Dental work pre-treatment? Uterine polyps and Tamoxifen?
I'm 45, premenopausal AFAIK (more on this later). My biopsy came back as IDC, ER+, PR+, HER2- for a 1cm mass on Friday. Feeling massively overwhelmed, anxious, scared, angry, and just so many emotions, but trying to keep it together so I can plan better. I have appointments with a surgeon and MO at Dana Farber in 2 weeks, but before then I was wondering what I should do about 2 issues:
1) Dental work - Because of COVID I haven't been to the dentist in 2 years. Aside from a cleaning, I think I may need a couple of fillings and possibly 1-2 crowns (no root canals) to go over 2 molars that my old dentist had mentioned would need to be upgraded to a crown in the future. I read that I should be getting that done before chemo/radiation. Should I go ahead and try to rush to get those done before my appointments at Dana Farber? Or would I run the risk of it interfering with any treatment they want to do ASAP?
2) I have an existing uterine polyp (last year, my PCP said she saw it peeking through cervix during pap smear, she recommended we keep it under observation). Is this something I wait on to mention to the surgeon/MO? I haven't had a period in almost 2 years because I've been on Lo Loestrin FE 1-10 (a low estrogen (10mg) + progestin)) pill for 6 years and apparently after a few years on it, you stop having periods entirely. I started on it in 2017 because I was having more and more irregular periods. I stopped using it when I found out my diagnosis, per my PCP's recommendation. She thinks I'll start getting periods again but I'm not sure. I'm scared of having polyps then going on Tamoxifen with the increased risk of uterine cancer. For those who had polyps, at around my age/pre-menopausal, did you have to get them removed / get a uterine ultrasound before going on Tamoxifen? Did they have to put you on a different hormone medicine?
Thank you for any experience/advice you have on these. Trying not to be scared shitless but I am 
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Hello - sorry you find yourself here, the beginning of this process is indeed stressful. You have not spoken to a surgeon yet, correct? I would not necessarily assume you will need chemo at this point - you should have an Oncotype Dx test done on your tumor tissue after surgery that will help determine whether chemo will offer any benefit. You don't appear to have the obvious givens for chemo - a triple negative tumor, or ER+ and Her2+, or ER/PR- and Her2+. For those with smaller tumors, chemo is not an absolute. Is the 1cm size estimate coming from the biopsy core dimensions or from imaging? On the question of dental work, it is mainly the cleaning that is needed prior to chemo. The reason is that cleaning dislodges quite a bit of bacteria and if your immune system is compromised it can introduce infection. Other than that, dental work itself - such as fillings or root canals, I don't think there is a rush for that. I am also unaware of any need for that related to radiation. The uterine polyp question is potentially trickier. Was there any discussion about later removal of the polyp? Might be worth a consult with a gyn rather than a primary care on that. I would also ask for a transvaginal ultrasound ahead of any anti-hormonal therapy to check the status. The uterine cancer risk with Tamoxifen is very low, but it can increase thickness of the uterine lining without causing uterine cancer, so if you are prone to issues there it should be discussed. If there is only one polyp it might be worth looking at removing it, but if your menopausal status is in question it is also possible that you could do one of two things - go straight to an AI drug instead of Tamoxifen (anastrazole, exemestane, or letrozole) if you are indeed menopausal by blood tests, or use ovarian suppression that allows you to use one of those drugs rather than Tamoxifen. Some docs need to see 12 months without a period to declare menopause, while others are more reliant on what the blood tests show. Good luck - you will be in good hands at DF.
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Thank you for replying, SpecialK. The 1cm estimate is from imaging, the followup ultrasound said it was 11m x 9mm x 5mm so a little over 1cm? They said the lymph nodes looked clear at that time. Nothing was said about the size of the mass to me during core needle biopsy. I didn't know that they don't give chemo to some patients. Doesn't that increase your risk of distant metastasis if you don't get chemo? I am worried that cancer will be missed in the other breast or the rest of my body without it.
Re: dentist work - Thank you. I was so concerned because crowns can take 2-3 weeks to be installed. I had just read that people were getting tooth pain and cavities becoming more obvious as a side effect of chemo or radiation, so was trying to make sure I got whatever needed done prior to that. I will probably try to get fillings done if I can fit them in the timetable.
Regarding the uterine polyp, because I have no symptoms of uterine problems and my pap smear came back normal, last year, my PCP recommended we just observe it and we didn't need it removed. I had just seen her prior to my biopsy results and the conversation about the polyp was similar, but she said I should talk about it with the DF team if I did have cancer.
I think I might need anti-anxiety meds of some sort. I have not been able to eat well for 2 weeks waiting for results, and have not slept well at all the last 2 days since I got the results on top of that. I keep waking up abruptly early in the morning just in a state of fear/anxiety about things pertaining to having cancer/the side effects of treatment/etc.
