Need your advice

Ann, I'm sorry that your mother has been diagnosed.

Reading the recommendations you've received from both doctors, it appears that both are wrong, although the first doctor is less wrong.

The first doctor is right that you should wait till the FISH test is back to determine HER2 status and whether surgery should be first or chemo should be first. I don't know large your mother's area of cancer is, but with possible nodal involvement and with the tumor being multicentric, it makes sense that chemo might be done first, particularly if the cancer is HER2+.

The first doctor is wrong in saying that if the cancer is HER2-, then treatment will be surgery and hormonal treatment only. Maybe that turns out to be the case, but it's too early to know that. Since your mother's cancer is multicentric, I am assuming that there is no question that a mastectomy is required. In that case, radiation may or may not be necessary. Rads usually isn't given after a MX, but is given if there are many positive nodes, if the tumor is very large and/or if the surgical margins are close. So until the surgery is done, it's impossible to know if rads will be required after her MX. As for chemo, if there are several positive nodes, or if the Oncotype score is high, then chemo will be recommended. The Oncotype test is 21-gene assessment of the breast tissue which determines the aggressiveness of the tumor and whether chemo would be beneficial or whether endocrine therapy alone (anti-hormone therapy) is recommended. The Oncotype test is used only for ER+/HER2- tumors that are larger than 5mm. It can be used for either node negative or node positive cancers, but if many nodes are positive, most Oncologists will skip the test and recommend chemo.

The second doctor is wrong in saying that the treatment will be mastectomy with lymph node dissection , chemo , radiation and hormonal whether the cancer is HER2+ or HER2-. First, as mentioned earlier, it won't be known if radiation is required after the mastectomy until after surgery. Second, if the cancer is HER2+, one additional treatment will be on the list, which is Herceptin. Third, if the cancer is HER2-, then there are lots of possibilities as to what the treatment might or might not be, as noted in the paragraph above.

Now the most important question. Are these doctors surgeons or medical oncologists? Surgeons operate; medical oncologists recommend the entire treatment plan. A surgeon is out of his league talking about any of these other things, and while many surgeons will be correct in what they say, they are not the experts on radiation or chemo and they aren't the ones who recommend these treatments to patients; it's the Medical Oncologist, and for radiation, the Radiation Oncologist. In many cases, with early stage cancers, the patient may not see the MO until after surgery - because in those cases it's clear that surgery should be the first course of action. But in your mother's case, it's not clear whether surgery should be first, or chemo (if HER2+). Even if her cancer is HER2-, depending on the size of the cancer, it might be recommended to have chemo first to shrink the tumor before surgery. So your mother should be seeing a Medical Oncologist prior to making any decisions about treatment, including surgery.

Hope this helps. And wishing your mother the best possible pathology results!

Ann_James, please try not to find anything to blame for your mother's cancer, particularly anything she may have (or have not) done. I only took contraceptives for one year, half a century ago. I had estrogen-based endometrial cancer in 2008, which led to a very thorough hysterectomy and NO hormone replacement. Surprise, in 2018 I got hormone-based breast cancer, very high percentages. Some of us crank out estrogen for absolutely no reason. Blame only makes people feel worse.

Don't be sorry for having questions. It's much better to be prepared!

1. If it turned out to be her2 negative , is there any chance that treatment will be hormonal only ? When can this happen ?

Yes, absolutely. If HER2-, then after surgery (usually either a MX with or without Rads, or a Lumpectomy with Rads), it is possible that endocrine therapy might be the only additional treatment. This depends in part on the size of the tumor and whether or not there are many positive lymph nodes. This is where the Oncotype test score would come into play. The test is done on a sample of the cancerous tissue removed during the surgery. A low to intermediate score would indicate that there would be little benefit to chemo and hormone therapy alone would be the recommended treatment plan.

2. If reconstruction with silicone implant was done immediately after mastectomy and then radiation was needed , do they dry out or can hide cancer cells ?

I have never heard a concern about an implant or expander (a 2-step implant reconstruction process) hiding cancer cells. It is true however that having rads after an implant or expander has been placed does increase the risk of complications. That said, this is being done more often these days. The following article explains in detail the risks associated with radiation and each type of reconstruction, with the conclusion being that "With growing evidence supporting the benefits of PMRT (post-mastectomy radiation therapy), the optimal integration of postmastectomy reconstruction with PMRT is of utmost importance. The risks and benefits of immediate versus delayed as well as autologous versus implant-based reconstruction must be considered for each individual patient. There is no level 1 evidence indicating an optimal strategy, and this complex decision process involves consideration of quality of life, surgical outcomes, history of radiation therapy, cosmetic outcomes, and life expectancy." Breast Reconstruction and Radiation Therapy

3. One doctor worried my mother saying that taking a biopsy led to spreading of cancer cells and that surgery should be followed immediately , he is wrong , right?

It does rarely happen that some cancer cells might be left in the needle track from the biopsy. That doesn't mean that these rogue cells will start spreading - they are just as likely to just sit there. Most cancers are slow growing, so this very small risk doesn't mean that the patient needs to rush into surgery. A 4-6 week wait between diagnosis and surgery is normal, and often the wait is longer. If the delay is longer because chemo is given prior to surgery, it's the role of the chemo to attack and kill off cancer cells in the breast (and any that might have moved into the body). It's not uncommon that after neoadjuvant chemo, no cancer remains in the breast.

4. Emotionally , how to take care of my mother during this time ?

There is no easy or single answer to this one. We're all different, so the right support for one person might be smothering for someone else. It's often hard for patients to ask for help or to say exactly what we need. My advice is to ask your mother what she needs and how you can help, listen to her, and particularly, read the subtle signs and follow her lead in terms of what seems to make her comfortable and what she seems to want to do. What not to do is push and force on her support that she doesn't want.

5. I'm afraid of lymphedema development , how can we prevent it , she is a housewife and uses both her hands quite often in lots of things , I don't want to see her unable to do what she is used to do .

Here's a place to start: Reducing Risk of Lymphedema

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Yes, it is possible. The role of the lymph nodes is to catch infection and keep the infection from moving further into the body. Nodes that are swollen are simply doing their job. Even a small infection or cold can make lymph nodes swell.

Hope this helps!

Microcalcifications aren't cancer. They are very common and most often are caused by something totally benign.

Sometimes however they are the result of an underlying process that occurs in the cells because of the presence of cancer. So microcalcs, if they are found to be in a suspicious formation (clustered or linear), simply alert the Radiologist to look further to discover the cause, and to see if any cancer cells are present.

Chemo and hormonal treatment are used to attack and kill of cancer cells that might be in the breast. You don't need to worry about the calcifications themselves.

There is no way to know for sure if all the cancer cells have been killed off until the breast tissue is removed and analyzed under a microscope. A few cells of cancer here or there would never be seen by screening.