Jame Abraham, Director of Cleveland Clinic’s Breast Medical Oncology Program
After hearing your doctor say “You’ve got breast cancer,” it’s hard to focus on what comes next. You’re understandably scared, and your mind probably is reeling. You’re not prepared – no one is – to have a conversation about your prognosis and medical choices.
Here are 14 questions you should ask your doctor. The answers you get will help you better understand your breast cancer diagnosis and treatment options. Your doctor may not have all the answers immediately, but don’t be afraid to ask, and to follow up. The more informed you are as a patient, the more you can actively and confidently participate in your care decisions.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. Probably the most basic is where the cancer cells originate. Their origin is a factor in whether your cancer may spread, and helps dictate the kind of treatment you’ll get. Most breast cancers – 70 to 80 percent – start in the milk ducts. They’re known as infiltrating or invasive ductal carcinomas, meaning that they’ve broken through the milk duct’s wall and have proliferated into the breast’s fatty tissue. Once there, it’s possible for the cancer cells to further spread, or metastasize, to other parts of the body. Ten percent of breast cancers start in the milk-producing glands, or lobules, and are called invasive lobular carcinomas. They’re also capable of spreading. Other, rarer, breast cancers may involve the nipple, the breast’s connective tissue, or the linings of blood vessels or lymph vessels. Some breast cancers are non-invasive. They haven’t spread. They’re contained within the milk ducts and are called ductal carcinoma in situ (DCIS). Generally, the prognosis for patients with DCIS is very good.2. How big is my tumor?
Tumor size is another factor that will determine your course of treatment. Your doctor uses the size of your tumor to “stage,” or further categorize, your cancer. The tumor’s dimensions are estimated by a physical exam, a mammogram, an ultrasound or an MRI of the breast. The precise size won’t be known until a pathologist studies the tumor after surgical removal.3. Is the cancer in my lymph nodes?
Whether your breast cancer has spread to your lymph nodes – the filtering mechanisms in your armpits and elsewhere in the body that are part of the immune system – is one of the most important predictors of the severity of your disease. When breast cancer cells have spread to the lymph nodes, we tend to discuss more aggressive treatment options, such as chemotherapy.4. What is the stage of my cancer?
Cancer staging is a standardized way of classifying the severity of a patient’s cancer. There are various systems that use number or letter codes to designate the cancer’s status and how far it may have spread. You may have heard of stages 0 through 4, which reflect a tumor’s size and the extent of metastasis. A higher stage means a larger tumor and wider distribution of cancer cells. Your doctor uses staging to plan your treatment, gauge your prognosis and communicate with other cancer specialists. What stage your cancer is in also will help determine whether you’re eligible for clinical trials, which offer newer treatment options.5. What is the grade of my tumor?
Grading is not the same as staging. While staging deals with tumor size, location and cancer cell distribution, grading is based on the cancer cells’ appearance under a microscope. The more abnormal-looking the cells are, the more likely they are to quickly grow and spread. A higher grade is a more aggressive cancer. It’s possible to have a stage I (relatively small, contained) tumor that’s also a grade 3 (highly aggressive) cancer.6. What is my estrogen receptor and progesterone receptor status?
Your body’s hormones, such as estrogen and progesterone, may play a role in how your breast cancer progresses. Normal cells are equipped with receptors that, as the name suggests, allow them to receive information (including growth signals) from circulating hormones. Cancer cells, too, may have hormone receptors, letting them tap into your body’s normal cell growth-regulating system. If your breast cancer cells have estrogen and progesterone receptors – in other words, if they’re ER/PR-positive– then they’re capable of detecting estrogen’s signal and using it to fuel growth. If the cancer cells lack the receptors – ER-/PR-negative– then they can’t hear the growth-signaling message. About 70 percent of breast cancer patients have positive ER/PR hormone status. While being ER/PR-positive sounds bad, there’s actually a benefit. Doctors can take advantage of the receptors’ presence, either by using an anti-estrogen drug such as tamoxifen that blocks the receptors and jams estrogen’s growth signal, or by using drugs such as aromatase inhibitors (anastrazole, letrozole, or exemestane) that lower your body’s estrogen levels to deprive the cancer cells of fuel. Those are highly effective approaches, which is why ER/PR-positive patients may be advised to take anti-estrogen pills for as long as five to 10 years. ER/PR-negative tumors, which are more aggressive, can’t be treated this way. Because they lack receptors, anti-estrogen pills don’t work, so chemotherapy is generally the preferred treatment. Your ER/PR status is determined by testing a sample of breast cancer cells removed during a biopsy.7. What is my HER2 status?
