You have breast cancer. Now what?
So you have been diagnosed with breast cancer. That means, at a minimum, you have had a diagnostic imaging test like a mammogram, ultrasound or breast MRI. Most likely, you have been called back for additional images. And, almost certainly, you have had a biopsy to confirm the findings.
When I was diagnosed with ductal carcinoma in situ in May of 2017, my surprise was only surpassed by confusion over what would come next. I wasn’t certain who would be involved in my care, what role each would play, and who was in charge. And I am a medical journalist who has reported on breast cancer before!
A Team Approach
Falmouth Hospital breast surgeon Peter Hopewood, MD, FACS, explained that breast cancer care is a team approach, with many clinicians involved in your diagnosis, treatment and follow-up care.
Like a relay race, the process usually starts with diagnostics in radiology and moves along from there to a series of specialties, including:
- Diagnostic radiology
- Tumor conference
- Surgical oncology
- Medical oncology
- Radiation oncology
In most cases, the first baton holder is the patient navigator in the diagnostic radiology department.
“Navigators are clinical staff who advocate for the patient. They call with results, they help with future appointments and smooth out all of the hurdles that the patient may go through to receive treatment,” said Dr. Hopewood.
Every newly diagnosed malignancy is discussed at a weekly gathering of breast cancer clinicians at the breast cancer conferences at Cape Cod Hospital and Falmouth Hospital. On average, there are two to three newly diagnosed cases of breast cancer per week at Falmouth Hospital and double that at Cape Cod Hospital in Hyannis, according to Dr. Hopewood.
Once a malignancy is diagnosed, the tumor conference members discuss:
- Are there signs that the cancer has spread?
- How should the tumor be treated?
- How can it be prevented from coming back?
“We consider not only the disease prognosis, but also the overall health status of the patient, their family history and any other psycho-social issues that might influence the way we treat her,” said Dr. Hopewood.
The conference also confers on post-surgical cases where there are unexpected findings, or a change in what was found from the biopsy that would alter treatment plans.
The handoff usually goes next to the surgeon, according to Dr. Hopewood. The surgeon plans and explains the procedure and what to expect pre-operatively and post-operatively.
Less commonly, the surgeon is the first diagnostician, especially when there are worrisome symptoms like a palpable lump, breast pain, or nipple discharge.
“When this happens and there is the need for quick action, the surgeon may be the one actively trying to get imaging and any follow-up biopsy scheduled as soon as possible,” he said.
The medical oncologist may be the cancer caregiver who you will see most frequently and over the longest duration. Even though less than 12% of breast cancer patients go on to receive IV chemotherapy, over 75% will take daily oral medications after treatment.
“Hormonal blockade medications like Tamoxifen ® and Arimidex ® are taken for years after the completion of other treatments. The medical oncologist remains involved for the duration,” said Dr. Hopewood.
In less than 10% of cases, patients with large tumors, metastatic tumors or ones that have spread to the lymph nodes will receive systemic IV chemotherapy to shrink the tumors prior to surgery.
Radiation is a standard treatment after lumpectomy, especially when the disease is low stage and small in size, said Dr. Hopewood. It happens once the surgical site has healed and IV infusion therapy is completed.
The radiation oncologists will see patients regularly during the 3 to 5 weeks of daily treatments.
After radiation is finished, there is not usually any need for additional follow up.
Who is in Charge?
The specialist who ends up advocating and working most closely with the patient is driven by the diagnosis and the order of treatment. For patients who receive chemotherapy first, the medical oncologist is most often the one in charge. They continue to direct the care until the patient is ready for surgery. Conversely, if surgery is the first line of treatment, the surgeon calls the shots.
“There is always a collaboration here,” said Dr. Hopewood. “I have patients who are receiving chemotherapy in advance of surgery and I like to check in to see what progress is being made with shrinking the tumor. It helps inform the next steps, especially what type of surgery is ultimately recommended—lumpectomy or mastectomy.”
After surgery, the surgeon may continue to be in charge of the patient’s care. However, if chemotherapy is required, the medical oncologist usually takes over. Not all patients require radiation treatments, but, when they do, it is usually done as one of the last steps.
When Treatment is Over
Once the planned treatment has finished, the social workers at the hospitals put together a survivorship care plan tailored to each patient’s unique situation. It outlines the schedule of follow-up.
In early breast cancer, stage 1 or 2, follow-up might be every four to six months with a breast specific specialist (it might be alternating visits with the surgeon and medical oncologist). Regular mammography is resumed, either every six or 12 months, as discussed with your physician.
If you have more advanced breast cancer or metastatic disease, the medical oncologist will usually see you every month or more frequently.
“We keep an eye on the disease state, and will direct additional visits to the other clinicians accordingly,” said Dr. Hopewood. “After a while, once the patient gets used to us and the process, they begin to realize that it’s kind of like getting car maintenance. We check the oil and rotate the tires- all to keep you in the best shape possible and make sure nothing new is happening.”