Treatment after lumpectomy in small estrogen negative tumors
Dear OncoLink "Ask The Experts,"
My wife has undergone a lumpectomy for a 0.8cm nodule, sentinel lymph nodes were clear. Pathology stated that the estrogen and progesterone receptors were less than 10% positive. We find very little information beyond the fact that tamoxifen probably will not help. Is there as clear a course of therapy in these cases as there is for the er/pr positive patients?
Julia Draznin Maltzman, MD, Attending Physician at the University of Pennsylvania School of Medicine, responds:
First let me reassure you, that your wife's tumor appears to be at an early stage. Although I cannot make direct recommendations in your specific case, I can discuss the standard of care for patients in this circumstance. The first and most important treatment is surgical resection (lumpectomy) of the breast cancer which has been completed. However, the risk of local recurrence after a lumpectomy is quite high and radiation therapy to the breast is certainly indicated. A consultation with a radiation oncologist to discuss this therapy should be arranged for all patients after a lumpectomy.
Most of the existing data assessing the benefit of chemotherapy is in patients with primary tumors larger than one centimeter. Of course, each patient's situation is assessed individually, but most women with a primary tumor that small do not gain a tremendous benefit from systemic chemotherapy. The decision on weather or not to offer chemotherapy is one where the risk of relapse is weighed against the benefit of chemotherapy and its potential side effects. In other words, most women with a tumor that small are cured with the lumpectomy followed by radiation therapy and the benefit of chemotherapy is much smaller than its potential side effects. Doctors go through the same thinking process when recommending hormonal therapy. If the tumor were hormone receptor positive, most physicians would offer Tamoxifen. Tamoxifen is easy to take, has few side effects and has potential benefits. However, if the tumor is ER/PR negative, as in the case you describe, the benefits of Tamoxifen are very low indeed. Physicians tend to think that exposure to another drug in a situation where that drug is not helpful is probably not the best option.
You are correct in your assessment, there is no clear course of therapy for women with small tumors that are not hormone responsive. Many of my patients are very frustrated when they are not taking chemotherapy or hormone therapy as they think they are not doing everything they can to make sure they get rid of their disease. What patients should do after completing radiation therapy is have very close surveillance and follow up, eat right, not smoke and drink alcohol in moderation. Living sensibly is the best defense against all diseases!