Making Hard Decisions Regarding Cancer Treatment and Care
Have you ever broken a bone?
The treatment’s fairly simple. You go to the hospital. Have an X-ray. Get the break set, have a cast put on, go home.
There’s not a single decision you have to make along the way.
But get breast cancer, and what’s the first thing that happens? The surgeon asks you to make a decision: lumpectomy, or mastectomy?
Choose a lumpectomy, you get to choose option A (standard radiation), or option B (brachytherapy).
Having a mastectomy? “Do you want reconstruction with that, Ma’am?”
And let’s not even get started with chemo. Now THERE’S a decision fraught with angst, if ever there was one. Go for it, and endure what may be lifelong side effects? Or skip it – and take a chance on the cancer spreading.
Strange, isn’t it? At that vulnerable time when you’re barely able to assimilate the fact you have cancer – let alone deal with the emotional fallout – you’re asked to make decisions that could impact whether you live or die.
Is it no wonder so many of us kind of mentally stand around going “Whaaaa….?”
Meanwhile, the clock is ticking. The surgeon needs to make a surgery date; you need to get slotted into the radiation or chemo schedule.
Come on, what’s it gonna be?
While it’s tempting to MAKE A DECISION NOW in order to please the doctor, keep to the schedule, or simply to get the whole process moving, please do yourself a favor: slow down. You’re making major decisions, ones that will affect your body for the rest of your life. It’s worth taking the time to think things through.
If your hospital has a facility that helps patients make health-care decisions, use it. There may actually be a department called “shared decision-making;” it’s becoming one of the hot new models in the field of medical medical. Or ask a hospital social worker; if anyone knows the facility’s resources in this area, it’ll be a social worker.
If there’s no one at the hospital to help you, take a look at the following posts on this site.
Lumpectomy vs. mastectomy
If your tumor is very small, or very large, you’ll probably get a recommendation from the surgeon as to which route to go: lumpectomy or mastectomy. However, for smallish to mid-size tumors, the surgeon may very well give you your choice. How do you decide?
It boils down to how much of a risk-taker you are. A mastectomy removes almost all of your breast tissue, thus almost all of your risk for a recurrence in that breast. But you also lose your breast.
A lumpectomy removes just part of your breast, often a small, unnoticeable part. You keep your breast – but you leave yourself more open to a possible recurrence.
What to do?
One breast, or both?
Often, if the cancer is aggressive, the surgeon may ask if you’d like to consider a prophylactic mastectomy: that is, removing both the breast with the tumor, and your other, healthy breast. This definitely cuts your risk for both a recurrence in the same breast, and a new cancer in the other breast.
But you lose both your breasts.
What to do?
Reconstruction, or not?
So, you decided on a mastectomy – single, or double. Now you have to choose whether to have reconstructive surgery; or wear an external prosthesis. Or simply go flat-chested.
What to do?
Now, or later?
Next step: the timeframe. Do you want your reconstruction now, at the same time as your mastectomy? Or later – weeks, months, even years later? What are the advantages to each?
What type of reconstruction is best for you?
Here’s another thorny issue: Do you want implants (saline or silicone), or reconstruction using your own body tissue (autologous)?
Each has its advantages.
Here’s the lowdown on autologous reconstruction. Thankfully, if you go this route, the surgeon will usually recommend what type to have; the two choices are usually tissue from your belly (TRAM or DIEP), or from your upper back (LAT).
What if you’re not a candidate for autologous reconstruction? Or if you just don’t feel comfortable with the extra surgery it requires? Read our description of implant surgery.
If you decide on an implant, you’re not off the hook yet. Do you want a saline implant, or one made of silicone? Seriously, they’re going to ask, so be ready.
Radiation: gold standard vs. a hot new treatment
OK, at last – we got through surgery. What’s next, radiation? Read on.
A new type of radiation, brachytherapy (a.k.a. MammoSite), is gradually making its way into mainstream use. If you’re given the choice for brachytherapy (which lasts just a single week, compared to standard radiation’s 5 to 7 weeks), should you do it?
Since brachytherapy’s so new, do they know if it works as well as standard radiation?
If you decide you’d like to give MammoSite a go, what’s it like? Since it lasts just 1 week, is it super-intense?
Chemotherapy: Do I REALLY need it?
Whether or not to have chemotherapy is one of those decisions with no really good options. Have chemo, you lower your risk for recurrence or metastasis.
But by how much? And at what cost?
Chemo’s side effects can be devastating, and long-lasting. You may be stuck with certain issues (tingling feet, burning eyes…) for the rest of your life.
But “the rest of your life” may be many years, with chemo; perhaps devastatingly short, without.
And, you may have no serious side effects at all. There’s no telling what chemo will do to you, and for how long, till you actually have it.
Talk about stepping off the cliff!
So, how do you examine risk vs. reward?
Luckily, in the past few years a tool has been developed that helps you do just that. Called the genomic assay (or genomic testing), this procedure looks at how groups of genes in your cancer cells are acting, then predicts how effective chemotherapy will be for you: very effective; not very effective, or… sigh… somewhere in the middle.
If you’re eligible (your estrogen-receptive cancer hasn’t spread to your lymph nodes), ask about the Oncotype DX® or MammaPrint test.
Hormone therapy: Tamoxifen, or an AI?
OK, one last decision you MAY have to make: hormone therapy. For postmenopausal women with hormone-receptive breast cancer (ER/PR+, on your pathology report), 5 or more years of drugs, post-treatment, is pretty much a given. In the past, you may have had two choices: tamoxifen, the gold standard for 30 years; or a new class of drugs, aromatase inhibitors.
Some oncologists stuck with tamoxifen; some started their patients on an AI. And some split the difference, going with tamoxifen for several years, then switching to an AI.
Now, the data is in, and it shows that for postmenopausal women, AIs are a more effective cancer deterrent than tamoxifen. So if your doctor recommends tamoxifen, ask why – and be ready to cite the latest evidence.
Not exactly like breaking your wrist, is it? I hope this guide has helped you make what can be some very tough and scary decisions about your breast cancer treatment.