Diagnosed with breast cancer? 8 things to ask the doctor

If you’ve just been diagnosed with breast cancer, or are close to someone who has, you probably have a lot of questions. Breast cancer surgeon Dr. Kristi Funk, also the director of the Pink Lotus Breast Center in Beverly Hills, spells out what you need to ask the doctor.

Two words: “It’s cancer.”

What did the doctor just say? You’ve been diagnosed with breast cancer? Your worst fears scream through your mind. This can’t be happening — and yet, it is happening. Take a deep breath. Exhale, and think, “I will survive.” Most women with breast cancer do survive, you know — so why not you? I’m not minimizing the strength and endurance it takes to get from here to cure — but you must believe that you will get there!

Let’s talk about what you can expect between now and the day this journey becomes history. What follows are the answers to the top eight questions I hear — questions you need to ask your doctor to make sure you get the care you deserve.

1. What exactly is breast cancer?

I always use pictures to explain how breast cancer starts — even a cursory understanding of this process takes away some of the mystery cancer holds. Stripped of its mystery, cancer looks a little less daunting.

The majority of breast tissue is made up of milk-producing glands, called lobules (broccoli-like bunches in the picture), and the tubes that carry milk down and out the nipple, called ducts. About 80 percent of breast cancer starts in ducts, 15 percent in lobules, and 5 percent is more unusual (but not necessarily more aggressive).

Normal ducts and lobules are lined by a single layer of cells that all look similar to each other. When those cells proliferate for whatever reason (genetic mutations, estrogen stimulation ... no one knows exactly why), this is called hyperplasia, and we really don’t care about that common, benign finding. However, when those new cells become disorganized, creating multiple layers and changing their look, this is atypical hyperplasia and needs to be removed when identified. Once those atypical cells bridge across a duct or lobule, and nearly fill up the central spaces, it becomes carcinoma in situ (CIS) ductal DCIS, or lobular LCIS, depending on where it is located. When left unchecked, some CIS will break through the duct or lobule walls, invading the surrounding breast tissue. Once cancer becomes invasive, it has the potential to enter the lymphatics or bloodstream and travel to other organs (metastasize).

2. What stage is my cancer?Ranging from stages 0 to 4, each stage assesses whether the cancer is invasive or non-invasive, the size of the tumor, how many lymph nodes are involved, and whether the cancer has spread beyond the breast to distant organs. Your cancer stage provides a universal language for surgeons and oncologists. It indicates how far along your cancer has progressed, and helps guide the treatment process. The true stage can only be known once your tumor and lymph nodes are removed, and your body has been imaged; prior to then, doctors can predict your stage based on clinical findings.

STAGE 0: This stage is called DCIS (ductal carcinoma in situ) or LCIS (lobular carcinoma in situ). The cancer cells are still within the intact ducts or lobules of the breast, and therefore Stage 0 cancers have no ability to spread. Stage 0 is the most curable type of cancer, although DCIS generally requires more treatment than LCIS.

STAGE 1: In this stage, cancer cells have invaded the walls of the duct or lobule, but the total size is less than 2.0 cm, and cells have not yet spread to lymph nodes or anywhere else in the body.

STAGE 2: Cancers less than 5 cm in size that have spread to one to three axillary (armpit) lymph nodes, and cancers over 2 cm that have not spread to nodes and have not invaded the chest muscles or skin are all Stage II.

STAGE 3: Cancers of any size that have spread to four or more axillary (armpit) lymph nodes, the nodes around the clavicle (collarbone), and/or the nodes near the sternum (internal mammary nodes); cancers over 5 cm that spread to any number of nodes; and tumors that have grown into the chest wall or skin are all Stage III.

STAGE 4: This stage cancer has spread beyond the breast and nearby nodes, and has metastasized to other organs or distant nodes. The most commonly involved areas are liver, lung, brain, and bone.

3. What kind of operation is best for me?

A lumpectomy removes the cancer with a rim of healthy breast tissue surrounding it. A mastectomy removes all of the breast tissue. Remember this: Your chances of survival, and your chances of cancer recurrence (with a single cancer site in your breast) are identical whether you choose to have a lumpectomy followed by radiation, or a mastectomy. Shocking, right? You can keep your breast and not sacrifice your chance of cure! Make sure your surgeon is offering you options tailored to you.

Here are six reasons why you might choose mastectomy, even though at first it might seem like a drastic measure:

1. Small breast/large cancer. Lumpectomy will be significantly deforming, whereas mastectomy with reconstruction actually looks much better.

2. More than one cancer in different parts of the breast.

3. Not interested in radiation after lumpectomy, for whatever reason.

4. Already had radiation for a previous breast cancer in the same breast.

5. BRCA genetic mutation, or strong family history of breast cancer — you might consider removing the other breast as well.

