Breast Cancer

Making Informed Decisions & The Right Choices
. . .an Interview with Dr. Charles Balch

What is the most important advice you can give to a woman about her treatment decisions?

A woman with breast cancer should become a student of the disease. You should learn all you can about breast cancer in general and about your particular type of tumor so that you are well-informed when discussing treatment options with your health care team. Studies have shown that women cope better with their disease when they feel fully engaged, so be sure to tell your doctors what is most important to you and be an active participant in decision-making.

What are the most important factors in making decisions about treatment?

The treatment plan for most women will include a combination of treatments, including surgery, drugs and/or hormone therapy and, possibly, radiation therapy. The starting point is an understanding of the breast cancer pathology for each woman and the biologic nature of her tumor. Advances in technology have allowed us to learn more about the biology of breast cancer, and we now know that breast tumors vary greatly among women. Armed with this knowledge, we know that certain tumor characteristics — for example, the HER2 and ER/PR status — have very important implications for treatment. In addition, the genetic profile of the tumor can help us determine the likelihood of recurrence, which is helpful in making decisions about adjuvant treatment. Other important factors to consider are the stage and grade of the breast cancer; the age and general health of the woman; and how likely the tumor is to respond to a particular treatment. Throughout the decision-making process, a woman should carefully consider the impact of treatment options on her quality of life. The exact treatment for each woman requires input from various breast cancer specialists as part of multidisciplinary treatment planning.

What is multidisciplinary treatment planning?

The treatment of breast cancer is multidisciplinary, which means that the health care team involves many different specialists; for example, members may include a medical oncologist, surgical oncologist, radiation oncologist, reconstructive surgeon, radiologist, and pathologist. These specialists work together — along with each woman with breast cancer — to determine the best possible treatment options. Multidisciplinary treatment planning has become even more important as the number of treatments available for breast cancer has expanded. Since we have so many choices, we need to spend time before the appropriate treatment begins to select the best options and make treatment decisions that take into account the characteristics and staging of the cancer as well as the quality-of-life issues that are unique to each woman. This is known as personalized breast cancer therapy.

Can you give some examples of decisions to make in planning treatment?

Women with breast cancer are faced with several decisions regarding treatment. What kind of surgery should I have — lumpectomy or mastectomy? Do I want reconstructive breast surgery? Do I need chemotherapy? Will radiation therapy help me? Is there a targeted therapy for my type of breast cancer? What kind of hormone therapy should I take? Every woman with breast cancer should talk to the specialists on her health care team to discuss the risks and benefits of treatment options. In making her final decision, a woman should consider what is important to her about the quality of life as she perceives it.

What kind of treatment decisions are the most challenging?

A treatment decision presents a challenge whenever the outlook for survival is similar for more than one treatment. This is especially true for adjuvant therapy for early-stage breast cancer. As one example, studies have shown that adjuvant chemotherapy offers substantial benefit for some women with early-stage disease, but about 70 to 80 percent of women with this type of breast cancer will have long-term disease-free survival without chemotherapy. Fortunately, there are biomarkers now available, such as Oncotype DX, and Mammaprint, and online predictive tools, such as Adjuvant! Online, that can help women and their doctors make decisions about adjuvant chemotherapy on the basis of their risk for cancer recurrence. As another example, women who are at a moderate risk for recurrence may or may not need radiation therapy. These “gray zones” require women to think about what is most important to them with regard to quantity versus quality-of-life issues. Some women want to know that they did everything possible to avoid recurrence, whereas others wish to avoid the side effects of treatment if the benefit is small. For example, if a treatment has a 4 percent potential for benefit but a 10 percent chance of toxicity, the risk may be too high for the small benefit for some women.

What other factors should women consider besides weighing benefits and risks? Side effects are a consideration even when the benefit is similar for multiple options. For example, all of the aromatase inhibitors used for hormone therapy provide similar benefit but the side effect profiles of the drugs are very different. A woman and her doctor need to discuss which drug will be safest in her particular case. Fertility is another important issue; younger women with breast cancer should carefully consider treatment options if they wish to have children in the future. Body image is a very important factor to consider when deciding on the type of surgery. Women with early-stage disease can now choose between lumpectomy plus radiation therapy or mastectomy with the option(s) of breast reconstruction. This option means that a woman must think about the importance of her breasts to her overall body image. Some women care deeply about how they will look in an evening gown or bathing suit, whereas other women may not have the same feelings about their body image. It is important to remember that there are no right and wrong decisions; the only right decision is the one that is appropriate for you.


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