Recurrence or Mets...HER2+ ER- PR-: When & Where?

Not sure about the spike in mets, but my guess would be that sometimes patients who are presumed to be stage 1 or 2 are not scanned at the time of diagnosis, or for those who were scanned, the cancer outside of the breast was simply not big enough to see at that point. A year or so later if they are scanned and something is found it's likely it was brewing from the get go, just not detected. If you have not already done so and your insurance will allow, get a PET scan (they typically cover "eyes to thighs") and a brain MRI with contrast. The bar for scanning is usually set pretty low for HER+ patients. Of course it won't find tiny mets, but at least gives you some peace of mind if all clear.

If you opt for the BMX, have you considered going direct to implants to avoid the expander/fill stuff? You mentioned on another thread that your breasts were large; I was in a similar situation and was going to skip reconstruction, but the PS I used offered the direct to implant surgery when I discussed my reluctance to get involved with expander method. He did the surgery along with the BS and explained that if the BS felt that more tissue/skin needed to be removed than expected during the BMX, he would have to use expanders. I asked him not to proceed with expanders if the direct to implants was not feasible, and he agreed; we wrote it in on the surgical consent form. As it turned out, I had enough skin to do it; it helped that I wanted to go much smaller than my disproportionately large breasts. The surgery went fine, but I unfortunately developed a hospital acquired staph infection in the healthy breast and had to have the implant removed a few months post surgery. Antibiotics worked for a while, but eventually could not control the infection. The cancer side is fine. I have not decided whether I will try a redo as the infection was very scary and i have since learned how unfortunately common infection is. However, I did not have bad post surgical pain; it seemed less traumatic than the descriptions of the expander experience. It makes sense; with the expander, the skin stretching is painful. That doesn't happen with the direct to implants, but I gather from my reading here that it's less common. If not for the damn infection (the infectious disease doc I saw said it was likely caused by a contaminated surgical instrument due to the tissue depth of the infection), I would have been satisfied with the surgery. The outcome would have been the same anyway; that type of infection can't heal while a foreign body is involved (implant or expander) so either one would have had to go. At least I did not have to worry about fills or swap surgery on the other side. The other thing I learned was that I like having the implants more than prosthetics. I did have a couple of months to enjoy my smaller, matching breasts and found they looked good in clothes and it was a relief for my neck and shoulders. The one prosthetic is a nuisance, but not sure I am up for any more surgery.

I would think that the stretching would cause even more skin delicacy(?) I also think that not all PSs are comfortable with all procedures. Most women don't have a ton of skin to work with post mast, so expanders are the norm, and PSs that aren't used to doing straight to implant don't offer it. The PS I saw does them fairly frequently, but always with the caveat that expanders will be needed if the BS opts to take more tissue/skin during the BMX than originally estimated. And true, use of radiation affects the decision also. I think maybe it's best not to get too hung up on the mets question right now. Your tumor is small, there is no evidence of hot nodes. Proceed how you would if mets were not on the horizon. My own gut on it is that mastectomy (either on the breast with cancer alone or both) would give me more peace of mind. The thought of long term mammos and scans post lumpectomy would not be appealing to me, especially with the HER2 situation. And if your node biopsy is clear, you can then skip radiation completely. But that is just my reaction, and as has been stated over and over in the forums, these are extremely personal decisions.