Doctors disagree on treatment

My wife has breast cancer and she has to decide between two contradictory medical treatment
recommendations, so we need some guidance. Here are some of the details.

She is 66 years old, in overall good health, though somewhat overweight and a smoker.

Biopsy on January 5 showed "moderately differentiated invasive ductal carcinoma...1 cm in
maximal length."  ER >90% nuclear staining.  PR >90% nuclear staining. HER-2 neu
score:negaitve (0 approaching 1+ staining).

She had a lumpectomy on February 10.  
Sentinel lymph node biopsy showed "micrometastatic carcinoma...the sentinel lympj node contains
three clusters of tumor cells, the largest measuring 0.5mm, identified by morphology."
These tumors were so small and of such "low nuclear grade" that they were not recognized
in the original frozen section slides, so the surgeon did not perform any further axillary dissection at
the time of the lumpectomy.

After the second pathologic report came in, an onco type dx test was ordered and the score on that
was 19.

The surgeon and the oncologist say that no chemo therapy is necessary and they scheduled her
for the standard 6 and a half week radiation treatment, to be followed by hormonal therapy,
tomoxifen. The radiation to be directed at both the site of the original cancer and the lymph nodes.

The radiation was scheduled to start last week but  we postponed that in order to get a second
opinion, which we just received.   The second opinion oncologist  says that the first
recommendations are "reasonable," but that he would proceed differently. He said that because
some tumor was found in the sentinel node, that he would recommend a more complete axillary
dissection be done now, to discover if there is any further tumor in the lymph nodes, at which point
chemo therapy might be required, and that would be done, as I understand it, before radiation. .

We have all the medical reports with lots more information than  I have  summarized here.. All the
doctors involved are certified and well-respected. The surgeon is a specialist in breast cancer
surgery. The second-opinion oncologist is the head of oncology at a large, urban hospital. We are
of course going to discuss this with the surgeon and the original oncologist and the radiation
oncologist, but we realize that my wife is caught between two schools of medical thought and we
expect the original team to say merely that any lymph node cancer will be handled by the radiation.

We also understand that only she can make that decision, but we would appreciate any guidance
that might help her weigh and consider her options.

Thank you,

rafesenior

[katarina777]

I am not an expert, of course, but I agree with the 'second opinion oncologist'.

This is not just a question relative to your wife's situation but a general risk associated with sentinel node dissection, and only testing the first one or couple of nodes.

In too many instances, I think, the affected lymph node(s)  happen to be not the first, or benign when assumed to be.

Yes, Radiation should be done in either case, and your current doctor is correct to plan on it but is  that good enough, or the best you can do?

I don't think so. On the other hand, your wife may not believe/think that the benefits of another operation followed by possible chemo outweighs the risks and trouble when it is uncertain that it's really worth it?

Katrin

[bluebutterfly2222]

Chemo should definitely be considered when lymph node involvement has been found. (Since there has been microinvasion there, cells could also have traveled to other parts of the body.)

Local therapies (surgery, radiation) remove or attack visible cancer,  while systemic therapies (chemo, hormone-suppressing meds, monoclonal antibodies)  attack and hopefully kill possible invisible cancer cells (micrometastases) at distant sites. It has been clearly shown in clinical trials that adding adjuvant chemotherapy reduces the chance of cancer recurrence.

Best wishes to both you and your wife...