The Journey Now: Part 4

Pathology and Numbers

After the shock of the incision burst, I began to recover.  I got a copy of my pathology report as my stitches healed. There are so many more dimensions to the process of staging breast cancer now:

 Diagnosis:

• Invasive Ductal Carcinoma, moderately differentiated (It's been upgraded! Lucky me!) Margins negative (they got it all.)
• Foci of Ductal carcinoma in situ, intermediate grade. Margins negative.

• Largest tumor size: 1.8cm (Ok, that's a lot bigger than the September ultrasound.)
• Histologic grade: Score 3 -- Less than 10% of the tumor is forming fingers to invade with (that's good.)
• Nuclear pleomorphism: Score 2.  It looks just like cancer cells look.
• Mitotic Rate: Score 2  How fast cells are dividing -- this is good.
• Total Nottingham score:  G2, Moderately differentiated.  I WIN 6 to 7 POINTS!!!

It appears there is only the one tumor, still in situ (meaning in site, in a single organ like a duct). There is no invasion of my lymph nodes that they can see.  

• ER (Estrogen Receptor) Positive -- 100%
• PR (Progesterone Receptor) Positive -- 1%

Both of these mean that hormonal treatments like Tamoxifen are likely to work. 

HER2: equivocal or negative (depending which report you read) 

TMN descriptors (short hand for the doctors to describe and stage the tumor):  pT1c: the tumor is stage I due to size, but a moderate grade based on the total tumor score.  Category pNX: there were no nodes because they were no longer there) and not metastatic from what they could see. The tumor is very similar and very close to the original (right next to the marker my surgeon left.) It is recurrent.

It looks like we caught it early.  If this had been the 90s, I might have been placed on a hormonal treatment like Tamoxifen and we'd be done. But there's a new test in town, pardner!

My surgeon's office belatedly sent samples of the tumor off for the latest in cancer diagnoses:  Oncotyping.  Essentially, a lab looks at the genes, and determines how aggressive they are by how much  Ribonucleic acid (RNA) they express. The genes are rated on a score of 0 to 100.  The oncologists (cancer docs) use this rule of thumb:

This made an impression.

• Under 18, no chemo necessary.
• 18 to 26, maybe.
• Above 26...oh, yeah. You need chemo.

I waited for two weeks to get my score, and when I learned, I was devastated:  34.  

My 10 year risk of recurrence on Tamoxifen alone was 23%.  Almost one in four. Too high!  With chemo, it drops to 6 or 7%.  

This is a good time for me to talk about how I feel about chemo.  I HATE CHEMO!!!  There, I said it.  I thought it would kill me the first time around, and as I got smug about recurrence, I allowed the thought to creep into my head that I would never, ever agree to chemo again.  It had been sooo devastating! Confronted with those numbers, I changed my mind.  I still have lots to do. Chemo it is. 

Absolute Benefit of Chemo on recurrence after 10 years.
Note the big difference in the solid (Tamoxifen)
vs. dotted (Chemo + Tamoxifen) line.

My oncologist told me this is going to be a bit more difficult, but for a shorter time: just 12 weeks, with chemo administered once every three:  A dose of Cytoxan (which was the "C" in the CMF chemo I had had years ago) and something newer: Taxotere, a cytotoxic drug made from the Yew tree.  

"Twelve weeks? Ok. Will I be able to work? I did the last time."
"No. This is more aggressive. I don't want you trying to work"  Hubby silently signs "yes!" He doesn't want me to be heroic.
"Will I lose my hair?"
"Everyone is different, but almost certainly." 

Great.  No hiding my cancer now. For the first time, people will know I am locked in a cancer battle. I have, up to this point, told very few my story.  Now, that's all gone. I would have to go on disability, and anyone who saw me would know. Including my daughter! She was little the first time around; I don't really want her to see me sick.

"I have plans to see my daughter in Texas after Christmas. Can I wait until after the holidays?"   

"No, not really. We can't wait that long, but you should be able to travel between chemos. You may not feel well, but you can travel." 

Next, we had to confront the possibility of metastasis.  Although the pathology report suggested everything was ok, I had actually had a phantom pain in my back/side/under ribs for weeks. It could be quite bothersome. My doctor sent me in for an ultrasound.

Cancer scare time:  
1. 10 mm echogenic lesion in the right hepatic lobe (MY LIVER!) is incompletely characterized. Although findings may relate to a hepatic hemangioma,given history of breast carcinoma malignancy is not excluded. Further evaluation with dedicated liver CT or MRI is recommended.
2. Multiple nonshadowing echogenic foci adherent to the gallbladder wall are suspicious of gallbladder polyps measuring up to 5 mm. A six-month followup exam is recommended to reassess.

AAAHHHHH! Any finding of cancer instantly puts me in Stage IV. Metastatic cancer is a whole new world. Next up, a PET Scan: 
Impression:1. No mass within the liver. The findings seen on ultrasound likely correspond to the small amount of diaphragmatic fat intimately associated along the posterior aspect of the liver.
Gallbladder and everything else looks good. Ok, back on the shelf, you little bugger. I am, officially, pM0 (no metastasis.)

Round 1 seemed to go well. I handled chemo with most of the usual and familiar side effects. It wasn't until day 17 that I had a problem.  It started with itchy palms on my way back home from Texas. Because I had had a seafood dinner in Louisiana, I thought I might have developed a sudden food allergy.  

But the next day, in the RV, I awoke covered in hives. By that afternoon, I knew I needed to see a doctor. We found a great ER in Decatur, GA. They got me loaded up on steroids and antihistamines, but they only lasted a few hours. We stopped again when my face and tongue began to swell, but the doctor in Tennessee didn't have anything more to offer than an epipen, just in case. Thank God we were in the RV where I could just lay back and try not to itch. Poor Brian, he had to put pedal to the metal. The next night we arrived home, but we were exhausted. I decided I would go to the ER the next day, if I was no better.  And I was definitely no better.  

I saw an allergist that afternoon.  She consulted with my oncologist.  They called it, no doubt about it: I was allergic to the chemo! 

Kudos to the allergist: there is a really powerful antihistamine, and I began to get better. But what would happen with my chemo?  My oncologist had an answer.

There is a version of Taxotere that is much easier on the system. It's called Abraxane.  It's the same cytotoxic drug, but instead of being dissolved in a solvent (which was the source of my allergy) it is dissolved in albumin...egg white protien.  It's given every week, however. Some believe it is more efficacious, both because it is given more frequently in smaller doses, but also because it "sticks" to cells better in the albumin.

Why didn't I get this all along?  One word: insurance.

I am heading for Round 3a this week. (The Cytoxan is still given every third week, so four total rounds are still anticipated.) I do tolerate the Abraxane better, but I do have side effects. More on those, next post.

Tell me about your journey in the comments, or on Twitter, Facebook or Inspire.com.