Dear OncoLink "Ask the Experts,"
My mother underwent a needle biopsy on her breast today. Her doctor told her last week when he scheduled the biopsy that he was sure it was cancerous and started planning her surgery. Today he did the biopsy, told her it would be 3 or 4 days before results are in but he has scheduled her for a mastectomy on October 13. Is this reasonable medical behavior? Can he be so sure that this lump is cancerous before he even performs a biopsy? Should he be planning a full mastectomy without learning about the test results and without discussing other options with my mother?
Eleanor Harris, MD, Assistant Professor, Department of Radiation Oncology, University of Pennsylvania Breast and Gynecologic Cancer Division, responds:
There are certain features of a breast lump on either physical exam or mammography that make it more suspicious for cancer. For example, on physical exam, if a mass is hard to the touch, immobile, fixed to the skin or chest wall, ulcerated, if there are skin changes such as dimpling or redness, or nipple discharge (especially if it is bloody), these are all worrisome signs for a malignancy (cancer), as opposed to a benign lump. On mammography, features consistent with malignancy include irregular (spiculated) masses, certain types of microcacifications, especially if they are new compared to previous studies, and solid masses. If your doctor tells you that a lump is suspicious prior to any biopsy, it would be reasonable to ask him or her what they find concerning. However, both physical exam and mammography are imperfect ways to evaluate a breast mass. The only way to 100% determine whether a breast mass is a cancer or not is to take a piece of the mass, typically either with a needle biospy or excisional biopsy, and look at it under a miscroscope. This is called a pathologic evaluation. While a biopsy is often a surgical procedure, it is a diagnostic one and not necessarily a treatment itself.
No doctor should plan a mastectomy, or any course of treatment, before having the pathology results proving the presence of cancer. In addition, your doctor should always discuss with you all of the treatment options before proceeding with surgery or other therapies. The recommended treatment depends upon the stage of disease.
Early stage breast cancer is defined as a small (less than 5 cm) mass in the breast WITH OR WITHOUT axillary lymph node involvement. The axillary lymph nodes are located in the armpit and are the main drainage of the breast. There is a 20-40% risk of having cancer spread to axillary nodes in early stage breast cancer, depending somewhat upon the tumor size. Stage I cancer is a small tumor in the breast (less than 2 cm) with no lymph node spread. Stage II breast cancer is either a medium size tumor (2-5 cm) or a node positive cancer still less that 5 cm. Either of these early stages of disease may be, in most women, equally well treated with either mastectomy or breast conservation therapy, which consists of a lumpectomy (surgically removing all the known cancer) and an axillary lymph node sampling, followed by radiation to the whole breast +/- the lymph node regions. Either of these treatments may be combined with chemotherapy and/or hormonal therapy, this depending on several factors including the lymph node status and whether or not the tumor expresses hormone receptors. There are a few contraindications to both radiation and mastectomy, so these considerations should be discussed with your surgeon, medical oncologist and radiation oncologist.
If the tumor is larger than 5 cm, or if it has certain other features that make it a higher stage cancer, then the most typical approach is to combine all of the treatment modalities of surgery (often meaning mastectomy), chemotherapy and/or hormonal therapy and radiation therapy to the chest wall (or breast) and lymph node regions. However, the best sequence (the order) of the three modalities is not known and should be individualized. This requires that a patient's situation be evaluated by a surgeon, a medical oncologist and a radiation oncologist, preferably before any treatment is initiated. If this is not possible to do in a timely manner, then the treatment options should be reviewed with the patient by the surgeon.
Finally, no treatment, including a mastectomy, should be undertaken until a full metastatic work-up is completed. This is a series of tests performed to assess whether the cancer has spread to areas outside the breast or lymph nodes. This work-up should include at a minimum a chest X-ray, blood tests assessing the blood counts and liver functions, and a bone scan in most women. It may also include CT scans of the chest and abdomen if indicated. Metastases are found even in a few percentage of women with small breast cancers. Evidence of metastases can drastically alter the treatment approach and so it is imperative to complete these tests before any treatment decisions are made.