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Breast Cancer-7


Welcome to part 7 of educational series on breast cancer. In sixth part, we learned about approach to a breast lump and approach to a nonpalpable lesion seen only on mammography. Remember that 20% of palpable cancers are not seen on mammography.

Question: I understand that once cancer diagnosis has been made, patient would obviously be evaluated by oncologist. But for general knowledge of our readers, what kind of work up do you advise, and how do you decide treatment for these patients?

Answer: Oncology is one branch where multidisciplinary evaluation of a newly diagnosed cancer patient is vital. Since cure rates can improve significantly and advances are rapidly occurring in this field, patient should benefit from integration of all modalities.

Goal of the initial work up is to determine stage, and certain prognostic/predictive parameters. Additional goals are to determine patient factors such as comorbidities, as well as patient’s choice and socioeconomic factors. All of these determine treatment, for example, choice of lumpectomy versus mastectomy is influenced by stage, patient’s personal choice, absence of comorbidities that preclude radiotherapy, ability and reliability to complete course of radiotherapy which in turn may be related to distance from radiotherapy facility, patient’s understanding of importance of adjuvant radiotherapy and so on…

Similar decision making is required at most steps, and treatment has to be tailored to get the best possible results.

Que: Thank you Dr. Shah, it is interesting to note that such detailed analysis is required, including even patient’s choice and social factors. Do you need a large number of tests?

Ans: Most of this is determined by good old history and examination. Number of tests needed are few. For a general understanding, patients are divided into three groups – early i.e. stage 1 and 2; locally advanced i.e. stage 3; and metastatic or spread disease i.e. stage 4.

First we will talk about so called early stage, where we need only a chest x-ray, Hb, TC/DC, platelets, SGPT/SGOT, alkaline phosphatase, and basic preoperative tests. Bilateral mammogram should ideally be done, but it alters management plan in a very small number of cases, and hence it is ok to exclude if not available in certain centers, as is the case outside most large cities.

Sonography may possibly be used where mammogram is not available. Abdominal sonography and bone scan are required only if there are symptoms or signs suggestive of spread, or if alkaline phosphatase is elevated.

ER/PR/Her-2 testing done from biopsy (or after surgery from main tumor – for early stage), is important. Now these tests are more widely available, cost has significantly reduced, and reliability is good in major centers. Some patient assistance programs offer even free testing. These tests are useful in determining prognosis, and more importantly for use of several targeted therapies, which we will talk about later.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001