Breast Cancer Questions for Your Doctor

After hearing your doctor say, “You have breast cancer,” it can be hard to focus on any of the words that follow. Your mind is probably reeling, and you’re not prepared (no one is) to have an in-depth conversation about your prognosis and medical choices.

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Oncologist Jame Abraham, MD, shares 10 key questions about breast cancer that you should ask your doctor. The answers you receive can help you better understand your breast cancer diagnosis and treatment options.

If you’ve been diagnosed with breast cancer, ask your doctor these five questions about your diagnosis and treatment options.

10 questions to ask your oncologist

Before we delve deeper into what each of these questions means, let’s do a quick overview. Here are 10 key questions to ask your oncologist when you’re diagnosed with breast cancer:

What type of breast cancer do I have?
What size is the tumor?
Is the cancer in my lymph nodes?
What grade is the tumor?
What is my estrogen receptor and progesterone receptor status?
What’s my HER2 status?
What stage is the cancer?
What kind of treatments will I need? (What about surgery, chemotherapy, radiation and medication?)
Should I participate in a clinical trial?
What’s genomic testing, and what kind will I have done?

There’s one important caveat, Dr. Abraham says: “Keep in mind that your doctor may not have all the answers right away. They may need more time to assess you.”

Having these questions on hand can help you better understand your diagnosis and the process of treatment — so if your doctors don’t have all the answers now, keep them on hand to ask again later.

Let’s talk more about each of these questions, including why they’re so important to understanding your diagnosis and treatment path.

1. What type of breast cancer do I have?

Breast cancers aren’t all the same. Doctors classify them in a number of different ways, starting with where the cancer cells originate. Their origin is a key factor in whether or not your cancer may spread, and that helps dictate the kind of treatment you’ll receive.

Infiltrating/invasive ductal carcinoma (IDC): Up to 80% of breast cancers start in your milk ducts and then grow into the fatty tissue of your breast. From there, cancer cells can further metastasize (spread) to other parts of your body.
Invasive lobular carcinoma (ILC): Another 10% of breast cancers start in your milk-producing glands, or lobules. “Lobular cancer has unique features,” Dr. Abraham says. “It’s less visible on mammograms, but at the same time, more sensitive to anti-estrogen therapies, etc.”

Rarer breast cancers may involve your nipple, your breast’s connective tissue or the linings of blood vessels or lymph vessels.

And some breast cancers are noninvasive, meaning they’re contained within your milk ducts and haven’t spread. This is called ductal carcinoma in situ (DCIS), sometimes known as stage 0 breast cancer.

“Generally, the prognosis for patients with DCIS is excellent,” Dr. Abraham says.

2. How big is the tumor?

The size of the tumor is another important factor in your course of treatment. Your doctor uses the size of the tumor to “stage,” or further categorize, the cancer (explained in detail in the next question).

To determine the estimated dimensions of the tumor, your healthcare providers will perform a physical exam and run tests that may include:

A mammogram
A breast ultrasound
An MRI of your breast

“The precise size won’t be known until a pathologist studies the tumor after surgical removal,” Dr. Abraham adds.

3. What stage is the cancer?

Cancer staging is a way of classifying cancer, with stages 0 through IV (4) reflecting the size of the tumor and the extent to which it has metastasized (spread) to the lymph nodes or other parts of the body.

In addition, the current staging guidelines include biological factors like ER/PR, HER2/neu and grade (which are all explained in detail in the questions below).

“A higher stage means a larger tumor and wider distribution of cancer cells,” Dr. Abraham explains, “like when cancer has spread from your breast to your liver, lungs or brain.”

Your doctor will use staging to plan your treatment, gauge your prognosis and communicate with other cancer specialists. What stage your cancer is will also help determine whether you’re eligible for clinical trials, which offer newer treatment options.

4. Is the cancer in my lymph nodes?

One of the most important predictors of the severity of breast cancer is whether it has spread to your lymph nodes. These bean-shaped organs, located in your armpits and elsewhere throughout your body, are a critical element of your immune system. They act as a filter for the fluid that flows through your cells and tissues.

“Involvement of the lymph nodes can potentially change your treatment plan,” Dr. Abraham states. “When breast cancer cells have spread to the lymph nodes, we may discuss more aggressive treatment options, like chemotherapy.”

5. What grade is the tumor?

Tumor grading isn’t the same as staging. Both are indicators of the cancer’s severity and prognosis, but they use different criteria.

Staging deals with the tumor size, location and the distribution of cancer cells in your body. Grading is based on how cancer cells appear under a microscope. Abnormal-looking cells are more likely to quickly grow and spread.

