Balancing quality of life and risk of breast cancer recurrence

Many patients who have been diagnosed with early-stage cancer are faced with the daunting challenge of charting a treatment plan that maximizes recurrence prevention and considers side effects that could affect long-term quality of life. Emma*, a 38-year-old with a strong family history of cancer, came to PHM shortly after being diagnosed with early-stage breast cancer. She had recently discovered that she carried an inherited mutation in the BRCA2 gene, which put her at an increased risk of developing breast cancer. This prompted her to get a screening mammogram that found a tumor. Emma turned to PHM to help navigate the important decisions involved in choosing a treatment course.

Sensation-sparing mastectomy
While the tumor was stage one, imaging identified multiple areas of cancerous cells, which indicated that this may be a more aggressive tumor. In addition, multiple areas of tumor meant it would be more difficult for a surgeon to remove all the cancer with targeted surgery. This finding, along with the BRCA2 mutation, meant that a mastectomy was the surgery that could provide Emma with the best chance of preventing both future breast cancers and local recurrences.

One major side effect of a mastectomy is loss of sensation in the chest skin and the tissue around the nipple. This is because the procedure involves removing nerves embedded in the breast tissue. For Emma, loss of sensation was a quality-of-life concern that deserved additional attention, and she had heard of a type of mastectomy that could help prevent loss of feeling. These sensation-sparing mastectomies employ two main techniques: 1) preserving nerves in the breast, which sometimes leaves behind a very small amount of breast tissue and/or 2) grafting nerve tissue from elsewhere to reconnect severed nerves in the breast.

However, several surgical oncologists suggested that this approach was not worth pursuing because there were no large, randomized studies demonstrating that the procedure could be successful. Still, Emma was determined to explore it further, so she turned to her PHM Personal Care Team to evaluate the scientific literature regarding two main unanswered questions. First, does leaving behind small amounts of breast tissue increase the risk of recurrence? And second, is there any evidence that reconnecting severed nerves could effectively return sensation?

As is often the case with newer technologies, results of large, randomized trials were not yet available, so the data regarding sensation-sparing mastectomies came from many smaller studies. Though smaller studies do not carry the same rigor as larger ones, PHM’s synthesis of the conclusions suggested that there was a good chance of at least partial return of sensation. These studies and others also suggested that leaving minimal breast tissue behind was very unlikely to increase the risk of recurrence. Additionally, PHM identified a surgical team with expertise in both mastectomies and nerve grafting who discussed their experience with Emma. She was impressed and comfortable with the data and the team, so with little downside but potential upside, she underwent a sensation-sparing mastectomy. The surgical team was able to spare the nerves for one breast and successfully grafted tissue for the other. Just two months later, Emma noted that signs of sensation were already returning.

Systemic treatment to minimize risk of metastatic recurrence
After surgery, it was recommended that Emma consider systemic treatment to ensure any cancer cells that may have escaped the breast were destroyed. The options ranged from intense chemotherapy to no chemotherapy to more targeted drugs, but because the biology of the tumor did not fit neatly into either low or high risk, several medical oncologists had differing opinions on the best path forward.

Emma was again clear that there were important quality-of-life aspects to consider. Some of the proposed therapies carried a low but real chance of persistent neuropathy, which is numbness and pain that can sometimes impede daily activities like typing, cooking, or playing guitar. Others carried a low but possible risk of secondary blood cancers or cardiac issues. Her PHM Personal Care Team again stepped in to help. The research team evaluated all proposed regimens and extracted data from the scientific literature to create a recurrence risk assessment for each therapy option. The assessment accounted for tumor size, tumor molecular profile, tumor grade, lymph node status, and BRCA status. These personalized recurrence risk values were then compared to the estimated risk of each long-term side effect.

By evaluating this information, Emma was able to confidently choose a treatment plan that included less intense chemotherapy followed by hormone therapy. This path carefully balanced the risk of long-term side effects with the reduction in risk of recurrence. She continues to do well and has stated that she is “completely comfortable and at peace” with her choice of a sensation-sparing mastectomy and systemic therapy.

“When you are given a diagnosis like cancer there is a lot you have to learn very quickly. Having my PHM team’s expert guidance to separate fact from fiction, determine which treatments are outdated and which are current best practices, and help select the best doctors for me was invaluable. Their support made a very scary, confusing process much less stressful.”

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*Name changed to protect privacy.