins [corresponding to the area] just behind the nipple. However, please specifically ask the RO for an explanation of the nature of the concern or concerns that lead to consideration of post-mastectomy radiation in your case.

Because the area of post-mastectomy radiation is complex and entails a risk / benefit analysis, I agree that seeking a formal second opinion from a second Radiation Oncologist at an independent institution is an excellent plan.

By the way, your diagnosis is not clear from the information you provided. To understand the various treatment recommendations you are receiving, it is important for you to learn as much as you can and to understand the details of your diagnosis that shape your treatment options.

Please request actual complete copies of the pathology reports from all biopsies and from your surgery, including all ER, PR, and HER2 test results. Look for information such as:

What type of cancer ("histology"): For example, do you have invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), and/or ductal carcinoma in situ (DCIS)?

What was the size and extent of each type of tumor?

What is your lymph node status? (e.g., pN0, pN0(i+), pN1mi, pN1, etc.)

What is your estrogen receptor (ER) and progesterone receptor (PR) status?

What is your HER2 status?

What are the sizes of the surgical margins? (Different sizes may be reported if DCIS and invasive disease are both present)

=> If margins are deemed "close" or "involved," what type of disease is at those margins and how does it affect recurrence risk?

With this type of information, you can also fill out your profile here, which helps people provide experiences or information more specific to your situation.

Best,

BarredOwl

Edited: Text in [square-brackets] added: . . . the size of the [anterior] margins [corresponding to the area] just behind the nipple. . .