Pink Lotus - My Treatment Options

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Now that I understand my pathology, I'm starting to be able to understand my treatment options. 

  • Both Dr. Giuliano and Dr. Miller said that neo-adjuvant (pre-surgery) chemotherapy with antibodies is necessary. Dr. Miller explained that the chemo will shrink the tumors, so much so that they'll probably be completely gone by the time I have surgery, which is what they call a pathologically complete response. However, both doctors said that chemo without surgery is not an option - the rate of recurrence is just too high. Dr. Miller said that I would probably need six cycles of chemo (once every two weeks).

  • Once the neo-adjuvant chemo is done, I'll need some time to recuperate and get my white blood cell count back up - possibly four to six weeks. Then I'll have surgery.

  • I have three surgical options: lumpectomy, single mastectomy, and double mastectomy. I went into my appointment with Dr. Miller thinking that I wanted to have a lumpectomy if possible, it being the least radical of the three options. However, in talking with her I began to understand that it may not be the best option for me. Overall survival is expected to be the same regardless of which surgical option is taken, so that's not a consideration. However, my life after the surgery could be quite different depending on which way I choose to go. These are the considerations, as I understand them:

    • All breast cancer patients have the risk of recurrence, and I am at a higher risk because my cancer is multifocal (more than one tumor) and because I am under 40 (there is a good chance that I could develop breast cancer again in my lifetime because I have such a long lifetime ahead of me - or that's the hope, anyway). The more breast tissue that I try to preserve now, the higher the risk of recurrence. Therefore, with a lumpectomy, the post-treatment monitoring of my breasts will be much more intense than with a mastectomy. I would need frequent mammograms and anything suspicious would need to be biopsied immediately. Many women find living with this hanging over their heads extremely stressful and anxiety-producing.
    • With a lumpectomy, postoperative radiation will be required for at least six and a half weeks, five days a week. Radiation might be required with a mastectomy, but Dr. Miller thought in my case it was unlikely.
    • A lumpectomy would probably be the least successful from a cosmetic standpoint, as the area of breast tissue that would need to be removed is quite large (about 7 cm). Double mastectomy would probably be the most cosmetically successful.
    • If I test positive for the BRCA mutation, the risk that I will develop cancer in my other breast is 60-70%. In this case, double mastectomy would be highly recommended.
  • After I recover from surgery, I will resume chemotherapy for the remainder of the year (one year from my first neo-adjuvant treatment).
  • For ten years after my treatment, I will receive hormone therapy (tamoxifen) to prevent recurrence.

Both doctors were in complete agreement about chemotherapy, antibodies, surgery, and hormone therapy as necessary to save my life. For better or worse, the only aspect of my treatment about which I really have any choice is which surgery, and I don't have to make that decision until well into chemotherapy (Dr. Miller said that her patients usually decide around the third cycle).

The next step forward in my treatment is to meet with the medical oncologist, Dr. Hurvitz (I didn't even understand before that I would need two oncologists, surgical and medical - and a third if I have radiation). I have an appointment with her on September 8, which is not ideal - we really want to see her this week and to start chemo as soon as possible. Seth and I both have a great sense of urgency because we've come to understand how aggressive this disease is, so on Tuesday, we're going to start making calls to see if we can get in sooner. But there is a lot to do this week, including a PET scan and a brain MRI on Thursday. The PET scan is used to detect unusual cell activity throughout my body, which would indicate cancer in other locations. The brain MRI is to check specifically for metastases in my brain (HER2 positivity is increasingly recognized as a risk factor for brain cancer). Dr. Giuliano said that he expected both tests to come back clean, but they need to establish a baseline for monitoring my health in the future.

It's starting to sink in now, that this is really happening, and I'm starting to think more about how to marshal my strength so that I can get through this long, hard war.

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