Tuesday, December 13, 2011

If You Can Hear Me, Stand on Your Head and Move Your Legs in a Graceful Undulating Motion

Today it was off to meet with radiation oncologist Dr. L., who proved to be the chairman of that department. Radiation oncology is the only thing located in the basement of the building, so when you push the down button for the elevator, everyone knows you have cancer and you feel a little gloomy.

Dr. L. was really great, as patient as could be, not one bit frightened by my clipboard and reportorial air. He explained something I hadn’t yet grasped in all this talk of stages and grades: the fastest-growing DCIS grows more slowly than the slowest-growing invasive cancer. That is, on a continuum, you've got DCIS Grade 1, then 2, then 3, then invasive cancer Grade 1, then 2, etc.

As previously mentioned, the lower the grade, the more normal the cell, but there is actually something good about high-grade DCIS: while it’s more likely to become invasive cancer (that’s not the good part), it tends to grow in a continuous pattern within the duct and be localized within the breast, so it can be the easiest to contain.

You’d be surprised how many people with DCIS immediately opt for a double mastectomy. I was scratching my head over this at first, but now understand there are several good reasons for it: a person might want to avoid radiation, or might have such a large area of DCIS that a lumpectomy is not feasible, or might have a strong family history of breast cancer, and/or might feel anything is worth it to have the lowest possible risk of recurrence. I suspect it also depends on what doctor or hospital you visit, or what area of the country you live in.

No one has mentioned anything other than lumpectomy in my case. As for radiation, my choices until recently would have been treatment once a day for five or six weeks, or a shortened course of radiation twice a day for one week, but with the new thing, intraoperative radiation therapy (IORT), there is just one dose of radiation and it is applied at the time of surgery. This has not been explicitly studied with DCIS, but it has been proven to be as effective as either of the other two options when it comes to early stage breast cancer; e.g., Stage 1.

Normally radiation treatment doesn’t start until after the lumpectomy incision has healed up, which can potentially give lingering cancer cells a chance to start growing again, which can’t happen with IORT. That is, it avoids “temporal miss.” Also, with IORT, they can be sure they’re aiming the radiation at the exact right spot: no “geographic miss.” I went to breastcancer.org to read up on IORT and read that another benefit is the “richly vascularized” treatment bed, which means “they’ll be putting the radiation right into a bleeding hole.”

Like Surgeon Number Two, Dr. L. considers DCIS to be pre-cancer, which on one hand is comforting, but on the other, if I have to schlep all over town interviewing surgeons and radiation oncologists, have surgery, be treated with radiation, and potentially take tamoxifen for five years—if I have to have a Tour of Cancerland—I'd kind of just as soon it would be called cancer. Also, what does this mean for the seemliness of going around referring to myself as a “survivor” later?

Dr. L. put my chance of recurrence after lumpectomy and IORT at 1.7%, though I’m starting to realize something about this thicket of numbers: they are meaningless without knowing what time period is referred to. Also, they’re probably kind of meaningless, period, as no two situations are identical, but I will try to remember to inquire about the time period from now on, anyway.

In sum, I am going to have a lumpectomy and IORT next week with Surgeon Number Three and Radiation Oncologist Number One. Dr. P., my surgeon, says that right after he does the lumpectomy, they will X-ray to make sure the margin appears to be sufficient, so he can take out more tissue right on the spot, if necessary.

A nurse telephoned to do pre-registration for the surgery and asked who should make medical decisions for me if I become unable to do so. I gave her my sister’s name and sent my sister an email letting her know that, generally speaking, I’m in favor of continuing to live, but if I’m a vegetable with very little hope of regaining consciousness, then they should take me off life support, and if I’m breathing but non-responsive, I might be like that guy in that movie who was fully alert but paralyzed—one of my worst fears—so she should make sure to have them try the “blink your eye once for yes, twice for no” thing before they pull the plug.
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