Grades usually run from 1 to 3, and a higher grade represents more rapidly dividing cells — a more aggressive cancer.

“It’s possible to have a stage I (1) tumor that’s relatively small and contained but that is also a grade 3, more aggressive cancer,” Dr. Abraham clarifies.

6. What’s my estrogen receptor and progesterone receptor status?

Your body’s hormones, especially estrogen and progesterone, may play a role in how your breast cancer progresses because cancer cells can have hormone receptors that allow them to tap into your body’s regulation of normal cell growth.

To determine your estrogen receptor and progesterone receptor (ER/PR) status, your doctor will order breast biopsy to test a sample of cancerous cells. About 70% of those with breast cancer are ER/PR-positive, and the outlook for these tumors is better than for ER/PR-negative tumors.

Based on your receptor status, your oncologist may prescribe medications, like:

Tamoxifen, an anti-estrogen drug to block estrogen’s growth signal
Aromatase inhibitors, a type of anti-hormone therapy that lowers your body’s estrogen levels to deprive cancer cells of fuel
CDK4/6 inhibitors reduce the chances of recurrence when given with anti-estrogen therapy

“There are very effective approaches,” Dr. Abraham says, “and ER/PR-positive patients may be advised to take anti-estrogen pills for as long as five to 10 years.”

But if the cancer is ER/PR-negative, these treatments aren’t an option.

“ER/PR-negative tumors that are more aggressive can’t be treated this way. Because they lack receptors, anti-estrogen pills don’t work,” Dr. Abraham explains. “In these cases, chemotherapy is generally the preferred treatment.”

7. What’s my HER2 status?

HER2, which stands for “human epidermal growth factor receptor 2,” is another type of growth signal receptor (sometimes known as an antenna) that may be present on your breast cancer cells. About 25% of breast cancers are HER2-positive.

This diagnosis brings both good and bad news. The bad: HER2-positive tumors tend to grow more aggressively than HER2-negative tumors. The good news is that like ER/PR-positive cancers, many medicines can switch off the HER2 growth receptor.

“A number of HER2-targeted drugs are extremely effective at this, and they’ve dramatically improved the prognosis for HER2-positive patients,” Dr. Abraham says. “Treatment outcomes are now as good as those with HER2-negative tumors.”

In HER2-positive tumors, he says that — even small ones — your oncologist may consider treatment with anti-HER2 medicines and chemo. This depends on the tumor’s other features.

8. What kind of treatment will I need?

“This is a straightforward question with potentially complex answers, depending on the specifics of the tumor and your overall health,” Dr. Abraham says. “Most people with breast cancer require multiple types of treatment.”

Let’s break down some of the specific possibilities.

Will I need surgery?

This is an important question, but the answer may be less than definitive, especially in the beginning. It varies from person to person — and you may have more than one choice. Plus, Dr. Abraham notes that not all breast cancers can initially be surgically removed.

“Based upon a variety of factors, your team may decide to proceed with the surgery as the first treatment or plan for medical approach — like systemic therapy with chemo and other medicines — upfront,” he explains. “This is known as neoadjuvant therapy to shrink the tumor. It’s the preferred approach in larger tumors, especially ones that are HER2-positive or triple-negative.”

If I do need surgery, what kind should I have?

The American Cancer Society reports that most people who have breast cancer have some type of surgery. For breast cancer that’s operable, the two broad categories of choices are:

Lumpectomy, a breast-conserving surgery often paired with radiation
Mastectomy, the removal of most or all breast tissue (sometimes including nearby lymph nodes)

“Talk with your oncologist and breast surgeon, and if you have any doubts, you may choose to seek a second opinion,” Dr. Abraham advises.

If you’re interested in breast reconstruction to rebuild your breasts at the time of breast surgery, your cancer team will connect you with a plastic surgeon to discuss those options, too.

Will I need radiation?

Oncologists generally recommend radiation treatment for people with breast cancer who have surgery only to remove their tumor (lumpectomy) or whose cancer had spread to the lymph nodes.

If you have a mastectomy, radiation may be recommended if you’re considered high-risk, especially if:

The tumor is larger than 5 centimeters
Your lymph nodes are involved
You have other high-risk biological features

“Your radiation oncologist will help you to make this decision based on your risks and benefit,” Dr. Abraham says.

Will I need chemotherapy?

Dr. Abraham says the term “systemic therapy” may be more appropriate these days. It encompasses not just chemotherapy, but also immunotherapy, HER2-targeted medicines, anti-hormone therapy, CDK 4/6 inhibitors, etc.

