Making Medical Decisions After Breast Cancer Diagnosis: You’re not Alone

Breast cancer is the most commonly diagnosed cancer in women in the United States. American Cancer Society estimates that 281,550 women with be newly diagnosed with breast cancer in 2021. These women will face the difficult phase of receiving the diagnosis after biopsy, followed by the bewildering process of understanding the diagnosis and various treatment options. Breast cancer treatment often involves a team of specialists in different fields, which may include a surgeon, a medical oncologist, a radiation oncologist, a radiologist, and a genetic counselor.

Typically, patients have consultation with a surgeon after a biopsy yields a breast cancer diagnosis. The surgeon decides whether the patient should go for upfront surgery or receive any pre-surgical medications, also known as neoadjuvant systemic treatment. Several different factors are taken into consideration when deciding the right treatment course: size of the tumor, status of the axillary lymph node, molecular subtype decided by estrogen receptor, progesterone receptor, and Her-2neu receptor, tumor size to breast size ratio, presence of genetic mutation, and patient’s overall general health status.

It is important to remember that not every breast cancer patient will receive the same treatment. Some patients may have different options of surgery, while others may not have a choice. For example, some women are eligible for breast conserving surgery (BCS) or lumpectomy. These women may ultimately undergo BCS, but in some cases may pursue mastectomy for various other reasons. Some women unfortunately do not have a choice due to the distribution of disease seen on diagnostic testing and will be recommended mastectomy. The type of medication needed also varies depending on the tumor. While some patients need chemotherapy, many breast cancer patients do not receive chemotherapy, especially those with favorable molecular subtype.

Patients who undergo mastectomy are often eligible for reconstruction, which can be performed as immediate reconstruction or delayed reconstruction. Depending on the stage of the breast cancer, either may be recommended by the plastic surgeon. Some women who are eligible for lumpectomy but require removal of significant portion of breast can also involve plastic surgeon for oncoplastic closure for optimal cosmetic result. New York State mandates that all hospitals that provides mastectomy surgery, lymph node dissection, or a lumpectomy provide information to the patient concerning the option of reconstructive surgery, and that health insurance policies pay for the reconstruction. 

It can be overwhelming to process all of the information from consultations and make decisions. Patients may not understand fully all the options are available to them but feel pressured to make quick decisions due to the cancer diagnosis. The authors of an article titled “How Well Informed Do Patients Feel about Their Breast Cancer Surgery Options? Findings from a Nationwide Survey of Women after Lumpectomy and/or Mastectomy” published in Journal of the American College of Surgeons in February of 2018 conducted a nationwide internet survey to explore how women become informed about their breast surgery options. Results of their study showed that only 47% of patients who underwent lumpectomy felt “completely informed” about treatment options before their operations, 67% of women who underwent mastectomy and 28% of those who underwent both lumpectomy and mastectomy felt the same. “Making a quick decision” was more important than “thoroughly researching all options” for 35% of lumpectomy-only patients, 31% of mastectomy-only patients, and 22% of patients having both procedures. 

What can patients do to improve their understanding?

The results from this study show that there is room for improvement for physicians in fully informing patients about their treatment options. However, patients can also take some measures to facilitate understanding and making the right decision.

  1. If possible, have a friend or family member present during the consultation. They can be your second set of ears and can help remember what was discussed during the visit.
  2. Take notes. If there are any follow up visits, make sure to bring unanswered questions to be addressed.
  3. Go for a second opinion unless you feel very comfortable with the initial consulting physician. It is encouraged and important as the patient must have complete trust and be very comfortable with the treating physician. Physicians should never be offended when patients seek a second opinion.
  4. Remember that everyone’s tumor is different and you may not require the same treatment as your family member or friend.

The period between the initial receipt of diagnosis and initiation of treatment often is the most difficult time for the patient emotionally. It also coincides with the time to make very important and sometimes difficult medical decisions. It is important for the treating physicians to treat the patient as a whole person, not just the disease, and for the patients to take steps to ensure they make decisions when they feel fully informed of all options.