New patient
Today I saw a new breast cancer patient. When we see a new patient with breast cancer the medical oncologist is interested in finding out certain information in which to determine whether that patient is a candidate for the various treatment options that we use in breast cancer. In breast cancer, there are three major treatments that we use: we use radiation therapy, anti-hormonal or anti-estrogen therapy, and lastly chemotherapy. Which of these therapies we utilize, depends on the health of the patient, the age of the patient and what is found on the pathology in each patient’s case.
The first thing that I look at in a woman with breast cancer is her age. Breast cancer can generally be divided into two major groups. The first group is those patients that we see who are pre-menopausal. The second group are those patient’s who develop breast cancer post-menopausal or after the change in life. In general, breast cancer in these two groups of patients, are two very different diseases. Breast cancer in pre-menopausal women tend to be much more aggressive, spread earlier and chances for survival tend to be lower stage for stage compared to women with post-menopausal disease. Women with breast cancer after they have gone through menopause tend to be slower growing and “better behaved”. Also, women with breast cancer after they have gone through menopause tend to be hormonally responsive. Hormonally responsive means that they have estrogen and progesterone receptors and may respond to anti-estrogen therapy, this is what some people call “estrogen fed tumors”.
The second thing that we look at is whether or not a woman’s lymph nodes are positive. In all the studies that have been done in breast cancer, the number one factor that best predicts which women are at risk for their breast cancer coming back is whether or not their lymph nodes are positive. This is why we sample lymph nodes. The removal of lymph nodes from under the arm doesn’t necessarily help in the overall treatment of a woman’s breast cancer. However, the information that we gain from the removal of the lymph nodes is extremely important in determining what therapy is necessary. Patient’s with lymph nodes that have disease involvement have a much higher risk of reoccurrence of thier breast cancer. This is why the chances of needing chemotherapy is much greater in patients with lymph node positive disease.
The next thing that we look at on the path report is the size of the tumor. The larger the tumor is the greater the risk of reoccurrence. This seems to be most prominent when tumors reach 3-4 centimeters and larger.
We are interested in the grade of the tumor which roughly tells us how fast the tumor is growing. The other molecular studies, such as estrogen and progesterone receptors, Ki- 67, HER-2/neu status are also important in determining a patient’s overall prognosis.
After reviewing the patient’s pathology, we can then determine the stage of a tumor. Staging is important in most cancers; a patient’s stage is usually categorized as stage 1, stage 2, stage 3 or stage 4. Stage 1 disease is the earliest, in breast cancer this means the disease is confined to the breast. Stage 2 disease includes larger tumors and women with a few numbers of lymph nodes positive. Stage 3 is what we call locally advanced disease, with very large tumors or multiple lymph nodes positive. Stage 4 disease is when breast cancer spreads beyond the breast and lymph nodes to involve other organs in the body, such as bone, brain, liver, lung, etc. All these factors go in to us determining what treatment a woman would need.
The breast cancer patient that I saw was a young lady who was pre-menopausal, she had multiple lymph nodes positive, and her tumor was estrogen progesterone receptor positive. She will require chemotherapy, followed by radiation therapy and then will be placed on anti-estrogen therapy. With these therapies her chances are good.
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