When a person is diagnosed with breast cancer, information comes quickly.
Before the news can sink in, a procession of physicians from different specialties follows — with each doctor sharing a mountain of information using a new (and sometimes scary) vocabulary.
“It’s overwhelming,” says Aki Morikawa, M.D., Ph.D., a medical oncologist who sees patients with breast cancer at the University of Michigan Comprehensive Cancer Center.
“That’s how I describe the hours and days after a patient first hears she has breast cancer.”
Despite the commotion, it’s important for patients to understand the situation and be ready to ask questions about their care.
Morikawa explains the most important details to emphasize during those early conversations:
Cancer treatment is a team effort
“One of the first things that can confuse a patient unfamiliar with cancer treatment is who does what,” says Morikawa.
At Michigan Medicine, cancer care is multidisciplinary. A team of specialists comes together in a forum called a tumor board to review each patient’s test results and background information and arrive at a consensus recommendation about treatment.
A patient is likely to interact with doctors from more than one specialty, including:
- Surgical oncology: Removing cancerous tumors and tissue
- Medical oncology: Treating cancer with medications such as chemotherapy or hormone therapy
- Radiation oncology: Treating cancer with radiation
“Many times, a patient will meet with a surgeon first, before they meet with a medical oncologist like me,” Morikawa says.
“The surgeon will focus on discussing the procedure to remove the tumor and will refer questions about follow-up chemotherapy to me (and vice versa if I see the patient first).
“In addition, each of these groups has nurse practitioners or physician’s assistants who are part of the team,” she notes.
“The multidisciplinary approach is proven to provide the most comprehensive care, but it takes some practice and patience to direct each question to the specialist best prepared to answer it.”
All breast cancers are not created equal
It’s important to know which type and stage of breast cancer you have.
Medical oncologists help patients understand three specific characteristics of their cancers and how those characteristics impact their prognosis and treatment options:
Staging: The stage of a person’s cancer describes how advanced the cancer is based on the size of the primary tumor in the breast and the extent to which it may have spread to other locations in the body.
Staging is expressed on a scale of zero to four, with larger numbers indicating more advanced disease.
Once the cancer is diagnosed, if a patient has surgery as the initial treatment, it is often staged based on the patient’s pathology report, which summarizes the findings after examining a sample of breast tissue under a microscope.
If a patient has drug therapy (chemotherapy, hormone therapy) before surgery, the initial staging may be based on breast imaging, such as a mammogram and ultrasound, and a physical exam.
Not everyone needs full body imaging, but this is determined with your doctor and ordered if appropriate.
Hormone sensitivity: Tests are also performed on breast cancer tissue samples to determine whether the tumor is driven by the hormones estrogen or progesterone.
Tumors that are sensitive to these hormones, called hormone receptor-positive, tend to grow somewhat more slowly, and may respond better to hormone suppressing treatments than tumors that are receptor-negative.
HER2: The pathologist will also report whether a patient’s tumor tissue sample tests positive for human epidermal growth receptor (HER2), a protein that influences the growth and spread of cancer.
“Like hormone sensitivity, HER2 has important treatment implications,” explains Morikawa. “A targeted treatment called trastuzumab (Herceptin) has been shown to be effective against cancer that is HER2-positive.”
There’s no such thing as a silly question — or too many questions
After reviewing and discussing the patient’s case in detail, the tumor board provides a consensus treatment recommendation. The plan is unique and based on many factors.
“No one element alone — staging, hormone sensitivity, HER2 status — tells the whole story,” says Morikawa. “For example, two patients with the same stage cancer may not receive the same treatment recommendation.”
In many, if not most, cases of early stage cancer, the patient will be a candidate for surgery to remove her primary tumor. Surgery may or may not be performed first.
“In some cases, drug therapy like chemotherapy might be recommended to shrink a tumor before surgery is performed,” explains Morikawa, noting that additional treatment recommendations could include hormone therapy, radiation therapy or a combination of therapies.
“A number of factors will determine what additional therapies a patient might benefit from, and how soon those follow-up treatments should start.”
Additional factors may also play a role in treatment planning, including:
Genetics: Some breast cancers are related to mutations in the genes BRCA1 and BRCA2, or other genes.
The results could impact the treatment recommendation and future cancer screening — not only for breast cancer, but for other types of cancer as well.
Fertility: “Hormone therapy and chemotherapy can affect fertility and family planning, so for women of childbearing age, this is an important treatment-planning consideration,” Morikawa says.
“Like so many aspects of diagnosis and treatment, this too can be overwhelming to consider. But I encourage women in this age group to at least meet with a fertility specialist on our team to discuss their options.”
Clinical trials: “Many patients, both soon after diagnosis or at some point in the future, may be candidates for experimental treatments available at top centers like Michigan Medicine,” says Morikawa. “We encourage patients to explore clinical trial options with their care team.”
Morikawa’s advice to every newly diagnosed breast cancer patient: “Ask, ask, ask. Every concern is legitimate and every question deserves an answer.”