20. 66-year-old woman with history of severe COPD. Core biopsy revealed infiltrating ductal carcinoma, ER/PR+. Patient would prefer breast conserving therapy if possible. Your suggested management:

Patrick Borgen, MD

In general for these patients, you have to determine what their pulmonary reserves are. Then they should see the radiation oncologist, so he can calculate what the loss is going to be. Very often, you'll find out that a three percent or a five percent loss is simply not tolerable. Then you're back to lumpectomy versus mastectomy. We don't do lumpectomy alone in someone where maybe her COPD is managed on meds and she has a ten-year life expectancy. Based on the B-06, we wouldn't be comfortable. We would talk about a mastectomy in that patient.

You can do this scientifically by calculating how much your radiation's going to cost you and, if you exceed that or you're close to it, I wouldn't under-treat her. I would lean towards mastectomy. Now, someone who'ss short of breath in the office in front of you and has a very poor performance status, this breast cancer is not going to be the cause of her undoing, and there are patients like this who you might do a wide local excision, put them on an aromatase inhibitor, send them home and watch them closely.

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