Ok.. coming! (pun not intended, hehe)

thank you dr bernard, on behalf of the next family whose mother / wife you are going to save.

1. For curative treamtment, under current technology and drugs available, surgery is still necessary, followed by various “adjuvant” or “adjunct” therapy like chemotherapy, radiotherapy, hormonal therapy and another group called “targeted therapy”.

2. However, if the tumour has already spread to other areas but is not troubling the patient in the breast, then treatment may not need to concentrate on the original tumour itself. This is the situation where surgery might not be offered to the patient.

In this case, we might use chemotherapy, hormonal therapy or “targeted therapy” depending on the patient and cancer characteristics.

3. There is also a situation where the cancer has spread AND the tumour is also giving the patient trouble… such as ulcerating (breaking out of the skin), or inflammed etc… then there is a place for palliative surgery. “Palliative” means treatment to provide relief for the patient.

The methods of palliative treatment for the breast itself are:

- surgery
- radiotherapy

So, there are still other avenues to treat the cancer without surgery.

You’re right that if the primary tumour is giving pain.. one of the options is to excise it. However, to control pain, there are also other options such as radotherapy and pain relief. It depends very much on the situation of the patient.

Also, as you have said, there’s the patient’s personal preference. Some people feel better and more in control if the primary tumour had been excised. Some people feel that they want their breasts intact.

ME, true. In palliative care (more than any other area of medical care), the patient ultimately has the decision in her hands. My job is to tell her what are the realistic benefits and hazards of therapy or witholding therapy and let her choose.

Even her family members’ opinion are secondary. Although they are important, ultimately the patient’s decision is the one that counts.

Regarding choosing prolonging life compared to quality of life, there might be a reason that she will sometimes share and sometimes keep to herself… perhaps she wants to see her grandchild, or her child to graduate, or reconcile some family problems.. .etc. Or just to live as long as she can.

For me, there’s one situation where it frustrates me. It’s when there’s a potentially curable cancer being diagnosed and the patient declines evidence-based treatment in order to try out complementary medical techniques and come back later with progressing disease. I just say.. “This door is always open for you to come back.” It’s sad but somehow respecting the patient’s wishes is still paramount.

Eve, yes I have.. and I’m sure every doctor has seen that too. But protocols and guidelines are just that.. guidelines… they do not dictate what the doctor or the patient must do.

Protocols and guidelines give the best recommendations based on available evidence collected thus far. And these recommendations are based on statistically significant differences between two methods of treatment….. that in itself already implies that neither are foolproof nor completely useless.

Otherwise there wouldn’t need to be any study in the first place.

I think even if the odds weren’t so good for Stage 4 cancer to be removed…I’d remove it.