Clinical:Case Study:Patient Centered Breast Cancer Care

Original materials created in February 1999 by Patricia Dawson, M.D., Ph.D., FACS

History

Five weeks ago AZ, a 42 y.o. white woman, who does regular SBE, noted a nontender left breast nodule about the size of a marble. She tracked it through one menstrual cycle to see if it would resolve, but it did not. She is G2P2 with first pregnancy at 35. Has regular menses with LMP two weeks ago. No h/o breast problems or symptoms. At age 75 her maternal grandmother was diagnosed with breast cancer. No other family h/o breast cancer or ovarian cancer.

Evaluation

AZ saw her PCP who confirmed the presence of a firm, mobile, ill-defined left breast lump at 2 o’clock and sent her for a mammogram. At a Comprehensive Breast Center (CBC) a diagnostic mammogram and left breast ultrasound were done. The mammogram had standard MLO, CC, and other views of both breasts with a skin marker on the mass. These films showed dense breast tissue with possible architectural distortion but no malignant calcifications in the lump. Ultrasound defined the lump as an irregular hypoechoic mass that was 0.8 x 0.7 x 1.9 cm.

After obtaining informed consent, the radiologist performed, under local anesthesia, a u/s guided core needle biopsy of the lesion. The patient was scheduled to see the breast surgeon in the CBC the next afternoon.

Further Evaluation and Treatment

When AZ and her partner, OT, met with the breast surgeon, she informed them that the biopsy showed an infiltrating ductal carcinoma with a small area of ductal carcinoma in situ. The hormone receptor and Her2/neu studies were still pending. The surgeon took a thorough history and did a physical exam. She, AZ and OT then spent an hour discussing breast cancer and treatment considerations. They reviewed and discussed the pathology report, talked about the difference between invasive cancer and DCIS; local and systemic therapy; chemotherapy and hormone therapy; breast conservation and mastectomy; types of surgical procedures, risks, complications, recovery periods, hospitalization, anesthesia, sentinel lymph node biopsy, lymphedema risk and risk reduction, radiation therapy; reconstruction after mastectomy: implant and TRAM flap; pros and cons of various treatments; the availability of second opinions; and the considerations related to treatment decisions. The discussion was tape recorded so that AZ could review it at home, if she desired. She was advised that she had time to gather the information she felt she needed, talk with family and friends, and seek other opinions, if she chose, before making her decisions. She was loaned a copy of Dr. Susan Love’s Breast Book and other resource materials on breast cancer to review at home. AZ did not feel ready to make any decisions that day and made another appointment in three days. She was asked to have a CXR, CBC, and LFTs. She also met briefly with the CBC nurse who reviewed the resource materials with her and discussed support systems available to her - including a social worker and a breast cancer support group.

At the next visit AZ and the surgeon again reviewed the findings and options. AZ’s CXR and labs were all normal. AZ decided to have a lumpectomy and sentinel lymph node biopsy using local anesthesia and sedation. She also scheduled to see the radiation oncologist. The next week the surgery was done in the Same Day Surgery Center, and AZ went home two hours postop. The sentinel lymph node biopsy was positive, so AZ returned four days later for a standard axillary lymph node dissection. She was discharged to home four hours after surgery.

The final pathology revealed a 1 cm infiltrating ductal carcinoma with a small area DCIS. The margins of resection were clear. The tumor was ER and PR negative and had positive over-expression of Her2/neu. The sentinel lymph node and 2 other lymph nodes were positive for microscopic metastatic disease. Fourteen other lymph nodes were negative.

AZ had a good recovery from her surgery. When her case history was presented at the CBC Multidisciplinary Clinical Conference, the consensus was that she should be offered a regimen of adriamycin-based chemotherapy and then breast irradiation. She also was given the option of participating in a clinical trial. She was seen by the CBC medical oncologist for evaluation and discussion of the treatment options.

Discussion

This case history illustrates several aspects of breast cancer treatment. Of note is the timely care with a minimum of “sleepless nights” for the patient, the collaborative multidisciplinary approach, full discussions with the patient of her options, and psychosocial support systems. We are just beginning to understand how important this patient centered care is for outcome. Patricia Dawson, M.D., Ph.D., FACS

References

Foster and Wood, Alternative strategies in the management of primary breast cancer. Arch Surg; 133, Nov 1988:1182 - 1186.

Osuch and Bonham, The timely diagnosis of breast cancer. Cancer 1994; 74: 271-278.

Morris, et al, Breast-conserving therapy vs mastectomy in early -stage breast cancer: A meta-analysis of 10-year survival. Cancer J Sci Am 1997;3:6-12. Eberlein, Current management of carcinoma of the breast. Ann Surg 1994;220;2:121-136.

Fisher, et al, Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: Findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol.1998. 16;441-452.