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Back in the day, prior to technological advances in genomic testing of tumor material, it was more common for everyone to have chemotherapy. That constituted overtreatment for a significant percentage of people, so the development of this type of testing meant that the treatment choices are now more personalized. For many who are strongly ER+ and have no other drivers of aggression, chemo may not work particularly well. Chemotherapy agents also inflict a lot of collateral damage, and for a segment of those diagnosed, can potentially cause more harm than good. OncotypeDx testing has been used for quite a while now and there are a number of studies that have looked at how the test results and subsequent treatment decisions have affected patient survival. For those who are early stage and ER+, and don't have other high-risk aspects of their cancer, anti-hormonal therapy may offer safer and more effective control than chemo. Here are some links to information that explains this:
https://www.breastcancer.org/screening-testing/oncotype-dx
Here is some study info that looks at survival data among users of OncotypeDx.
https://breast-cancer-research.biomedcentral.com/articles/10.1186/s13058-021-01453-4
If you know that you have some cavities it might be worth asking if your dentist can expedite and do a cleaning and the fillings in the same visit? If you can't do that, the cleaning is the most important.
It is super common to need some anti-anxiety meds right after diagnosis. The waking up in a state of trepidation happens to all of us. I will say that most feel a little more at ease once a treatment plan has been put in place, and even better once it has started. Then you feel more proactive, and less like you are just in waiting/panic mode. Hang in there!
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I'm a little ahead of you, also pre-menopausal, with an ER/PR positive cancer and no HER-2 (technically low but they consider low Her-2 no Her-2 as far as treatment goes). What was your grade at biopsy? That's the last bit of info to consider. Anyway I don't want to overwhelm you but I think I can tell you the most likely scenario with what you said. First of all, for breast cancer, all that you stated is actually positive. It's a small tumor, hormone positive, and it looks like lymph nodes are negative. That's great and because of that they will more than likely recommend surgery first and foremost. Probably a lumpectomy although you'll have some say so with that. With a lumpectomy you're going to have to go through radiation no matter what and will have mammograms every six months with possible MRI for the near future. With a mastectomy and a node negative pathology you can skip radiation. Long term survival is not influenced by either surgery you choose (local recurrence is slightly higher with a lumpectomy) so it's entirely up to you which path feels most comfortable. Surgery will result in your pathology report which will also test your hormone receptors and grade again. And you will definitively know the size of your tumor and node involvement from that along with whether there was any lymphatic invasion. Of course it's preferable if you don't have node involvement or lymphatic invasion but if you do it's completely treatable. If your nodes come back negative they'll do an oncotype test which tells them whether you would benefit from chemo. Most hormone positive tumors don't but some do and your chances of that are higher if you are pre-menopausal with a higher grade tumor. If you won't benefit you'll go straight to hormone treatment and my guess is ovarian suppression if needed along with an AI. They are finding that those seem to be more beneficial than tamoxifan as far as recurrent rates go. Plus considering you have anxiety issues with is super common you don't have to worry about drug interaction with AI's (if they put you on something for your anxiety) nor will your uterus issues be compromised. You've got plenty of time to worry about dental issues and getting those resolved. You've just got to worry about that if you need chemotherapy and if you need it you won't start chemotherapy until three to four weeks after surgery. So I would just focus on your doctors appointments right now and get your plan underway so that you feel better and more in control.
Just as an FYI I am undergoing chemotherapy since my oncotype came back as it being worthwhile for me (if I was over 50 it wouldn't have been recommended but I'm not. The same score may mean a different recommendation depending on your age). But I was node and LVI negative (although a good sized 32 mm tumor at grade 3) so I only have four chemo sessions three weeks apart and will be taking two of the recommended drugs and not three. So I hate it, it's not like it's going to be great, but it could also be worse. And I won't have to do radiation so after chemo I'll go straight to my endocrine therapy (ovarian suppression and AI for 10 years with a possible ovary removal in my future and then reconstruction). So yes it's overwhelming but it does have a definitive end point and that's what you hold on to. Your's looks like it had a definitive endpoint, too, so all of that is hugely positive in the breast cancer world.
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Mumuriri, other than a cleaning before chemo, having dental work completed before treatment refers to those who take an aromatase inhibitor (AI) and a bisphosphonate to prevent osteoporosis. Osteonecrosis (bone death in the jaw) can be caused by an invasive dental procedure (such as a root canal or extraction) when taking bisphosponates, so it is recommended to postpone such procedures or stop that treatment for six months before the procedure. You are relatively young for worrying about osteoporosis, but even if it were a problem, you could safely have any invasive dental procedures done before starting treatment.
I second specialk's advice about having the Oncotype DX test done if you are eligible by pathology. Since the results are specific to the genomic makeup of your tumor, it makes treatment decisions much easier.
Once you know what you are dealing with and start treatment the anxiety usually lessens. You will get good advice at DF. I hope things go as smoothly as possible.
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