Close but no Cigar?

Following surgery, I set up meetings with 2 Medical Oncologists and 1 Radiation Oncologist. The question on everyone’s mind, especially mine, is what’s next?

The final results from my pathology look like this (you might only understand this if you had breast cancer or know someone who has):

• Stage IB: T0 or T1, N1mi, M0: (on 0-IV scale) Invasive Ductal Carcinoma (IDC) non-necrotic tumor is 1.3 cm with a .5mm micrometastases in 1 of 3 sentinel lymph nodes (the other 2 nodes tested were clear). The cancer has not spread to distant sites.
• Grade 2 (on 1-3 scale – intermediate/moderate differentiation)
• ER Positive (yes– 100%)/PR Positive (yes – 60%)
• HER2 (negative)
• BRCA1, BRCA2 (negative)

My first meeting is with Dr. Fred Smith, a very highly regarded Medical Oncologist in the DC area. Dr. Smith has been practicing for 30 years. He has a very handsome office in Chevy Chase. It’s the kind of office that makes you feel like “Hey maybe I don’t have cancer!” The nurse came in to take my vitals. My pulse clocked in at 130, woa! My ability to look calm and collected on the outside, yet be completely freaking out on the inside is actually quite impressive. Dr. Smith walked through the door and shook my hand. He is a soft spoken man with a calm demeanor. He puts me at ease. He recommends having my tumor sent for further genetic testing (an Oncotype DX analysis) to see what the “fingerprint” of my tumor looks like. This newer test gives more insight into whether or not your particular cancer will respond to chemotherapy. While the study is still new, it is well verified that if you come back with a score lower than 5 you definitely will not benefit from chemotherapy, while if you score over 25 you definitely will. OK, so there is a chance I might not need chemo if the score is really low? Woo hooo, I like this.

My second meeting is with Dr. Victoria Croog. Dr. Croog is a very sharp, young Harvard Medical School grad, who did her residency at Sloan Kettering in NYC. Dr. Croog’s specialty is Radiology. Dr. Croog walks in smiling and shaking her head a little bit. She marvels at how early I caught this cancer and explains that she is really torn, but feels like maybe I don’t need radiation. I like Dr. Croog right away. Her hands are almost as small as mine (why this is important to note, I don’t know, but I wanted to.)

I am feeling pretty proud of myself at this point. Maybe if the Oncotype score comes back really low, I won’t need chemo and now maybe I won’t need radiation either! I am the master of my domain!

Then Dr. Croog furrows her brow as she combs through the detail pages that support the pathologists summary. “Hmmm, the detailed report doesn’t totally correlate to the summary for me.” Dr. Croog continued to study my chart looking perplexed. “What is this 6 cm pink fleshy mass they describe at 12 o’clock?” Dr. Croog continues, “I would like to get some clarification on this report, I am concerned about making a final call on treatment before I fully understand this report.” Um, yes, now I am concerned too!

Dr. Croog explained that Sibley actually selected my case to be discussed at the “Tumor Board” the next day where all the surgeons, medical oncologists, pathologists and radiation oncologists would gather to review my case and have a discussion about how I should be treated. It seems I have caught this early, but is it so early that I could really avoid chemotherapy and/or radiation? Dr. Croog said she would call me the next day to fill me in on what they discuss and that she would  have clarification on the pathology report. I leave the office feeling like my pulse might be above 200.

The next day, Dr. Croog gave me a call as promised. She explained to me that they amended my pathology report to include some additional details that were left out in the summary. The amendment now clearly explains that there was also a large amount of disease in the upper outer quadrant of the left breast. This disease has now been described to me as mostly  “high-grade, aggressive necrotic Ductal Carcinoma In-Situ “DCIS”, (stage 0 breast cancer) and at 12 o’clock there were also 2 micro invasions of less than 1mm of Invasive Ductal Carcinoma “IDC”. This area of DCIS had narrower margins achieved in surgery than the area around the 1.3 cm tumor.

Given the new information, the tumor board at Sibley was split on whether they would recommend additional surgery to do a full axillary dissection of the nodes and to try to achieve closer margins around the DCIS, or whether they would skip further surgery and opt for radiation to take care of the close margins plus the sentinel node involvement.

Bubble number one is officially burst. Radiation treatment is recommended. It doesn’t come without risk either, as the left chest wall will need to be radiated, and my heart will absorb some of this radiation. Dr. Croog explained that she will do her best to shield the heart during treatment. Treatment will consist of 30 treatments, 5 days on, 2 days off. The sessions only last about 30 min. Radiation will follow chemotherapy.

My third appointment is with Dr. Claudine Isaacs, a Medical Oncologist at Georgetown. She and Dr. Smith are considered to be the two real experts in the DC area. Dr. Isaacs is curious to hear what Dr. Smith recommended. She concurred that if the Oncotype comes back very low, that we will not need to do chemo, but she thinks the likelihood of getting a score that low is so slim that she wouldn’t have even ordered the test.

Bubble number 2 burst? Not officially, but likely. We will still wait for that Oncotype score, but it now sounds very unlikely that I will avoid Chemotherapy. Isaacs and Smith both recommend the same treatment plan if the Oncotype score is not low. Taxotere and Cyclophosphamide, “TC”- 4 sessions spaced 3 weeks apart. Dr. Isaacs explained that I will lose my hair and I might lose most or all of my eggs. She suggested I get in to see a fertility specialist asap to have my eggs extracted. Let the good times roll.

(Side note: I have been wearing tennis outfits to my doctors appointments. I have a good friend who swears that when you are sick, if you change into sweat pants or pajamas you will get sicker. I decided to apply this logic with my own twist, and thought that a tennis outfit would be a good way to feel and look really well. The nurse even asked me on my way in to see Dr. Croog, “You didn’t just come from playing tennis did you?” I explained my philosophy to her, she laughed and said, “Well you look great!” This is exactly what I wanted to hear, if the nurses and doctors think I look great maybe they will go lighter on my treatment. I know I must sound a little nuts at this point.)