Another biopsy, 3 yrs. later

Women's Imaging: orchids at the doorway, orchids inside... 

It's always a surprise.  

We show up for our annual mammogram, and the doctor sees something.

(Actually, not all of us show up.  Women who do not have health insurance or who live far from a clinic may not have that surprise until they feel a lump--much later in the growth of a tumor.)

Today after the usual two x-rays per breast, my radiologist asked for three more of my right breast, including a close-up of the lower breast.  Ten minutes later she asked for a closer close-up.

Then came the news: a patch of eight or so tiny specks of calcification.  They looked like the cluster of stars we call the Pleiades.

"Calcification is sometimes a sign of cancer, sometimes not," Dr. Iyengar said.  "We won't know until we do a core needle biopsy."

Vocabulary Lesson One for breast cancer patients: needle biopsy.

Cancerquest.org defines needle biopsy:

A needle biopsy is rarely used to obtain skin tissue; it is usually used to remove a sample from internal organs, lymph nodes, or deep skin areas. These techniques involve the use of a small, hollow needle and is sometimes aided by an imaging technique such as x-ray.  There are two types of needle biopsy, fine needle aspiration (FNA) and core needle biopsy.  They differ in the amount of tissue removed. Core needle biopsies remove a larger tissue sample than FNA.1More about these are in the sections that follow.

See also:

http://www.mayoclinic.org/tests-procedures/breast-biopsy/details/what-you-can-expect/rec-20236113

I had plenty of time to think about it between x-rays: the right breast, not the left, site of my lumpectomy three years ago.

Does that mean all the cells of my body are vulnerable to going haywire at this point in my life--coming up on 69 years?

Or is it just the cells of my breast?  Why didn't I have a double mastectomy last time?  Go for it now.

I'm so grateful for the expertise of Dr. Geeta Iyengar.  She's kind and she recommended the ultrasound three years ago that revealed my stage 2 tumor.  I think ethnically she may be from India.  I trust her completely.

It was also great to see Winona, the radiology technician who did my ultrasound three years ago and showed the tumor to me and Dr.Iyengar.  She knows me by face and welcomes me each time I show up a year later.  She's African-American and very warm-hearted.

Anyway, I'm strapping my seat belt for another ride--whether a short trip or the beginning of a roller coaster, I don't know.

Triple Negative

A friend just got a diagnosis of breast cancer and had her lumpectomy on Wednesday. 

Today, five days later, she's a breast cancer survivor and probably on her way to a full recovery.

 

Good news: her lymph nodes (those that drain the breast, called sentinel nodes) were not involved! 

The margins around the removed tumor looked good too.  Yay!

With those two factors and with God's help, I think she has this beat. 

The bad news is that the cells of her tumor test as triple negative: no estrogen receptors, no progesterone receptors, and no overproduction of the Her2 oncogene.  

Cells of this type are very fast-growing, but chemotherapy really knocks them out. 

I've met women who have 20-30 years survival after Triple N.  

Note: you make friends with a lot of cancer survivors after a breast cancer diagnosis.  

The book I find helpful:

 The Breast Cancer Survival Manual, 5th ed., by John Link, MD (NY: Holt, 2012). 

WLE aka Lumpectomy

A successful day--all went as planned, more or less.

I spent 8 - 10:30 am digging up the last section of my kitchen garden and setting in five tomato plants, some herbs, 6 seedlings of corn, and three cucumber plants.  On the other side of the yard I replaced a dead pink bougainvillea with a new one.

I showered and reported to the Barbara Kort Women's Imaging Center at 11 am--but was told I was late for my 10:30 appointment.  What???  Oh well... I was there to have a wire implanted before the surgery in order to guide the doctor to the exact spot for the lumpectomy, also called a wide local excision (WLE).

The young doctor and radiation technician couldn't find the lump on the ultrasound screen, so they called in a senior doctor (my age).  I glanced to my right at the screen and couldn't blame them: it looked like a black and white photo of an ocean with a lot of dark waves and some streaks of white.

They decided to do a mammogram to find it and the clip that had been placed three weeks earlier to mark the spot.  That worked well and they felt confident they had found the right spot.  

There was a lot of whispering at the back of the room at intervals.  I wasn't as confident that they had found it, but I wasn't in any position to question things.

All were women--which was great.

After a local anesthetic they stuck a needle in the breast and injected it with blue dye that would identify the lymph node to which this part of the breast drained.  Then they inserted the wire. 

"Squeeze my hand," said Trang Le, the mammogram technician, and I did when they inserted the needle, but she was such a small person I didn't want to hurt her hand by squeezing too hard.