Chemotherapy, which uses drugs to destroy cancer cells or slow their growth, is a consideration for patients with high-risk breast cancers.

You may need chemotherapy based on:

What type of tumor you have
How high-grade the tumor is
Lymph node involvement
The likelihood of recurrence

Your age

“Chemotherapy is given as an outpatient treatment every two to three weeks, delivered either directly into a vein or through a port,” Dr. Abraham explains.

Are there medications that can help?

There’s no single way to treat breast cancer. Your specific treatment will depend on the tumor’s ER/PR/HER2 status, how advanced it is and other factors.

If the tumor is HER2-positive, your treatment will include HER2-targeted medicines designed to attack breast cancer cells, like:

Trastuzumab (Herceptin^®)
Pertuzumab (Perjeta^®)
Trastuzumab emtansine (Kadcyla^®)
Trastuzumab deruxtecan (Enhertu^®)
Neratinib (Nerlynx^®)
Tucatinib (Tukysa^®)

If you have a tumor that’s ER/PR-positive, you’ll be prescribed anti-estrogen therapy. Your doctor may also talk to you about newer medications, like CDK4/6 inhibitors like abemaciclib (Verzenio^®), or ribociclib (Kisqali^®), which help stop cancer cells from growing.

If you carry the BRCA1 or BRCA2 gene and have a high-risk tumor, your doctor may talk to you about newer options, like olaparib (Lynparza^®) or talazoparib (Talzenna^®), a medication that stops cancer cells from growing.

Another possibility is immunotherapy, a cancer treatment that uses your body’s immune system to find and destroy cancer cells.

“If the tumor is triple-negative and locally advanced, your treatment may include an immunotherapy called pembrolizumab (Keytruda^®) to shrink the tumor,” Dr. Abraham says. “Then, immunotherapy is continued for a year.”

Will I need to take any long-term medications?

If you have an ER/PR-positive breast tumor, oncologists strongly recommend continuing anti-estrogen therapy for five to 10 years after the cancer treatment, unless there are medical contraindications (specific reasons why you shouldn’t).

Usually, anti-estrogen therapy is a once-a-day pill.

If you haven’t entered menopause, tamoxifen (Nolvadex^® or Soltamox^®) is the most commonly prescribed medicine.
If you’re postmenopausal, options include anastrozole (Arimidex), letrozole (Femara^®) and exemestane (Aromasin^®).

“In addition, we use other long-term medicines like olaparib for people with BRCA gene mutation. In people with ER/PR-positive, HER2-negative tumors with high-risk features, CDK4/6 medicines like ribociclib or abemaciclib could be an option,” Dr. Abraham adds. “We may also use bone-protective medicines like zoledronic acid to strengthen the bone and reduce the chance of recurrence.”

9. Should I participate in a clinical trial?

Breast cancer treatment has improved tremendously in the past years, thanks to people’s willingness to take part in tests of newer treatment options.

“For any stage of breast cancer, a well-done clinical trial could be your best treatment option,” Dr. Abraham notes. “If you qualify for such a trial, your doctor can answer any questions you have about participating so you can determine if it’s a good fit for you.”

10. What is genomic testing, and what kind will I have done?

There are two types of genomic testing: germline and somatic. They test for possible genetic mutations in your cells. Germline testing reveals whether you carry a gene — like the BRCA1 or BRCA2 mutations — that puts you at high risk for breast cancer or other cancers.

“Usually, we recommend a consultation with a genetic counselor to finalize the risk and benefit of genetic testing,” Dr. Abraham says. “Genetic testing may give additional treatment options, like olaparib or talazoparib in BRCA carriers.”

Current testing criteria are broad, so you should talk to your oncology team. But you’ll likely have this sort of testing done if:

You have a family history of breast cancer, ovarian cancer or other cancers
You’re under the age of 50
You have triple-negative breast cancer
Your care team determines that positive genetic testing results would add more treatment options

Tumor genomic tests like Oncotype DX® or MammaPrint® can help your healthcare team better understand the tumor’s behavior, Dr. Abraham explains. This can help predict the chance of recurrence or benefit from various forms of therapy, including the benefit from chemotherapy.

These tests aren’t done for HER2-positive or triple-negative tumors.

Keep the lines of communication open

After being diagnosed with breast cancer, you’re probably feeling scared and more than a little bit overwhelmed. But keep this list on hand, and don’t be afraid to ask questions — or follow up on anything that your doctors don’t yet know the answers to.

“The more informed you are as a patient, the more you can actively and confidently participate in your care decisions,” Dr. Abraham encourages.