I talked about the indication for radiation after neoadjuvant chemotherapy. Basically the indication for radiation was always based on having surgery up front because the surgery will give us a lot of information to decide whether we need to give radiation or not and where. If there is a lumpectomy we give radiation to the breast for sure but it’s not clear whether we need to give radiation to the lymph nodes around. If the patient undergoes mastectomy we don’t know whether we should give post-mastectomy radiation or not.

So all the indication was always based at presentation of the patient with the type of tumour, with the extent of tumour and doing surgery up front. Nowadays a lot of patients undergo chemotherapy up front so the tumour and the lymph node status starts to change. So what do we do if all the information that we have is based on surgery first? Now we are not doing surgery first so things got confused. So I tried to explain that first there is a big study in the US which is addressing this issue, a phase III study, a randomisation between radiation and no radiation based on a clinical situation. The specific situation that I addressed yesterday was that if a patient starts with a palpable lymph node, the cancer has extended to the lymph node, and it is documented with a biopsy, so we are sure she has a positive lymph node, and undergo chemotherapy. Then when she does surgery after that the lymph node disappears, the whole cancer disappears. So what should we do? Should we still give the radiation and consider the indication based on the original presentation or now the cancer has disappeared, why do we need to give radiation? So this is the question which we tried to answer.

If the cancer remains in the lymph node after the chemotherapy we have to give radiation. If it disappears we just don’t know. So sometimes we do, sometimes we don’t because the study now is looking at this. But I personally lean towards being more safe and I just give radiation if I have documentation that the lymph node was positive. So that’s what the talk is about.

Is the patient involved in this decision between treatment options?

We always involve the patient in the decision. Sometimes the decision is clear cut from data but when the data is blurry, when there is no data, when it’s a grey zone, we just don’t know the answer, involving the patient is extremely, extremely crucial because some patients will tell you, ‘I want to do everything, I want to go as far as possible,’ and other patients will say, ‘Unless you are sure, I prefer to have a good quality of life and if you are not sure that this treatment is necessary I don’t want it.’ So this choice makes things really very clear for us and just involving the patient is very important mentally and emotionally for the patient and for the physician too.

Do you notice a difference in the discussions surrounding this topic depending on what part of the world you are in?

The culture is completely different. In Western, specifically actually among most of New York, the intellect of patients is quite high. They read a lot before they come to you and they ask questions as if they give you an oral board exam – ‘Why do you do this? How do you do that? What is the data?’ – that’s what I am expecting when I go back to Boston actually in the majority of patients. In Egypt, and I’m originally Egyptian, it’s a completely different culture. It’s sort of you are the doctor, you are the one who knows and just take care of me and I trust you and that’s the other side of things. I also trained a lot in France and I know back then when I was resident the French culture is rather closer to the Egyptian culture, they just trust you and they tell you just to do what you need to do. But I hear from my colleagues this has changed now, that they’ve started to read and to question you and you have to explain all what you need to do. So it’s a completely different world actually.