Soon I was swaddled like a baby and wheeled outside to a van waiting on the street where I had often pushed my mother in her wheel chair six years ago.  Ah, the changes that time brings!

I was driven around the corner and the next corner, half-circling the block, and deposited at 1223 16th Street, where I was grandly wheeled in now feeling like a queen on the red carpet.

Soon I was in the Surgical Center on the second floor.  It was about five minutes before 1 pm.  Neither John nor my friend Lee Jones, who were planning to be in the waiting room throughout the surgery, saw me enter.  Just as well. 

I changed to a new surgical gown, met the anesthesiologist--another wonderfully warm woman--who decided to do an EKG before the surgery just in case.

She said she would be giving me propyfol and a gas, as well as something to calm me before surgery.  A nurse put an IV on the back of my right hand.  

Ivar Guttierrez, who had been my wheel chair escort, was now sticking the round disks on my chest and abdomen.  We chatted and as he removed them and left, he said, "Good luck, young lady!"

I never leave that stone unturned.

"I am 66 years old," I said politely.  "I could be your grandmother."

"No, not my grandmother," he reflected.  "My mother is 66 too.  I'm 38."

I sure wasn't going into surgery being addressed like a ten-year-old. 

(Note that today Bobby Shriver, candidate for LA City Council, addressed his rival candidate Sheila Kuhn, as "young lady."  She's about 74 years old.  She let him have it.  Good for her.)

The next thing I knew I was in the same place waking up.  John was sitting there.  

A nurse was telling me that I could drink some cranberry juice and soon get dressed and go home.

I wanted to tell her, "I don't want to go anywhere.  I just want to stay in this bed."

But that was not the plan.  This was an outpatient procedure.  I found that I was wearing a surgical vest (actually a short strait jacket) to keep my sutures and all in place.  Once changed, I was wheeled out and got in John's car, waiting at the curb.

By 5 pm I was home and in bed.  

Allowed to eat for the first time since Thursday evening, I asked for French toast.  

John had to walk the dogs, go to the store for cranberry juice, watch a hockey game, and who knows that else.  The French toast appeared closed to 11 pm.  

Meanwhile I lay in bed answering the phone and calling my brother Bill.  When I told him about the problems locating the tumor to insert the wire, he said that in 5% of lumpectomies, the surgeon can't find the correct spot, and the surgery has to be redone.

He also delivered a complicated lecture on how older people often don't need to do anything about small cancers because the treatments are more dangerous than the slow-growing cancer itself.  Some people die of treatments that would have lived much longer with slow-growing cancer.

I appreciated the prayers of so many friends, and the prayers and vigil of Lee Jones.

The Big Consultation

I met at 9 am with four doctors, a coordinator, and a nurse today at the UCLA Breast Center, 1223 16th St., Suite 1000, in Santa Monica :

1)  Amy Jacobson, RN and Nurse Practictioner, who is doing a study of breast cancer patients pre-and post-surgery

2)  Parvin Peddi, Medical Oncology -- head of the team;

3)  Amy Kusske, Breast Surgeon;

4)  Charles Tseng, Plastic and Reconstructive Surgery;

5)  Susan McCloskey, Radiation Oncology;

6)  Robyn Dvorak, Breast Center Coordinator, and

John Arthur (my spouse) accompanied me.  The room was about 8' x 10'.

I sat in a white-covered examination chair as each doctor came in one by one, introduced herself, explained the procedure, and explained her role.  John sat slightly away from us, forming a triangle with us, and remained quiet during most of the hour and a half.

The doctors were each different but all very warm, engaging persons sitting face to face with me, almost nose to nose.  There was no big desk between us, no big impressive office.  The intimacy of each woman-to-woman encounter was delightful and made me feel confident in their decisions and their abilities.  I was so happy to have an all-female team (almost).

1)  Amy Jacobson, a nurse practitioner and researcher at UCLA, came in and asked if I would be willing to participate in a study of the physical and emotional health of women with first-time breast cancer shortly before and shortly after their surgery.  I said I'd be happy to participate.  

2)  Dr. Peddi was ethnically from India or Pakistan or an area near there and outlined the general plan.  She did an intake interview, which included me reporting three childbirths, 9 lb. 15 oz, followed by 9 lb. 3 oz. and 9 lb. 10 oz.  She said she had recently had her first child and compared her baby's weight.  It was a pleasure to talk woman-to-woman like this.

She reported that my cancer is invasive ductile carcinoma, the most common type of breast cancer (80% of breast cancer cases).  It's "been around for a while," is slow-growing and considered low-grade, and is estrogen-positive.   

Furthermore, breast cells depend on estrogen, and "estrogen-positive" means that the type of cancer cell I have still has its estrogen receptors, so cutting off its supply of estrogen is a way to kill off any cells that remain in the body after steps 1 and 2.

