When a loved one learns she has breast cancer, she's most likely to seek advice from someone who has been there. Even if you haven't there are ways you can help. One of the most helpful things to do is offer to accompany her (or him) to appointments and suggest questions to ask the doctor. "I always recommend that patients take someone along to offer emotional support and be an extra set of ears," says Rosalind Benedet, RN, NP, director of Breast Cancer Recovery at California Pacific Medical Center in San Francisco and author of Understanding Lumpectomy: A Treatment Guide for Breast Cancer.
Here are some questions to get you started:
Q. Am I a candidate for lumpectomy? If not, please explain why not.
A. If your doctor says you're not a candidate for lumpectomy, get a second or even a third opinion. Women with breast cancer who choose lumpectomy followed by radiation live as long as those who choose mastectomy, if the cancer is diagnosed early, according to the journal Cancer. "Breast cancer on average takes seven years to develop, so you have time," says Carolyn Runowicz, MD, president of the American Cancer Society and director of the Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center. "I had breast cancer and I got the opinions of three different people."
Q. If I must have a mastectomy, can I have immediate reconstruction or do I have to wait?
A. To determine which procedure is best, first talk with a qualified plastic surgeon. "Factors that play into this decision include general health, body type, desired appearance, and type of postsurgical breast cancer treatment a patient has had or will need," Benedet says. Most women undergo at least part of the procedure during their mastectomy, but you can wait years.
Q. Do I need to have my lymph nodes sampled? If so, will you perform a sentinel node biopsy?
A. Whether you have a mastectomy or lumpectomy, the nodes are usually biopsied at the same time. In sentinel lymph node biopsy, the first lymph node (into which the tumor would first drain) is identified and that node, along with one or two in the area, are removed and analyzed. If these nodes are cancer-free the patient can avoid having other nodes removed. If they contain cancer, more lymph nodes can be removed during the same surgery.
Q. How should I expect to look after surgery?
A. Expect a dressing over the surgical site. You may even have one or more plastic or rubber tubes coming from your dressings. These drain blood and lymph fluids. Patients are taught how to empty and measure the fluid and look for problems. Ask your surgeon to show you photos before surgery to give you an idea of what to expect.
Q. How long will I be in the hospital?
A. Less time than you think. Most women stay one to two days following mastectomy without reconstruction, the American Cancer Society says.
Q. What type of cancer do I have?
A. Ask for a copy of your pathology report for your personal records. The main types of breast cancer include those confined to the milk ducts or the lobules (referred to as carcinoma in situ) or invasive or infiltrating cancers, which have spread from where they started. Invasive ductal carcinoma, or IDC, is the most common form of breast cancer. About 80 percent of all breast cancers are IDC. It starts in a duct and then spreads to surrounding breast tissue. From there it can spread to other parts of the body.
Q. What size is the tumor?
A. Size isn't everything. "You can have a small tumor that goes into three lymph nodes or a large tumor that doesn't go to the lymph nodes," Runowicz says. "Size is a piece of the puzzle but only part of it." Measured in centimeters, a 1-cm breast tumor is about the size of a pea and a 5-cm tumor is about the size of a golf ball.
Q. What is my ER/PR status?
A. ER/PR status refers to whether the cancer cells are stimulated by the female hormones estrogen and/or progesterone, which can make tumors in the breast grow larger. If tumors are found to be hormone-receptor positive then hormonal therapy taken in pill form can be prescribed. This helps prevent tumors from getting the hormones they need to grow.
Q. What is my HER-2 status?
A. HER-2-positive breast cancer is one that shows overexpression of a protein called human epidermal growth factor receptor-2. This is found in about one of every three breast cancers. "If you are HER-2 positive your cancer will be more aggressive," says Deborah Stewart, RN, a breast health educator at Johns Hopkins Breast Center in Baltimore. This cancer tells the cells to divide more than cancers that do not overexpress this protein, she says. Herceptin, an intravenous drug, is used to slow the growth of cancer and even decrease its size. A study found that in patients with overexpression of the HER-2 protein, herceptin reduced recurrence by 50 percent. Certain chemotherapy medications also can be used with herceptin to treat patients who are HER-2 positive.
Q. What stage is my cancer?
A. Knowing the stage is key to determining how your doctors will treat your cancer. Invasive cancer is categorized as stage 1, 2, 3, or 4. The first two are considered "early stage" and typically refer to smaller tumors that haven't spread. Some of the stages are further divided with letters A, B, and C. Stage four is advanced or metastatic disease. "Stage 4 is more like a chronic disease," says Stewart, adding that, in some cases, stage four cancer can be managed for years. "It depends on how aggressive the tumor is, how responsive it is to drug therapies, and what organ it's in."
Q. Will I need chemo or radiation?
A. Following lumpectomy a patient automatically gets radiation, Runowicz says. Whether or not chemotherapy is done is determined by the stage of cancer. In general, tumors larger than 1 cm and tumors with positive lymph node get chemotherapy, Runowicz says. A new diagnostic test called an Oncotype DX also can be done on a tissue sample removed during surgery. The recurrence score can give information about the likelihood that a cancer will recur. This information can be helpful in making decisions about adding chemotherapy to the treatment regimen.
Q. What's next?
A. Once treatment is complete you will have follow-up visits every four to six months and continue with yearly mammograms. Read everything given to you about breast cancer and do research on your own. "The more patients know, the easier it is on everyone because they know what questions to ask and what to expect," says Runowicz, who advises patients to gather information from reputable sites such as the American Cancer Society (www.cancer.org), Susan G. Komen for the Cure (www.komen.org), and the National Cancer Institute (www.cancer.gov).