Expert Q&A: Getting the Best Breast Cancer Treatment

An interview with Duke University Surgeon Lee Gravatt Wilke, MD

From the WebMD Archives

Each year in the United States, close to 250,000 women learn they have breast cancer. As they deal with their diagnosis, they are also asked to make daunting decisions about how to best fight their disease.

New patients facing treatment need to understand their options, and that means learning all they can about their cancer, says breast cancer surgeon Lee Gravatt Wilke, MD.

Wilke, who is an assistant professor of surgery at Duke University Health System and a board member of the NavigateCancer Foundation, shares with WebMD some of the things breast cancer patients need to know.

Q: What are the questions you recommend all breast cancer patients ask their doctor?

A new patient may be referred to a surgeon or in some programs they may see a team of providers that will help them understand their treatment options.

Some basic questions to ask are:

  • What type of cancer do I have? Is it ductal or lobular or a different variant?
  • What stage is my tumor and how big is it? Is my cancer localized to the breast (in situ) or has it spread to my lymph nodes?
  • What are the characteristics of my tumor? Is it fueled by estrogen (estrogen-receptor positive) and is it HER2-positive. About 25% of breast cancer patients have HER2+ tumors, which tend to be more aggressive.
  • Should I be tested for a BRCA mutation? A treatment consultation should always include questions about family cancer history. A woman with close relatives who have had breast or ovarian cancer or had cancer at an early age may want to be tested.
  • What are my surgical options? Many patients are candidates for either breast-conserving surgery with radiation or mastectomy, in which the breast is removed.
  • Should I see other providers, such as an oncologist or radiologist?

As soon as someone learns they have breast cancer, they should start learning about the condition; and it is the doctor’s job to help you learn.

Q: I’m anxious to start treatment, but I need more time to consider my diagnosis and treatment options. How long do I have to decide on a treatment course?

Ideally, we like to have a treatment plan within two to three weeks of diagnosis, but if a patient is going for second opinions and needs more time, that is usually OK. I tell most of my patients they shouldn’t wait longer than a few months to start treatment, though, because cancers do grow in that time.


Q: When should I seek a second opinion?

A second opinion is important for a patient who doesn’t feel she understands her treatment options. With some late-stage cancers there aren’t a lot of options, but with most early stage cancers there are. The patient should be the driver. If the patient doesn’t understand the treatments being proposed or wants to hear about them in a different way, a second opinion is important.

Q: I’m overwhelmed with all the information I’m getting about my cancer and possible treatments. How do I remember it all?

Many of my patients bring either a family member or friend to act as a second set of ears or to write everything down. If a patient doesn’t have someone with them, bringing a tape recorder is not a bad idea. And a patient can ask the doctor to write down key points, if they aren’t doing this already.

Q: Should I join a cancer support group?

That depends. If a patient feels it would be beneficial, then support groups are great. But I have patients who have actually been made to feel guilty because they don't want to join one. People who aren’t particularly social to begin with aren’t going to become social after learning they have cancer. These patients may be more comfortable gathering the information they need and digesting it on their own.

Q: How do I find the right doctor or treatment center for me?

Again, if you don’t feel comfortable with the doctor you are referred to, get a second opinion. The Commission on Cancer is a good place to go for information on top surgical centers. A joint consortium of health organizations including the American College of Surgeons and the American Cancer Society, the Commission has accredited more than 1,400 cancer programs in the U.S. and Puerto Rico.

Q: When should I consider traveling for treatment?

That’s a tough one. If there are complexities with the cancer, such as a strong family history or a large tumor, a patient may want to consider traveling if they don’t live near a treatment center that has been accredited by the Commission on Cancer (CoC). The National Cancer Institute also designates cancer centers and comprehensive cancer centers of excellence. A list of these centers can be found on the NCI web site.


Q: When should I consider a clinical trial?

The only way we are going to identify the best and most effective therapies is with clinical trials, so it is important to consider joining one. Usually a hospital’s web site will list the trials that are available. Another good source is the clinical trials web site of the National Institutes of Health.

Certainly, the majority of women with metastatic disease are entered into clinical trials. And many women who are candidates for neoadjuvant therapy, which may include either chemotherapy or endocrine therapy prior to surgery, are placed in clinical trials.

Q: My surgeon tells me I can have a lumpectomy with radiation or a mastectomy. What do I need to consider?

Survival rates are the same for the two procedures in women who are candidates for breast-conserving surgery, but cancer recurrence rates are slightly higher with lumpectomy. These days women with BRCA mutations and a strong family history of breast cancer often choose mastectomy or even double mastectomy to remove both the cancerous and non-cancerous breasts. And women with small breasts and large tumors often choose mastectomy with breast reconstruction because the cosmetic results from lumpectomy may be poor.

Women who want to avoid radiation or who want to avoid regular mammograms may also opt for mastectomy over breast-conserving surgery.

Mastectomy rates have been rising in recent years, and if the trend were explored I think we would find this is because women are much more comfortable with cosmetic surgery (to reconstruct the breast) than they once were.

Q: I want to have children after treatment. What do I need to consider now?

It is very important for younger patients who want to preserve their fertility to talk to a fertility specialist as soon as possible after diagnosis. Her cancer team should also be willing to work with this specialist to identify the best way to preserve fertility.

Q: What if I want to explore alternative or complementary treatments?

Patients need to be comfortable with the treatments they receive. We don’t know a lot about how alternative treatments impact breast cancer outcomes. We are only beginning to investigate this. Standard of care treatments for breast cancer work very well, but I have patients who have rejected these treatments and I can’t say that in 100% of cases this was the wrong thing to do.

WebMD Feature Reviewed by Louise Chang, MD on September 28, 2010



Lee Gravatte Wilke, MD, assistant professor of surgery, Duke University Health System.

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