Expert: Claes-Gustaf Nordquist, M.D. - 9/8/2008

Question
QUESTION: Sent this earlier, not sure it went thru.  Sorry for the repeat.

In my 20's, had ILC T1,NO,MO-estro/prog neg.,brca 1 and 2 neg lympnod checked (21 allclean) had lump,rad,and tamox for 5 yrs.

Now,(at age 33) 9 years later, had an excisional biopsy show 1.5mm DCIS,no necrosis (low grade).

Dr wants to be agressive and have masectomy,maybe both breasts.

My questions are:

New primary or a reoccurance?

What would you suggest?

Chances of it being more then DCIS?

Since we can't have tamox or rad, what other things can I take/do after the masectomy?

How do they screen me after masectomy? Can I request ultra sound/chest MRI in addition to physical exams?

Would you suggest a breast cancer profile?  Something more detailed then the standard profile?  Oncotype DX?

Thank you in advance...

ANSWER: You obviously have a high tendency for breast cancer so I understand the attitude of your dr. - even the idea of a mastectomy of both your breasts, something I normally seldom support but do here though reluctantly.  It is probably a new primary and I think should be treated as such. Radiation therapy is probably not neceesary. I do not recommend chemo therapy either with such a small cancer in situ (stage 0) and of a low grade. Especially if already treated with a mastectomy.
Well since there will be at least one mastectomy - I suppose - the pathologist will be able to tell us if there is anything more. You can always request whatever you want including ultra sound & MRI wherever and whenever appropriate. PET-scans may be a possibility too. Genetic studies may definitely be of value! Especially if you have children. Your mastectomies can probably be done in such a way that you can have breast reconstruction quickly. Good luck!


---------- FOLLOW-UP ----------

QUESTION: Just a correction and a follow up question.

The ILC I had in my 20s was proges/estro+ would that change your mind on taking some type of drug after the operation???

Qusetion: spoke to the surgeon yesterday and she reccomends to do a skin sparing masectomy with implants (both breast) and possibly save my nipples,  what are your thoughts on this? Good/bad/issues...

You stated that genetic studies may be of value, can you explain in more detail what I should be looking into?
I do have a daughter (age 4)and already tested negative for BRCA genes.

Thank you again so much...

ANSWER: Yes it must have been since you had tamoxifene. No it does not change anything. Was the latest biopsy checked for that?


---------- FOLLOW-UP ----------

QUESTION: with regards to having a second bc (new primary), even though i have a high tendency for bc, because it is a new primary, how does that effect my numbers>  Meaning that if a person having a bilat masc have a 98% chance of no reoccurance within 5 years, what would i be looking at?

Answer
This IS a hard question and finally it must be you who makes the decision. While I do understand why your dr. is recommending these actions I can still not avoid thinking they are drastic. She may be right though and I may be wrong. However since no more radiation is possible a new lumpectomy is just out of the question. So a skin sparing mastectomy on the affected side it has to be with an implant - if you want that - afterwards. With regards to your other breast if I happened to be you I would just have MRI breast scans there regularly (every 6 months or so) with needle biopsies of anything unclear seen. But again she may be right and I wrong. Surely a double mastectomy would increase your safety somewhat and if done in the same way you could have implants in both sides. The choice must be yours.
Good luck!