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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But oncologist Jame Abraham, MD, shares some important questions you should ask your doctor. The answers you receive will help you better understand your breast cancer diagnosis and treatment options.
“Keep in mind, too, that your doctor may not have all the answers right away,” Dr. Abraham says. “They may need more time to assess you.”
But 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.
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.
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 very good,” Dr. Abraham says.
The size of your tumor is another important factor in your course of treatment. Your doctor uses the size of your tumor to “stage,” or further categorize, your cancer (explained in detail in the next question).
To determine the estimated dimensions of your tumor, your healthcare providers will perform a physical exam and run tests that may include:
“The precise size won’t be known until a pathologist studies the tumor after surgical removal,” Dr. Abraham adds.
Cancer staging is a way of classifying your cancer, with Stages 0 through IV reflecting the size of your tumor and the extent to which it has metastasized (spread). The recent staging guidelines also 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.
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.”
Tumor grading isn’t the same as staging. Both are indicators of your 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 the 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 tumor that is relatively small and contained but that is also a Grade 3, more aggressive cancer,” Dr. Abraham clarifies.
Normal cells have receptors that allow them to receive information (including growth signals) from your hormones — kind of like the way your cell phone picks up satellite signals. Cancer cells may also have hormone receptors, which allows them to them 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 that tests a sample of cancerous cells.
“If your breast cancer cells have estrogen and progesterone receptors, they’re ER/PR-positive and are capable of detecting estrogen’s signal and using it to fuel their growth,” Dr. Abraham explains. “If the cancer cells lack these receptors, meaning they’re ER/PR-negative, they can’t hear the growth-signaling message.”
About 70% of those with breast cancer are ER/PR-positive. The outlook for ER/PR-positive tumors is better than ER/PR-negative tumors.
That’s because doctors can take advantage of the receptors’ presence by using an anti-estrogen drug like tamoxifen to block the receptors, which blocks estrogen’s growth signal. Or they can use other drugs like aromatase inhibitors, a type of hormone therapy that lowers your body’s estrogen levels to deprive the cancer cells of fuel. In ER/PR-positive tumors, other medications called CDK4/6 inhibitors may reduce the chance of recurrence.
“There are very effective approaches,” Dr. Abraham says. “That’s why ER/PR-positive patients may be advised to take anti-estrogen pills for as long as five to 10 years.”
But if your 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 continues. “In these cases, chemotherapy is generally the preferred treatment.”
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.”
Some HER2-positive tumors — those bigger than half a centimeter or that have spread into your lymph nodes — will require treatment with chemotherapy and one of the medicines that specifically targets the HER2 receptor, like trastuzumab or pertuzumab.
This is an important question, but the answer may be less than definitive, especially in the beginning. “It will vary from patient to patient, and you may have more than one choice,” Dr. Abraham notes.
The American Cancer Society reports that most people who have breast cancer have some type of surgery. In some cases, whether to operate and the type of surgery may depend on factors like:
Not all breast cancers can initially be surgically removed. But for breast cancers that are operable, the two broad categories of choices are:
“Talk with your oncologist and breast surgeon, and if you have any doubts, you may choose to seek a second opinion,” Dr. Abraham advises.
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:
“Your radiation oncologist will help you to make this decision based on your risks and benefit,” Dr. Abraham says.
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 if:
“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.
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.
Immunotherapy is 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 — meaning that it’s Stage II and above — your treatment may include an immunotherapy called pembrolizumab (Keytruda®) to shrink the tumor,” Dr. Abraham says. “Then, immunotherapy is continued for a year.”
If your breast cancer is HER2-positive, your treatment will include HER2-targeted medicines like:
But these medicines aren’t chemotherapy. “While you’re taking them, the hair you lost during chemotherapy will regrow, and your energy level will improve,” Dr. Abraham adds.
If you have a high-risk tumor that’s ER/PR-positive and HER2-negative, you’ll be prescribed anti-estrogen therapy. Your doctor may also talk to you about newer medications, like CDK 4/6 inhibitors. These include abemaciclib (Verzenio®) and/or ribociclib (Kisqali®).
If you have an ER/PR-positive breast tumor, oncologists strongly recommend continuing anti-estrogen therapy for five to 10 years after your 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 yet entered menopause, tamoxifen (Nolvadex® or Soltamox®) is the most commonly prescribed medicine; postmenopausal patients have many options.
“In addition, we use other long-term medicines like olaparib for people with BRCA gene mutation and abemaciclib or ribociclib for people with ER/PR-positive, HER2-negative tumors with high-risk features,” Dr. Abraham says. “We may also use bone-protective medicines like zoledronic acid to strengthen the bone and reduce the chance of recurrence for about three to four years.”
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 that you can determine if it’s a good fit for you.”
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 that puts you at high risk for breast cancer or other cancers, like the BRCA1 or BRCA2 mutations. You’ll have this sort of testing done if you:
“Usually, we recommend a consultation with a genetic counselor to finalize the risk and benefit of genetic testing,” Dr. Abraham says.
“Genomic tests like Oncotype DX® or MammaPrint® can help your healthcare team better understand the tumor’s behavior,” he continues. “This can help predict the chance of recurrence or benefit from various forms of therapy, including the benefit from chemotherapy.”
In general, these tests aren’t done for HER2-positive or triple-negative tumors.
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 to 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.