Step 1:  The tumor itself - "It's easily taken out."

Step 2:  The area around it - Radiation of the entire left breast in case any cancer cells have moved away from the main mass.  This will be done 5 days per week for about 5 minutes for 4-6 weeks.

 Step 3:  The rest of the body - Killing off any cancer cells that might have moved through the bloodstream or lymph system to the right breast or anywhere else in the body by taking one tablet per day of an aromatose inhibitor (Arimidex) for five years.  The aromatose inhibitors block formation of estrogen from hormones produced in the adrenal glands.  In post-menopausal women, these drugs cause a 99% reduction in estrogen.  They are more effective than Tamoxifen (a selective estrogen reception modulator) with fewer side effects.

3) Dr. Kusske was Caucasian with chin-length brown hair, maybe 50 years old.  I liked her as much as Dr. Peddi--nice to be looking into her light brown eyes.    

She explained that I would have a wire inserted before the surgery to specify the location of the tumor.  In addition to removing the tumor (7 mm x 4 mm x 5 mm), she would be sampling 1-3 lymph nodes.  If there is no invasion into the sentinel lymph node, that would mean that probably there are "no little tumor cells floating in the lymphatics in the breast tissue."  

She seemed very experienced and competent; I felt I was in good hands.

4)  Dr. Tseng, the plastic surgeon, was next.  He talked about "breast conservation therapy," "restoring shape after lumpectomy," "deformity," "improving the symmetry and shape of the breasts," and "rearranging tissue," which would only leave a "scar around the nipple and bottom of the breast."

I listened to him politely, but no way am I going to have any of this done.  John watched me as I listened to Dr. Tseng and knew exactly what I was thinking.   

5)  Dr. McCloskey will be in charge of my radiation.  She was much younger with blonde straight hair elegantly coiffed and with a Southern accent.  She said that during their preliminary conference before talking with me, the doctors had noted how I had "interestingly" and "fortuitously" chosen to have the ultrasound screening when receiving the letter with that option after my mammogram report was "normal" but with dense breast tissue.

Radiation is needed because there could be "small sub-centimeter tumors" remaining in the left breast after the lumpectomy.  "The lumpectomy with radiation has been shown to have absolute equivalence with mastectomy in six randomized trials with thirty years of follow-up," she said.

The full mastectomy is a risk-reducing decision, but she compared other risk factors:

• 10% of the general population of women will develop breast cancer over their lifetime.
• 10-15% of women treated for breast cancer will have a recurrence.
• 25-30% of women with breast cancer will have a recurrence if they don't have radiation.
• Under 10%--even as low as 2%--will have a recurrence if they have radiation.

She earnestly explained the radiation and its side effects.  The breast may have redness, like with a sunburn, and some change in texture.  There will be some tiredness and some weakening of the immune system.  They try to avoid exposing the left lung and heart to radiation, but they will receive some.  

All this begins in the fourth week after the surgery.  I asked her if I could have some of it done in Colorado, where I like to spend my summers, but she explained that you get measured and tattooed to hit the right spot using a particular radiation machine, and changing to another machine could affect the accuracy of the treatments.

Oh well-- half of June and all of July in busy Los Angeles instead of the mountains.  I should be able to live with that for one summer of my life.

6) Robyn Dvorak then worked with the doctors to determine the date of my surgery.  They had told me that it could be scheduled for Tuesday, May 20, at the earliest, but I explained that I would like to be in Colorado over Memorial Day weekend.  

"Can I leave by Thursday?" I asked.  "If my husband does the driving?"  Dr. Kusske said okay, but I needed to have my post-operative exam about a week after the surgery.  

I said that I had hoped to stay in Colorado for a week or two and just return for the radiation.

After some consultation with Robyn, suddenly I was offered Friday, May 16, instead.

Hooray!  My post-op will be Wednesday, May 21, and I will be alllowed to drive to Colorado after the appointment.  Without John... (with two dogs--well, I didn't mention the dogs).

I will get there in time for Telluride's Mountainfilm Fest, and a couple of friends are planning to stay at my house there.  Also I will visit my brother Bill, who will be in town that weekend.  I will stay another two weeks and report back for radiation at 4-5 weeks after surgery.

I am so grateful to be given this earlier date.  All the rest of what I heard doesn't bother me--well, the information about recurrence was big news.  

I'd been thinking that doing surgery, radiation, and either chemo or Tamoxifen/Arimidex would pretty well wipe out stage 1 cancer.  The statistics about recurrence mean my chances of recurrence will be somewhere under 10%. 

Hmmm.  Good, but still 1 in ten.