Breast health: Your questions answered

Treatment

IF I'M DIAGNOSED WITH BREAST CANCER, WHAT SHOULD I DO FIRST?
Consider getting a second opinion, preferably from a cancer center that coordinates care using a team that includes surgeons, oncologists, radiologists, pathologists, and nurses. Consulting such specialists changed the original surgery recommendations for more than half of the breast-cancer patients in a recent study from the University of Michigan.

In several cases the team found that the original doctor failed to follow treatment guidelines and proposed overly aggressive surgery. For example, five patients advised to undergo a mastectomy could instead get a breast-conserving lumpectomy.

And 19 could have just one lymph node removed, at least initially, rather than several. Second opinions also disclosed problems missed by the first physician. In 43 women, radiologists spotted signs of tumors that required additional biopsies or imaging tests. In addition, the team found that two women who were originally told to undergo a lumpectomy could not tolerate the follow-up radiation, so a mastectomy was recommended instead. You're likely to find such a team at a large medical center, especially one affiliated with a medical school.

If the prognosis is particularly worrisome or the cancer doesn't respond to aggressive measures, consider modifying treatment to preserve your quality of life. A consult with a palliative-care specialist can help. Such professionals are trained to consider the patient's entire medical and personal situation and to focus on symptom management and pain relief along with curative treatments.

WHAT DOES A DIAGNOSIS OF DUCTAL CARCINOMA IN SITU MEAN?
It's a relatively unaggressive form of breast cancer in which abnormal cells are confined within the walls of ducts in the breast and lack the ability to invade other parts of the body. Eventually, however, some of those lesions become invasive.

The problem is that doctors can't predict which DCIS will progress to invasive cancer, says Monica Morrow, M.D., chief of breast surgery at Memorial Sloan-Kettering Cancer Center in New York. So although some experts tentatively question the need for surgical removal, DCIS is currently treated very much like more clearly dangerous tumors. Most women opt for lumpectomies often followed by radiation.

But more aggressive care, including mastectomy and one of a new class of drugs called aromatase inhibitors, can be reasonable if you have extensive areas affected by DCIS.

SHOULD I CONSIDER RECONSTRUCTIVE SURGERY?
Yes, though surgeons who perform lumpectomy and mastectomy often don't discuss that option with their patients. Indeed, only about 17 percent of mastectomies, and even fewer lumpectomies, are followed by breast reconstruction.

If you choose it, try to schedule both surgeries on the same day. For mastectomies, surgeons can use silicone implants or tissue from other parts of your body. The so-called "TRAM flap" involves shifting skin, fat, and abdominal muscle into the chest area without removing them from the body. The "DIEP flap" transplants skin and fat, often from your stomach, and leaves the muscle intact.

But it is slightly riskier than the TRAM flap, and fewer centers offer it. Mastectomy that spares the nipple is also available, though keeping the nipple might allow cancer to recur. After lumpectomies, plastic surgeons say that they can enhance the appearance of the breast by rearranging its architecture or adding tissue. The key, they stress, is to make the changes before radiation creates further changes in the breast. Benefits from such reconstruction may be more than cosmetic. A recent survey of more than 600 women post-lumpectomy found that those with pronounced breast asymmetry were far likelier to have depressive symptoms than those with less asymmetry.