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WOMEN IN
MEDICINE

The Challenging Complexities

of Treating Breast Cancer

What does Google say?

By Sharon T. Wilks, MD

R ecently, a dear medical school friend of mine reached out

to me about her step daughter who is a 42-year-old pre-
menopausal female who was diagnosed with a multifocal,
node positive stage III breast cancer. I was asked about management
and prognosis and to talk with the young lady who I last met when
she was in college. She now is a mother of six, married, home
schools her children, a strong believer in God and had been previ-
ously healthy.
As this young lady and I talked and as I had tracked her progress
on her online journal (this has been a wonderful way to keep all of
her friends and family up to date and current regarding her status),
I have been reminded again about how complex treating cancer –
particularly, breast cancer – has become. Adding to the oncologist’s
efforts of best choice is the establishment of online web sources Where does one begin?
and social media groups that can establish what should or should At initial diagnosis, she was deemed inoperable. This was due to
not be done or offered. the current opinion that when a person presents with a lymph node
This young lady’s case highlights a number of aspects in current positive (nodes are involved with cancer), the prognosis and disease
breast cancer care: burden may be improved by use of Neoadjuvant chemotherapy
• She is young; (NAC). Another factor with this case is the multifocal nature of the
• The disease was inoperable at presentation; cancer. When NAC evolved, it was hoped that cases that were in-
• She is BRCA mutation positive ( this appears to be inherited operable due to unknown margin and tumor clearance would be
from her dad who just turned 70 and is a prostate cancer survivor made operable and might improve a patient’s ability to have an op-
and just learned he is BRCA mutation positive); portunity for breast conservative approaches surgically with lumpec-
• Her initial chemotherapy did not reduce her tumor and she went tomy or partial mastectomy.
to surgery recently where a small residual primary tumor (mix- Today, though NAC is used frequently, many who present with
ture of ductal and lobular) but a lot of lymph nodes were still stage III breast cancers are usually offered mastectomy with radia-
active with breast cancer at resection; tion (data now show that patients with large axillary lymph node in-
• She originally had an Estrogen (ER) and Progesterone ( PR )pos- volvement and large tumors > 5 cm experience a 30 percent
itive and (Human Epidermal Growth Factor 2 ) HER 2 Neu reduction of relapsed improved breast cancer survival with post-
Negative tumor but on mastectomy, the tumor is now HER 2 mastectomy irradiation). With the initial hormone positivity, one
Neu positive though still ER & PR positive. could have entertained use of estrogen blocked, but with such a

28 San Antonio Medicine • November 2018