6. Personal preference: “It’s my breast and I just don’t want it.”

4. Do I have a choice about radiation?

Well, yes and no. Lumpectomy without radiation leads to a cancer recurrence rate in the breast tissue of about 40 percent. If you add radiation to “sterilize” the breast after lumpectomy, recurrence drops to 4-8 percent. So if you choose lumpectomy, you really need radiation. However (here’s your choice!), you might be a great candidate for APBI, accelerated partial breast irradiation. Standard radiation is Monday through Friday, every day for about 33 treatments, taking 6.5 weeks. APBI takes 5 minutes, twice a day for 5 days, and you’re done!

Ask your surgeon about APBI. If you are over 45 years old, your cancer is under 3 cm with clear margins, the lymph nodes are negative (no cancer), and the type of cancer is not lobular, you might save yourself 6 weeks of heat!

5. If I get radiation, do I need chemotherapy?

People often don’t realize the distinction between chemotherapy and radiation. Chemo is all about killing rogue cells that are “out there” floating in the bloodstream, trying to land (or those that have already landed) in a distant organ. Radiation is only about reducing the chances of cancer coming back in the breast, chest wall, or breast skin. Chemo causes hair loss and nausea. Radiation causes skin redness and fatigue. Radiation and chemotherapy target totally different cancer issues — having one therapy does not mean you can avoid the other.

6. Will chemotherapy really help me?

The absolute benefit of chemo varies from one woman to the next. Wouldn’t it be great to know if your cancer really needs to be treated with chemo or not? Well, guess what? We have a new tool to assess how beneficial chemo will be for you, fighting against your cancer. Tests such as Oncotype Dx® and MammaPrint® are valid for Stage 1 and 2 cancers that have not gone to lymph nodes. (Stage 0 never needs chemo.) These tests evaluate the biologic activity of your cancer by measuring a number of different markers that either increase or decrease the likelihood of distant metastases (remember, it’s these metastatic cancer cells that are life threatening and are the target of chemotherapy).

If, for example, the test shows that you have a 30 percent chance of distant recurrence (e.g., cancer showing up in your liver), but if you do chemo, that number becomes 15 percent, wouldn’t you be motivated to do the chemo? On the other hand, if the test shows a recurrence rate of 10 percent and chemo will bring this to 8 percent, maybe that benefit isn’t enough to make you brave baldness.

Ask your surgeon and medical oncologist about these tests to help determine whether or not chemo is “worth it.”

7. How do I best weigh my options?

Arming yourself with information specific to your situation allows you to explore choices. I believe that having a choice about your treatments empowers you, and makes you calmer as you march into battle. Many survivors have chosen different paths, and yet they are all alive.

Team up with your doctors to discuss the pros and cons of each treatment option. Understand how the stage of your cancer, your age, and your family history might make certain choices more appropriate than others. Consider the opinions of your partner, supportive family, and trusted friends. Talk to survivors who have traveled this road before you.

Above all, remember this: Your cancer treatment is ultimately a personal decision, and it has to be one you can live with — figuratively and literally.

8. What should I expect?

Expect a struggle. Surgery and treatment can be difficult; you will need a strong support system. Lean on the love of your family, partner and friends.

Expect to grow old! There are two good reasons why we live in a world with over 2.5 million breast cancer survivors: earlier detection, and better treatment options. One thing is for sure: the earlier one catches cancer, the better. The 5-year relative survival rate of Stages 0 and 1 breast cancer is 98 percent! No matter what your cancer stage, every stage has hope.

Expect to give back! You will be so grateful for your journey that you will want to give back. We need to fund research because that’s how treatment options evolve. Research matters. Find an easy way to support the cause. I like simple programs that raise money for the cause, like Yoplait’s Save Lids to Save Lives, which raises funds through special pink lids on Yoplait yogurt cups for Susan G. Komen for the Cure, an organization that engages millions of citizens in fundraising. Another personal favorite is Pink Lotus Petals, a non-profit I co-founded that provides free breast cancer screening, diagnosis and treatment for low-income, uninsured women. Run a race. If that sounds exhausting, walk a walk. Buy a pink bracelet or ring. Encourage a newly diagnosed friend.

Expect to live! Statistics are just that — statistics. In fact, if you’ve been diagnosed and you’re reading this article now, you’re already a SURVIVOR. Welcome to the sacred sisterhood of survivors — find a sister, share a cup of coffee, and laugh together about how life is beautiful.

Editor’s note: Any ideas and/or suggestions in this article are not intended as a substitute for consulting your physician.