HER2 (which stands for human epidermal growth factor receptor 2) is another type of growth signal receptor that may be present on your breast cancer cells. About 25 percent of breast cancers are HER2-positive. HER2-positive cancers are a mix of good and bad news. The bad news is the tumors tend to grow more aggressively than those without the HER2 receptor. The good news is that, like ER/PR-positive cancers, medicines can switch the HER2 growth receptor off. New drugs such as Herceptin (trastuzumab), Perjeta (pertuzumab), Kadcyla (T-DM1) and Tykerb (lapatinib) are extremely effective at this, and have dramatically improved the prognosis for HER2-positive patients. Treatment outcomes are now as good as those with HER2-negative tumors. But HER2-positive tumors bigger than half a centimeter, or that have spread into the lymph nodes, may require treatment with chemotherapy and one of the medicines specifically targeting the HER2 receptor, such as Herceptin. 8. Will I need surgery, and what kind should I have?
The answer to this important question may be less than definitive, will vary from patient to patient, and you may have more than one choice. According to the American Cancer Society, most women with breast cancer have some type of surgery. Some breast cancers can’t initially be surgically removed. In other cases, whether to operate and the type of surgery may depend on the cancer’s stage, the tumor’s size and location, the size of your breast, and your preference. In women whose breast cancers are operable, the choices are breast-conserving surgery (often with radiation), or mastectomy, which is the removal of most or all breast tissue and possibly nearby lymph nodes. Within each of those two broad categories are further options. Talk with your oncologist and breast surgeon and, if in doubt, seek a second opinion. 9. Should I have breast reconstruction, and when?
This is another question whose answer is multi-layered, and involves both medical and personal considerations. Some women opt not to have reconstruction. Others believe it benefits their appearance and psychological recovery. If you’re having one or both breasts removed and are considering reconstruction, the stage of your cancer may dictate the timing of the reconstructive surgery. For patients with early-stage breast cancer, immediate reconstruction is reasonable. With a stage 3 cancer, you should discuss with your oncologist and surgeon whether immediate reconstruction is advisable. 10. Will I need radiation?
In general, Cleveland Clinic oncologists recommend radiation treatment for all breast cancer patients who undergo only removal of the tumor (lumpectomy). For women who undergo whole-breast removal, radiation may be recommended for those who are considered high-risk, especially those with tumors larger than 5 centimeters and with more than four cancerous lymph nodes. 11. Will I need chemotherapy?
Typically, chemotherapy is a consideration for patients with high-risk breast cancers. Some factors that may indicate the need for chemotherapy are lymph node involvement; tumors that are higher-grade, ER/PR-negative, HER2-negative or triple-negative (both ER/PR- and HER2-negative); tumors that are HER2-positive; a high score on the Oncotype DX test, which predicts the likelihood of metastasis; and breast cancers in younger patients, especially those younger than age 40. If you need chemotherapy, it will be given as an outpatient treatment every two to three weeks, delivered either directly into a vein or through a port. 12. If I have chemotherapy, will I need to take any other medications, such as Herceptin?
If your breast cancer is HER2-positive, you should take Herceptin for one year to ensure that the HER2 growth receptor on any remaining cancer cells stays shut off. Herceptin is not chemotherapy. The hair you lost during chemotherapy will regrow and your energy level will improve while you’re taking Herceptin. 13. What about other long-term medications?
If you have an ER/PR-positive breast tumor, Cleveland Clinic oncologists strongly recommend continuing anti-estrogen therapy for five to 10 years after your cancer treatment, unless there are medical contraindications. Anti-estrogen therapy usually is a once-daily pill. In premenopausal patients, tamoxifen is the most commonly prescribed medicine; postmenopausal patients have many options. 14. Should I consider participating in a clinical trial?
Breast cancer treatment has improved tremendously, and the reason for that progress is because patients have been willing 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. If you qualify for such a trial, your doctor can answer any questions you may have about participating, so that you can determine if it’s a good fit for you.