November 1 - The Final Demise of the Cancer

I had an appointment with Dr. H's office last Thursday, and we were able to schedule my surgery for Wednesday, November 1 which is exactly four weeks from my last chemo treatment on October 4. - two dates worth celebrating!

I saw Anna, the nurse practicioner first, and she seemed very encouraged after feeling the tumor. She announced that I have definitely had a response. It is still obviously there, but it feels different and smaller, and she too, said that it is hard to determine what may be dead tissue or inflammation and what may still be viable tumor. I envision it to be all dead. I told her that it has been hurting near the site of the tumor and under my right arm and asked her what that meant. She said that she didn't know but said the dying tissue may be causing the pain. Good. That is what I have been telling myself.

One reason for neo-adjuvant chemotherapy (chemo before surgery) is for prognostic purposes. Women who experience a partial or complete response, are more likely to have a better long-term outcome. A complete response (when the tumor becomes undetectable) is better than a partial response, but any response is a good thing. As Anna pointed out, if the chemo is reducing the size of a fairly large tumor, imagine what it is doing to any microscopic cells that may have settled elsewhere in my body. "Besides", she said, "You will have a CR (complete response) on November 1."

Then Dr. H arrived. He also did a physical exam. He very solemnly said that he recommended a mastectomy due to the size of the original tumor (large) and the size of my breast (small.) His rationale for that recommendation was communicated in a slightly more professional and technical manner, but I just condensed it down to the basics. I told him that he didn't have to try to talk me into a mastectomy because that had been my position from the moment I learned I had cancer. "In fact," I announced, "I want both removed."

Upon hearing this news, he exchanged glances with Anna, and actually pulled her in for reinforcement. "Well, Anna will tell you that the women we see who have bilateral mastectomies have a very difficult time." I asked, "Physically or emotionally?" The response from Dr. H was "Both."

I thought about that for a couple of seconds and then said, "Personally, I think I will do better emotionally if both are removed. Obviously early detection doesn't work really work very well for me." Dr. H said that we would use MRIs to monitor the left side. Hmmm... I tried to envision my future under this proposal, and what I saw were deafening semi-annual dates with the big claustrophobic-inducing metal tube. That isn't even the bad part. What I would really mind is having to return to the biopsy table for the inevitable false positives (or not) and the agony of waiting. Talk about emotionally difficult! I reminded him of the recent study that concluded that 40% of breast cancer patients with a family history of breast cancer develop cancer in the other breast. He said he thought that number was a little high.

I told him if I have both removed I never have to worry about back trouble as a result of being unbalanced. Anna appreciated my positive take on the matter, but Dr. H didn't seem amused. Regardless, I know what I want. I mean, think about it. What good is one going to do me anyway? It is not like I can wear low cut, revealing clothing after the right one is removed (not that I ever did.) My days of nursing infants are over. And Bo is a self-professed derriere man. Leaving one gains me nothing, but having a bilateral mastectomy delivers some peace of mind. I cannot eliminate the possibility of a distant metastatic recurrence in my future, but I can eliminate the possibility of ever developing the same or different type of breast cancer in the unaffected breast by removing it. As far as I am concerned, it's a no-brainer.

I was actually surprised that I wanted a more aggressive approach than he did, but I think his position was to hold off on putting myself through a double mastectomy until we have a pretty good idea that the cancer has not mestasticized elsewhere in my body. Generally, the risk for that is highest in the first 18 months following the initial cancer. How utterly depressing - I just don't think that way.

I received an equally uplifting response when I asked him if he could remove the portacath (used for administration of the chemo) out of my chest at the same time he performed my surgery. He said he could but said that some patients liked to keep it in for awhile in case they needed it again. I looked straight into his eyes and told him that I wasn't going to need it again - ever.

From there, I moved onto the topic of reconstruction, and the conversation didn't get any better. This whole reconstruction thing is still kind of confusing to me, but I will try to explain. I had met with Dr. B, the plastic surgeon, a week earlier. Sure enough, I don't have enough abdominal tissue to do the flap surgery (which uses abdominal muscle, fat, and skin to replace the breast). That seemed to leave implants as my only viable option, but implants require tissue expanders at the time of the mastectomy. This enables the skin to stretch enough for the implants to be inserted later. Since radiated skin won't expand, Dr. B said I would need to postpone radiation for four months until the skin is sufficiently stretched and the implants are ... well, implanted. Dr. B actually discussed this option with Dr. G, the radiologist and Dr. P, my oncologist, and both of them felt the delay wouldn't have any effects on my longterm health. I relayed all of this to Dr. H who said that was an unacceptable option because the radiation damages the implants.

He also did a physical exam and asked me if I had been experiencing any back pain or headaches (signs of mestastacized cancer, I assume), and I said "no." (Reflecting on that question later in the context of the whole visit, my masochistic mind started wondering why he asked that question. Did he know something I didn't? Are there other signs it may have spread? I told my overactive imagination to get a grip, and then I just reminded myself again as I often do that the odds are in my favor for beating this cancer and never having a recurrence. It would be nice to hear him say that though.)

So other than finally getting a date on the calendar for surgery (which my still very structured, anal-retentive self had been long awaiting so I could plan my life accordingly), I left his office feeling incredibly deflated about the entire visit. (I am getting depressed all over again just writing about it!) Even Bo said that he didn't have a very good feeling about things after the visit, so when we left, we went and ate - lunch. Food - the universal anti-depressant! There isn't much a good dose of salsa won't help.

When I returned home, I called Dr. B and told him about the conversation with Dr. H. Dr. B said, "Well, I told you that it wasn't an ideal option, but it's about the only one we have. It is true that radiation damages implants about 50% of the time, but that means 50% of the time, it doesn't damage them. It can be fixed. Of course, there is a more complex form of flap surgery that you may be a candidate for, but no one in the area performs it, so you would need to be referred out for it." He offered to call Dr. H and discuss my situation with him, and I accepted his offer, but I haven't heard back from Dr. B yet.

While I had been on the fence about reconstruction, I was actually leaning towards it after my initial consultation with Dr. B. I got especially excited when I asked him if I could pick the size and he said, "Yes." Then he paused and said, "Well, with some limitations of course, but I could give you a pretty good C cup." I am going to do a little more research before ruling out reconstruction, but I think I will be okay if that popular schoolyard expression "Flat as a board" is used to describe me, as long as it is accompanied by the adjective "HEALTHY".