Breast Cancer Process

The first visit post-diagnosis will be a discussion of the biopsy results, type of cancer, and treatment options. Additional tests will be mentioned. This will take in the order of 45 minutes to an hour. There should be ample time for questions. Families are encouraged to take notes. Literature may be provided to the patient and family. There may be referrals to other team members such as radiation oncology, medical oncology, plastic surgery, social work or counseling.

The NCCN publishes guidelines for followup.
http://www.nccn.com/files/cancer-guidelines/breast/index.html#/86/
Physical exam is indicated every 4-6 months initially. Annual blood work and tumor markers are often drawn. There is a trend away from routine imaging in asymptomatic patients.

Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves.

Most often a woman will see a breast surgeon early in the process - either before diagnosis as many breast surgeons perform their own minimally invasive biopsies, or shortly after diagnosis. The breast surgeon will usually consult with the medical oncologist, radiation oncologist and plastic surgeon and the specialists will all work as a team to determine the breast treatment approach for a patient.

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

The first thing to realize, is that the term "biopsy" often means different things to different people, so hopefully I can provide some clarification as well as some advice to women who might be in this situation.

It used to be that when a woman felt a lump in her breast, she was given one option - surgery. The lump was removed, and depending on the results she either was told to resume routine follow up (if it was benign) or had a mastectomy (if it was cancer) - women used to sign a consent form that would allow for lump removal and mastectomy all at the same time if the pathology showed that it was cancer. At the time, we did not have the sophisticated imaging and biopsy devices that we do now, and there was only one operation for breast cancer - a radical or modified radical mastectomy.

Thankfully, a lot has changed. Our imaging has significantly improved - ultrasound can be invaluable when dealing with a palpable lump, especially in a young woman, as often we can make the distinction between normal "lumpy" breast tissue, a fluid-filled cyst, or a solid mass. In addition, ultrasound can give us some idea based on the characteristics of the lesion whether a solid mass is benign or malignant, but ultrasound and any imaging test does not take the place of obtaining a tissue sample that the pathologist can review to make a definitive diagnosis.

The standard of care is that minimally-invasive, image-guided biopsies be performed to make a diagnosis, not surgical removal. There are a few situations when image-guided biopsies are not technically possible or are not appropriate, but they can be performed in the majority of cases. If the biopsy demonstrates a benign lesion, the patient may not need surgery at all, or may be a candidate for a minimally invasive method of treatment, such as cryoablation (see my answer on cryoablation for more details). Approximately 80-85% of biopsies result in a benign diagnosis, and we try to reserve the operating room for therapy, not diagnosis.

If the lesion is found to be malignant, further workup such as MRI or other testing might appropriate in order to properly plan the surgery. There are also plenty of studies demonstrating that if surgery is the first procedure performed in the setting of breast cancer, the woman is more likely to require more than one operation either due to positive margins, the need for lymph node biopsy, or other factors. A more appropriate and more cosmetic procedure will be done if the diagnosis is established prior to surgery. This is supported by the American Society of Breast Surgeons (http://www.breastsurgeons.org/statements/PDF_Statements/Percutaneous_Needle_Biopsy.pdf)


As to who should perform the biopsy, surgeon or radiologist - it depends on the individual practice situation and training of the physician. More surgeons are being trained in performance of ultrasound, ultrasound-guided biopsy, and stereotactic (mammogram-guided) biopsy, and the American Society of Breast Surgeons has education, certification and accreditation programs specifically for surgeons. As a surgeon, I would rather perform the imaging and biopsy myself, as I will then have a better appreciation for exactly where the lesion is (more important when dealing with non-palpable lesions), especially if surgery is eventually required. However radiologists do perform the imaging and biopsies as well, and in many situations, work collaboratively with the surgeon.

However the most important point is not necessarily who performs the biopsy (assuming that anyone performing it is qualified), but that whenever possible, a minimally-invasive needle biopsy be performed rather than surgery as the initial procedure.

When the radiologist called me with the news, she recommended two doctors and said I should call them right away. I hung up the phone, it rang again and it was my ob/gyn. He recommended the same two doctors. I enquired why neither had recommended a nearby particular big-name cancer center. He said “You have breast cancer, you need someone who will care for you with your best interests involved”. I was stunned. Apparently I thought this was the case at all cancer centers. I was wrong.

I researched both doctors. I needed to read that they were the best in their field. I needed to know that they were current in their methods. I needed to know they could help me.

I called the first doctor, gone for the weekend. my diagnosis was given to me on the Friday of a long weekend. Called the second office, gone for the weekend. Great. I then called back the radiologist and told her. She said she would make the call to the doctors..at home! she called me back and said one would see me that Monday, yes, the holiday. The other would take me the following week. My husband and I saw the first surgeon. A lovely man, quite paternal, who explained the cancer and the options to me. We liked him, but left scared. We had not expected to hear that mastectomy was really my only option and we thought perhaps his methods might be outdated, or the way things have always been done. We saw the second doctor. He walks into the room smiling, and the first thing he says is “First let me tell you, you are going to be fine.” And he meant it. No scary words, just a strong plan of action, one of which I was part of. I could see why he'd performed more mx's than any other surgeon in NY, this guy cares. Being part of the team and plan are a huge part of healing. We knew he was our ticket out of this mess. I asked him about options and he told me of some I was not at all aware of. I made requests and he listened to and agreed with me. He then asked if we would like him to go get the plastic surgeon, one he works with as she is fantastic. He says he will ask her to see us now so we don’t have to make another appointment. She comes in and allays more fears. I am to come out of this looking good and sans the cancer. I have found the right team. They care about me and my cancer.