Do I need to see an oncologist prior to surgery?

freak4fiber · July 2016

Hi I was just diagnosed. I have had a chance to meet the breast surgeon and plastic surgeon, nursing staff and cancer navigator. I was offered the chance to make an appointment to meet the oncologist if I wanted to. Should I? I mean other than to make sure I am happy with the choice of oncologist there is there any input they can offer at this point? It sounds like surgery first so until that happens and tumor is tested and lymph nodes checked is there a reason to speak with the oncologist? Thanks in advance for your input.

edwards750 · July 2016

Typically you do see your Oncologist after the surgery because at this point you don't know what you are dealing with yet. I don't think it would hurt but frankly unless you just want to meet who will be in charge of your treatment there is no real reason to.

Good luck!

Diane

NancyD · July 2016

I would meet and get a feeling for them. And if there are others in your area or in the practice, I would meet with a couple of them, too. As you said, at this point there are no tests results to discuss, but you want to have a good rapport with the oncologist more than any of your other specialists since they will be directing your treatment for years.

BarredOwl · July 2016

Hi freak4fiber:

I might be tempted to meet with the medical oncologist, since it was offered (and often is not). You can still schedule your surgery on the assumption of a surgery-first treatment plan, and see if the Medical Oncologist concurs with the plan. I say this because in another post you mentioned, "I have two separate tumors in the same breast rather far apart from each other." What are the (a) type; (b) size; (c) grade; and (d) ER, PR, and HER2 statuses for each of the tumors (as they could be different)?

Also, your profile is currently showing Stage IB. Did you have clinical evidence of lymph node involvement or a lymph node biopsy? Stage IB requires some limited lymph node involvement. Specifically, Stage IB requires a nodal status of "N1mi" (micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm)). See for example, this summary from the AJCC regarding staging (Chart at page 1, bottom center, lines 3 and 4).

https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf

I am not sure what type of biopsy you had, but sometimes, people are confused by size designation (e.g.," T1b" Tumor > 5 mm but ≤ 10 mm in greatest dimension). But that is a size designation only (and not a stage assignment). See the link above, at page 1, top center for "T" size information.

Best,

BarredOwl

freak4fiber · July 2016

Hi BarredOwl,

In terms of your questions above I don't have my pathology report with me right at this moment but the stage 1B was told to me from the meeting with the breast surgeon. My understanding was this was the stage at this point without having had my MRI yet or surgery so it could change. My understanding was the two different areas had spread outside the ducts so considered invasive but there was no macroscopic evidence that it was in the nodes and that they would check for microscopic evidence during surgery. Both tumors are ER and PR positive and both are her2 negative. One of the tumors was much more PR receptive than the other but both were listed as PR+. Both are about 1cm. The type was IDC. Let me know what you think. Thanks

BarredOwl · July 2016

Hi freak4fiber:

With IDC, people may consult with a medical oncologist prior to surgery to obtain advice regarding the possibility of neoadjuvant systemic treatment prior to surgery. Such treatment is within the area of expertise of medical oncologists (and not breast surgeons). With IDC, factors such as the extent of disease (e.g., large primary tumor), "triple-negative" (ER-PR-HER2-), and/or "HER2-positive" status may lead to consideration of "neoadjuvant" (pre-surgical) therapy. However, it is also used in other situations.

In the appropriate case, with extensive disease, neoadjuvant treatment may cause shrinkage of the tumor and may permit the option of lumpectomy plus radiation instead of mastectomy. Another potential advantage of neoadjuvant treatment is that it can provide information about "pathological response", meaning they can monitor during treatment and at later surgical removal, if the tumor responds / responded to the chemotherapy regimen (shrinks or disappears completely (i.e., "pathological complete response")). If the response is not adequate, this information allows a switch to a different regimen. If you would like case-specific, expert professional advice, please do not hesitate to meet with the medical oncologist prior to surgery.

I am a layperson, so perhaps I am missing something, but a person who has no clinical evidence of lymph node involvement, with widely separated tumors considered to be "multiple" tumors by a pathologist applying AJCC criteria, in whom surgical pathology reveals the largest tumor to be "T1" in size, with no node involvement ("N0"), and no clinical or radiographic evidence of distant metastases ("M0"), would be deemed Stage IA (T1 N0 M0), according to AJCC. This still seems formally possible in your case (as are higher stages, because lymph node status cannot be predicted from negative imaging and negative clinical findings).

