33. About what percent of your patients receiving adjuvant chemotherapy experience major deleterious effects on quality of life (e.g., missing work)?

Nancy Davidson, MD

I agree completely with the majority of the voters here. I tend to have a pretty young practice, and not more than about 10 or 20 percent of my patients miss more than a couple of days of work. It is the rare individual who ends up going on disability, for example, during her adjuvant therapy.

34. Medical oncologists tend to overtreat patients with metastatic breast cancer with chemotherapy.

Monica Morrow, MD

Clearly, we don’t cure metastatic breast cancer, but patients often want to receive treatments, because otherwise they may feel a sense of hopelessness that nothing is being done. So, giving treatment that conveys hope to a patient may not be such a bad thing. Having said that, I think once a patient has failed all standard therapy, just treating to keep treating is not a very good thing.

Nancy Davidson, MD

The perception that oncologists overtreat is very common in non-medical oncology physicians and probably in some patients, families and the community at large. But this is such a complicated issue, and I find myself actually often being interested in stopping chemotherapy long before my patients. Frequently outsiders don’t understand what goes on in these discussions between doctor and patient and who’s really driving the chemotherapy. It’s a very tough issue.

35. What questions should a clinician ask about HER-2 test results?

Nancy Davidson, MD

This is a great question, and I was very interested to see the distribution. I agree with the majority, which is that you’d like to know all of the above. However, in general practice, it’s mighty tough to do. I see patients from a lot of different places, so I get many different kinds of HER-2 test results. I dread it if it says something that is related to positive, because it requires all the homework that is listed here — trying to find out how it’s done, what’s positive, what’s negative, trying to talk to the pathologist. It can be a real headache in terms of getting this information. What’s happened to us more recently is that if there’s any equivocation, we send it out for F.I.S.H., which takes a while and is expensive.

36. 58-year-old woman with inflammatory breast cancer, ER-negative, HER-2 strongly positive. Would you recommend that Herceptin be included in her systemic therapy?

Monica Morrow, MD

These responses are either a reflection of the enthusiasm about Herceptin or the lack of enthusiasm about outcome in inflammatory breast cancer. But, Herceptin is only approved for the metastatic setting, and this is not the metastatic setting.

Nancy Davidson, MD

I absolutely would not use Herceptin in this situation. We have had a single trial that suggests substantial benefit with the use of Herceptin in metastatic disease in addition to standard chemotherapy. I am not prepared to extrapolate that into earlier stages of breast cancer.

Physicians in practice may be using Herceptin in the adjuvant setting more than we think, although one practical obstacle is insurance coverage. Herceptin is one of the items that’s on the reimbursement radar, and frequently third-party payers ask us for documentation about why we’re using it and the HER-2 test results, etc. So, there might be some non-medical barriers that would keep people from using Herceptin for this type of patient.

37. A 32-year-old woman is 18 weeks pregnant and has a 1-1/2 centimeter breast mass in the upper inner quadrant of her breast. Fine needle aspiration shows adenocarcinoma. The physical exam, including the axilla, is otherwise negative. You advise her to:

Monica Morrow, MD

Breast cancer during pregnancy is troublesome. Advising someone to terminate a pregnancy is not appropriate, but it is appropriate to talk to a woman about her risks of dying of breast cancer, the need for treatment, the risk of harm to the fetus, and her childbirth history and plans. Of the choices given here, I think that lumpectomy and axillary dissection is clearly preferable. However, the choice that I would make in someone early in their pregnancy like this patient would probably not be to delay and do lumpectomy and axillary dissection, but rather to do a mastectomy.

38. The patient is a 35-year-old woman with a 1.1 centimeter, node-negative, infiltrating ductal carcinoma. She had four cycles of Adriamycin and Cytoxan and continues to menstruate regularly. She wishes to become pregnant. You would advise her to:

Monica Morrow, MD

It is difficult to tell a 35-year-old who’s already had chemotherapy to arbitrarily wait two years to start attempting to become pregnant when her fertility may already be impaired. Telling her to wait five years is potentially impossible. There are no conclusive data saying that pregnancy changes outcome after breast cancer treatment. It is important to have a very frank discussion about what the risk of relapse is, and put that in the context of wanting to have a child. If you’re cured, becoming pregnant doesn’t cause a relapse. It may accelerate the speed to relapse because of the hormonal environment.

For a patient in her 20s with a potentially long period of fertility ahead, it would be reasonable to note that within two years, really bad-acting breast cancers tend to relapse, and that waiting that long would provide some extra insurance. But in a patient who is 35, you run a risk that she may not be able to become pregnant. This is a 1.1 centimeter, node-negative breast cancer — a tumor with a low risk of relapse in the first place, and that risk has been reduced by about a third with chemotherapy.

39. What would your usual surveillance be for a 42-year-old woman, whose sister had premenopausal breast cancer, and who has a 5-year Gail risk of 2.9% and lifetime risk of 25%?

Monica Morrow, MD

We tend to advise these patients to have a physical exam every six months and a mammogram once a year, as most of the audience responded. Obviously, the breasts of premenopausal women may change more as a function of their menstrual cycling and make it more difficult to know what’s normal and what’s not for them. But, that is our practice for women in that risk level, regardless of their age.

40. The main factor responsible for patient dissatisfaction after prophylactic mastectomy is:

Monica Morrow, MD

These answers show great faith in psychological counseling, which is nice, but I’d be curious to know if everyone really refers their patients for psychological counseling. I think some patients — and they’re usually the ones who you’re most concerned about being dissatisfied after prophylactic mastectomy — are very resistant to that idea. They say, "I’ve made up my mind. I know that I want this. Why should I go talk to a counselor?"

My answer to the question is "physician initiation of the procedure." Several studies have demonstrated this.

41. If you had high quality breast MRI readily available, how often would you order it in patients undergoing neoadjuvant therapy?

Monica Morrow, MD

There are some issues about standardization of MRI that are quite unresolved. Since normal techniques of assessing response to neoadjuvant therapy — that is, physical exam and mammogram — aren’t very good, I agree that if you have a radiologist who provides sensitive and specific interpretations, MRI would be a good test.

There could be a role for MRI in more advanced breast cancers and in trying to decide whether or not patients can undergo breast-conserving therapy.

42. About what fraction of your breast cancer patients do you believe are accessing treatment-related information on the Internet?

Nancy Davidson, MD

This is extremely common. Sometimes patients bring in very reputable information that I learn from. Other times they bring in things where I am sort of embarrassed to think that anybody would believe. By and large, it’s positive, but it can be time-consuming, because a lot of times there isn’t much distillation that goes on. Patients bring in a lot of stuff, only a very little bit of which is relevant to them. I recommend the NCI website and also give out the ACS, Komen Foundation, "Why Me" — all the official agencies or well-regarded breast advocacy groups.

43. About how often do you go to the Web to access information relevant to patient care?

Monica Morrow, MD

There are certainly a group of physicians who use this as a primary source, especially people who like abstracts rather than complete papers, or information that’s been digested for them in some form. I think that’s one of the advantages of that kind of approach.

Nancy Davidson, MD

I go to the NIH’s Pub-Med site almost every day — not necessarily to address questions for a particular patient, but more to think about my research directions and so forth. Sometimes I read the abstract and realize I don’t need to get anything more from that paper. But often, it drives me to have to figure out whether I can print the full text article, or am I going to have to make a trip to the library?

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