Information overload

Surgery details:

Dr. S was great today about answering all of our questions. We've scheduled the surgery for Friday, December 7, at 7:30 in the morning. I'll need to go to the hospital Thursday night for some injections, but I'll at least get to toss and turn in my own bed. The surgery should last around 5 hours, then I'll need an hour or so to wake up. I should get to go home on Sunday or Monday, depending on how I feel.

Dr S. will do a sentinel lymph node biopsy on the left side (to make sure that the cancer hasn't traveled that way), and then a 'simple mastectomy', meaning she will just take out all the breast tissue and leave the lymph system alone for the most part. On the right, she will do a modified radical mastectomy, which means she'll remove all the breast tissue and the cluster of lymph nodes in my right armpit. Once she is done, she'll turn the surgery over to Dr. L, who will add the spacers for the implants and close me up.

Once I get home, I'll need to deal with drainage from the surgery site (eeeeeew) for about a week. I'll also start physical therapy to help me figure out my new front-to-back balance, and start an exercise regimen to prevent lymphedema (swelling in the right arm from the removal of the lymph nodes). Dr. S indicated that I should be mostly back to my old self in a few weeks. In her experience, the patients who are seriously incapacitated post-mastectomy are those who do more extensive reconstructions (using the tummy tuck, for example). My surgery is - relatively - straightforward.

In parallel to my initial recovery, the pathologists at LFH will go over the tissue from the surgery with a fine toothed comb to see how much active cancer remains, and whether any active cells still circulate in my lymph system. This analysis has major implications for the next part of my treatment (see chemo 2, below).


Possible Chemo round 2:

There is a new paper in the Journal of Clinical Oncology ( Symmans et al 2007, 25:28 p. 4414) looking at predicting disease free survival post neoadjuvant chemotherapy based on an index of residual cancer burden. (translation: how much cancer is left after having chemo before the surgery). The numbers (for recurrence) look very high for someone in my situation. We know that the tumor remains in the 5-7 cm range (about a 50% reduction from its original size on an 8 cycle AC/T regimen). What we won't know until after the pathology reports come in after my surgery are: are there lymph nodes still involved (probably yes, since they were heavily engaged at the beginning), and how much of the remaining tumor is necrotic vs. still viable.

Dr. B's concern is that based on the aggressiveness and size of the original tumor, I am probably in a category that gives me a high risk of recurrence (though hormone therapy should take that down some). My response to the chemo has been good, but the tumor hasn't shrunk away to nothing. She is considering having a 'thought leader' take a look at my case to see if another round of chemo could lower my risk of recurrence.

I am trying to wrap my head around this new information. Adding a second round of chemo seems pretty unusual (certainly off protocol), but I don't know how far out there it is, if it is really appropriate in my case, and what other factors I would need to consider. We have so far made choices (going for the bilateral mastectomy, for instance) to reduce the risk of recurrence, but I don't really have a good sense of what the floor for that risk might be.

Coming soon, at the Gazmoy Cancer Chronicles:
Next week - my last round one chemo treatment!
Thanksgiving week - planning with the radiation oncologist!
Zack figures out visits for the new year!