BarredOwl

MinusTwo · July 2016

freak4 - I insisted on meeting with an oncologist before I moved forward with surgery even though the diagnosis was DCIS. I was so glad to know who would be dealing with the fall out, although the surgeon got clear margins & serial node biopsies were clean the first time. The second time - I was already following up with the oncologist every 6 months, so that's where I took my questions about a recurring lump. And as BarredOwl is discussing, I did have neoadjuvant chemo the 2nd time and I think it made a difference. I do understand that part of my insistence on meeting the MO first was because I am a control freak. But part of me just wanted a second opinion of the options before I had my BMX.

LoveMyFamily · July 2016

I didn't choose or meet my oncologist until after the surgery.... I would think it would be your choice, though.

freak4fiber · July 2016

OMG yes you guys are right so I just got home and this is exactly what the surgeon wrote:

Clinical stage I: (m)T1b(1cm)N0 M0

Pathological stage: TBD

So does this mean I do not have stage 1b? Does this mean I have stage 1a or I just don't know the stage yet?

Thanks for pointing this out 😀

Artista928 · July 2016

I would meet with them. I'm glad I did. The first one I thought was going to be good I didn't like. So my second option is who I went with. After sx I was concerned I may not be "all there" to really decide so I wanted to have it all planned out, bs, ps, mo, ro, infusion center-- all decided before.

BarredOwl · July 2016

Hi freak4fiber:

"Clinical stage I: (m)T1b(1cm)N0 M0

Pathological stage: TBD"

The code "(m)" is used to indicate "multiple" tumors in one breast. Under the TNM system, with multiple tumors, tumor size (T) for staging is based on the single largest tumor.

There are two types of staging: "clinical" and "pathological". The latter is more definitive.

From the information you posted, it looks like the pathologist assigned a "clinical stage" of "Stage I". This assignment is provisional or preliminary in nature, because in this case, it is based on clinical findings and breast biopsy only, and may not reflect the whole picture. I understand no lymph node biopsy has been done, but with no clinical signs, you are clinically node negative ("N0"). The report is NOT saying you are Stage IB, because "T1b" refers to the size of the tumor only, not the stage. These are the various "T" size designations under the TNM system:

https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf

T1mi Tumor ≤ 1 mm in greatest dimension

T1a Tumor > 1 mm but ≤ 5 mm in greatest dimension

T1b Tumor > 5 mm but ≤ 10 mm in greatest dimension <== This is the size of the largest one in your case

T1c Tumor > 10 mm but ≤ 20 mm in greatest dimension

T2 Tumor > 20 mm but ≤ 50 mm in greatest dimension

T3 Tumor > 50 mm in greatest dimension

Pathological stage (the definitive stage) is noted as "TBD" (i.e., to be determined). The "pathological stage" will be assigned based on what the surgical pathology and axillary staging (e.g., sentinel node biopsy) reveal about the actual tumor sizes and actual lymph node status.

As I noted above, in the best case scenario, if after surgery the biggest tumor was still "T1" size (e.g., T1b or T1c), and you were found to be purely node negative ("N0") and M0, then your "pathological stage" would be Stage IA (T1 N0 M0). Again, that would be the best case scenario, and other outcomes are possible.

Sending good vibes your way for the best possible results.

BarredOwl

ElaineTherese · July 2016

Hi!

I began treatment with my oncologist before surgery, but that was primarily due to 1) the fact that my tumor was large (5 cm. +); 2) my tumor was HER2+ (it's easiest to get a targeted therapy for HER2+ cancer [Perjeta] before surgery); and 3) my tumor was aggressive (Grade 3), and I was going to get chemo anyways. For someone who is Stage 1 and doesn't show any nodal involvement (yet), meeting with the oncologist is not a must for now. But, you might want to meet some possible oncologists now so that you find one you're comfortable with. Because you are ER+/PR+, it is likely that your oncologist will recommend that you do hormonal therapy after surgery. For many, hormonal therapy lasts 5 years; for others (like me) 10 years is recommended. If you do end up doing hormonal therapy, you will be visiting your oncologist for 5 years, and it helps to be with someone who is sympathetic and listens to your concerns.

Good luck!

Do I need to see an oncologist prior to surgery?

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