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CASE:
51-year-old
female with newly diagnosed infiltrating ductal carcinoma and
ductal carcinoma in situ of the right breast
MDExpert
- Assessment and Recommendations
Disclaimer:
This opinion is based solely on my review of those medical records
provided to MDExpert by the treating physician. I have not examined
the patient nor is it my present intent to do so in the future.
Those opinions to be rendered herein are intended for advisory
purposes only. It is within the sole discretion of the treating
physician to determine the course, scope, and extent of treatment.
It is expressly agreed and understood that my review of those
records provided and the rendering of any opinion based upon my
review of those records provided do not create a physician/patient
relationship.
MDEXPERT
TREATMENT RECOMMENDATION AND RATIONALE:
The
opinion that I will render has to do primarily with the use of
tamoxifen in this case.
My
assessment is that this patient has a very low-risk breast cancer
and is a marginal candidate for tamoxifen therapy. Her risk of
developing metastatic breast carcinoma is very low, her risk of
in-breast recurrence in the radiated breast is relatively low,
and her contralateral breast cancer risk must be taken into consideration
as well. Tamoxifen will serve to reduce all of these risks to
some degree. The benefits of tamoxifen, quantitatively speaking,
are small. I believe that the decision to use or to reject tamoxifen
in a low-risk case can best be assessed after a brief trial of
tamoxifen, during which time the patient’s short-term toxicities
can be best assessed. A three-month trial of tamoxifen should
be adequate for the assessment of such toxicities as vasomotor
symptoms, menstrual irregularities, vaginal dryness, weight gain,
and mood swings. If the patient finds three months of tamoxifen
to be intolerable, then there is no merit in asking that she endure
through a full five years. In such borderline cases, however,
I think it useful for patients to consider a trial of the drug
to assess the risk-benefit ratio more thoroughly. I would therefore
encourage the patient to consider a drug trial.
ADDITIONAL
INFORMATION OR TESTING THAT WILL FACILITATE OR IMPROVE TREATMENT
DECISION-MAKING:
There
is no additional information or testing that will facilitate this
decision, and there are no advantages at the moment to treatment
alternatives, as none have been declared the equivalent of tamoxifen
in adjuvant therapy trials.
ARE
THERE ANY CLINICAL TRIALS THAT YOU ARE AWARE OF, AND WOULD SPECIFICALLY
RECOMMEND FOR THIS PATIENT:
She
is not clinical trial eligible, at least at our institution.
ADDITIONAL
SPECIFIC QUESTIONS FROM THE PATIENT:
1.
Could the hormone replacement therapy the patient was previously
on have encouraged the development of her cancer?
The
additional question that was rendered was whether the patient’s
prior hormone replacement therapy could have encouraged the development
of her cancer. Without question, the use of hormone replacement
therapy is capable of increasing one’s risk of developing breast
cancer. To consider estrogen replacement therapy as causative
factor I think would be misguided, but it is quite possible that
the growth of this breast cancer was encouraged by the use of
hormone replacement therapy. The patient should not be concerned
that this has given her a particularly bad prognosis; in fact,
her prognosis is quite excellent.
SHOULD
THE PATIENT’S SIBLINGS OR CHILDREN BE CONCERNED ABOUT GENETIC
RISK FACTORS:
The
final question was whether the patient’s siblings or children
should be concerned about genetic risk factors. There was nothing
in this patient’s profile or family history that would suggest
undue genetic risk. I could not, therefore, recommend routine
genetic testing for this patient or her family.
By:
Kevin Fox, M.D.
The
University of Pennsylvania Cancer Center
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