I have the following patient who is seeing 2 Oncologists for opinions–the first a general rural Oncologist and the second a bone marrow transplant specialist. I am sure she will ask me for my opinion of their opinions, so I ask your advice.
44 year old white female, normal mammograms 6 years ago, 2 young maternal cousins have had and are surviving breast cancer, 1 slightly older paternal cousin died of breast cancer, no other family hx of breast cancer.
Presented with upper outer quadrant mass (non-distinct about 2 cm by palpation) and diffuse suspicious microcalcifications throughout left breast, normal right breast mammogram.
At biopsy, mass was invasive ductal and intraductal and ca was present at all my biopsy margins (generous biopsy).
Mod rad mastectomy showed another non-palpable focus of cancer in upper inner quadrant separate from primary mass and extensive intraductal and intralobular components, 5 out of 70 nodes positive–all positive nodes were low in axilla (and from visual observation appeared far lateral–assuming that the clinically enlarged nodes were the positive nodes).
I tried to send her to an Oncologist in our closest referral center, but he said that he would not personally treat her, instead he recommended referral to the bone marrow transplant specialist.
What do you think:
1) Is the best chemotherapy for her?
2) Should she have Radiation Therapy?
3) She wants to know whether she should have right mastectomy prophylactically
4) Should her daughters have genetic testing, if so, at what age should this start?