Dear Dr. Roach: I have a dilemma. I’m a 68-year-old, sexually active woman just diagnosed with stage 1 breast cancer (1.2 centimetre, tumour grade 1, ER and PR positive, HER2 negative, Ki67 at five per cent-10 per cent). I am planning to get a lumpectomy, no problem. No exam yet of lymph nodes. But I am very concerned about follow-up treatment. Now, I understand that doctors are zealous about going full-bore to rid the body of cancer. I get that, and appreciate it. But I have read, too, that overdiagnosis and overtreatment are becoming major issues, particularly with breast cancer. Many autopsies show cancer in women, and there are some studies that show that mammograms and treatment have no appreciable effect on death rates.
I am concerned about side-effects, of course. But I also wonder, given some of the treatments, if the medical community really takes into account a woman’s libido. I don’t want to give that up! Would it be totally insane to do nothing but the lumpectomy and take a wait-and-see posture with a follow-up mammogram and ultrasound in a year? I see it as a roll of the dice, to some extent, either way. I would be most interested, too, in finding a specialist in this field to discuss it candidly and help me sort out the hormonal issues — without the uberpressure from doctors. I am in a rural area with few specialists.
You have early breast cancer with many good prognostic signs, so far: Your tumour is small; the tumour appears to be not aggressive; the estrogen and progesterone receptors are positive; the tumour does not overexpress human epidermal growth factor 2; and the nuclear antigen Ki67 is low. I put all of these together into a model (the AJCC UICC 8th edition) and found the likelihood of a woman dying of breast cancer with these characteristics within five years is about one per cent. This is true even if there are a few breast cancer cells found in the closest lymph nodes (called micrometastasis), but if other lymph nodes are involved then the prognosis would change. Women with positive nodes are usually treated with mastectomy, not lumpectomy, plus radiation.
Assuming your lymph nodes are negative, I used a second model (breast.predict.nhs.uk/tool) to estimate the benefit of hormonal therapy or chemotherapy on overall risk. This model gives a 10-year risk of dying from breast cancer of two per cent, which can be reduced to one per cent with the addition of hormonal therapy or with chemotherapy (either of which often adversely affects libido). Even both of these together reduced risk by only one per cent. Some experts might recommend additional information, such as a gene expression profile, that can help identify those who would be most likely to benefit from additional treatment.
I hope this information makes it easier to discuss the risks and benefits of additional treatment with your specialist.
Dear Dr. Roach: A recent column commented on liquid bandages for a home first aid kit. What else should be in a home first aid kit?
Depending how large a family you have, how active you are, how often you travel and what types of activities you enjoy, your ideal first aid kit might vary a bit from standard guidelines. I found one pretty complete list from U.C. San Diego at tinyurl.com/kitforfirstaid. Most of the kit is for care of minor lacerations, but there are some additional types of supplies as well. The list includes several medications: If you use those, be sure you replace them after expiration. Several well-stocked first aid kits are available for sale online, some for as little as $25.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu