Expert: Claes-Gustaf Nordquist, M.D. - 8/4/2009

Question
QUESTION: Dear Claes-Gustaf,
My wife has had triple-negative breast cancer since November ´08 with 7/10 lymph node invasion. She had surgery to remove a portion of breast in December and then started a course of six chemotherapy treatments.

Widespread bruising on the breast after four treatments revealed ongoing tumour growth. She had a masectomy in May and then more chemotherapy - partly with a different cytostatica. A small bruise has now occurred close to the operation scar and tested positive for cancer - in the remaining skin/tissue.

Her oncologist has recommended an operation followed by radiotherapy as she does not respond to chemo. Her prognosis, as I understand it, is not encouraging. Does this sound the right way forward to you? Are there any alternative routes that we/the oncologist might consider at this present time?

Many thanks for your time.
Greg McIvor
Malmo, Sweden

ANSWER: I'm very sorry to read of her - and your - problems! Yes her cancer seems to be very aggressive which certainly is not a good sign. In view of her obvious chemotherapy failure the recommended new treatment of more surgery in combination with radiation therapy is the primary remaining option - in fact I can not see any real alternative. However I have to ask you since I suppose her original therapy was more of a kind of "lumpectomy" with lymph node dissection. Was never radiation therapy in combination with her chemotherapy discussed before or after surgery?


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

QUESTION: Dear Claes-Gustaf,
Heartfelt thanks for your swift and kind response.

In answer to your question: no serious consideration was given to a combination of radiation and chemotherapy - which, in hindsight, might have been preferable. The oncologist also preferred a chemotherapy-only approach after the first recurrence (or rather re-emergence of cancer cells remaining from the first operation). The reason given was that radiation can damage the pathways and channels along which the chemotherapy drugs travel.

I had my reservations about this at the time as my gut feeling was that the cancer would re-emerge given that it had been so unresponsive to the first chemotherapy drugs. However, the oncologist took a second opinion from a professor in Stockholm and this was the route chosen.

It would be interesting to hear your view on this - and also what the prognosis might be for radiation therapy, assuming (as we have to) that the cancer remains confined to the chest region.

Answer
Thanks! my question was based on the fact that "lumpectomies" are normally combined with radiation therapy and I personally would have felt rather uncertain if that modality of treatment had not been included. But there are different views on this and my view is not automatically the correct or the predominant one. In this case with such an aggressive cancer her prognosis is unfortunately uncertain regardless of therapy.