Wednesday, March 20, 2013

Rare medical update

I have never liked discussing my diagnosis, and have spent as little time as possible contemplating it, as doing so has generated a fair amount of anxiety.  As the chemo fog has begun to lift, I have realized it is time to ask Dr. Raish some direct questions about all of it, come out from under the veil of deliberate naivete.  The reason for my squeamishness has been a number, and that number is 3.  The stage of my cancer at diagnosis was 3a, which is determined by tumor size and lymph involvement.  Specifically my cancer was T3N1 - tumor 3 and node 1.  For me the difference between a 2b and a 3a was 1.6 cm of tumor length.  I learned today in speaking with Dr. Raish that while with many other cancers these staging numbers mean more dire things, especially that pesky number 3, with breast cancer the staging is no longer the driver in treatment or prognosis unless it is metastatic (mine was not).  While a stage 3 lung cancer or melanoma is pretty dire, with breast cancer the biology and other things drive outcome to a greater degree.  The biology includes whether the cancer is hormone receptor positive or negative (mine is estrogen receptor positive) and whether it is HER2 positive (mine is).

So... I asked Dr. Raish a bunch of questions and here are the answers, as best I can remember them.  

My current status, which I have not known what to say about to people brave enough to ask, is cancer free.  While no scan can see a single cancerous cell, as far as what the doctors know about me, I am cancer free.  The term cured is not used until at least five years have passed without recurrence.  I asked him about what I saw as frighteningly small numbers on the pathology report describing the size of the margins.  Dr. Raish (Mr. Data and Statistics, I love this about him) said that with margins it is a yes or no prospect.  Either the margins are clear or they are not, the distance is irrelevant.  So, my margins were clear.  This may have been due in part to the neoadjuvant chemotherapy I had, which is a fancy way of saying chemo before surgery.  He and Dr. Garreau both said that more and more in cases where it is known that chemo will be necessary (for example a positive lymph node biopsy, like I had) the neoadjuvant option is becoming the norm.  The advantage is the likelihood of a better surgical outcome, like clearer margins.  Also, doctors can establish how effective the chemo is in treating the cancer.  With mastectomy first it is not known, unless there are tumors elsewhere, to what degree the chemo is killing the cancer.  An aside, as a patient, the neoadjuvant chemo was both good and difficult.  Good, because it was the worst part, and I got it done.  Difficult because mentally carrying the cancer around with me for five months rather than have it cut out right away was challenging, given that the definitive information about whether it was working would not come until the surgical pathology was done.  In my case the chemo worked very well and much of the cancer was gone by the time of surgery.  

The anti-estrogen therapy I will have for five and perhaps ten years cuts my risk of recurrence by about 45%, Dr. Raish and his computer brain told me.  Herceptin further reduces the risk of recurrence.  (While HER2 positive cancer is a more aggressive cancer, the development of Herceptin, a targeted therapy, has been a miraculous game changer for those with the HER2 marker.)  My lifestyle, which includes a healthy diet and plenty of exercise, further reduces the risk of recurrence (though this is shady to me, as it doesn't then make much sense that I got cancer in the first place!).  

When Jon and I first looked at a breast cancer brochure it said, in very simplistic terms, that for stage 1 9 in 10 women are alive in ten years, with stage 2 it was 8 in 10, and for stage 3 it was 7 in 10.  This was not fun for me to read or to contemplate so I solved that conundrum by doing the denial thing.  Today my goal was to have Dr. Raish tell me directly what my chances are, what numbers apply and what tweaks them in one direction or another.  I did ask for a number, and after going over all the above analysis with me he said my risk of recurrence is about 10%.  Which made me happy, very, very happy.  I am glad to understand the limits of staging in the case of my cancer, and the other factors and data that matter.  I am glad I have this computer-for-a-brain oncologist who can pretty much cite the specifics of three or four relevant studies in response to any question I might ask.  

So...  cancer free and 10%.  A pretty good visit with the doctor.

1 comment:

  1. What a terrific description of your visit to an MD who sounds amazing!

    What a relief. Thank you for writing about it.