May 4th: Time to Meet my Oncology Team

Kaiser Permanente is a well-oiled health care machine.  At that same phone call letting me know my biopsy result, I was scheduled for a breast cancer class and private consultation with my entire oncological team the following week.  I wouldn’t have to go searching piecemeal for surgical, chemo, and radiation expertise and if I wanted someone different from my assigned team, I could choose from other physicians.

On May 4th, Earl and I headed to our appointment.  Upon check-in I received a thick folder replete with information about breast cancer from diagnosis to surgery, recovery, adjuvant treatment, and beyond, as well as my complete pathological report for my biopsy.  We were then shepherded into a meeting room along with 2 other patients and their respective partner/friends/families.  As a group we all viewed an instructional video about breast cancer and then were introduced to representatives from the different departments where we would be receiving care.  Simultaneously, our medical team was meeting in a different room discussing our case histories and planning our treatments.  After the video we were separately guided to examination rooms to meet with our physicians.

My radiation oncologist, Dr. Seaward, was the first to arrive.  She quickly stated that I would likely not need radiation.  Due to the large size of the DCIS in comparison with the size of my breast, a lumpectomy with radiation would not be advisable.  A partial mastectomy would be possible but with poor cosmetic result.  So mastectomy would be the recommended treatment with radiation appropriate only if invasive disease or an affected lymph node was detected.

After Dr. Seaward left my medical oncologist Dr. Jeske visited.  My stress level rocketed while she explained that my high nuclear grade paired with the “extensive” calcification area viewed on the mammogram was “worrisome.”  This could indicate an invasive element lurking in the suspect 5 cm area.  Also, because of my young age (<50) paired with my mother’s ovarian cancer history (coming up on 5 years of survivorship now), she recommended genetic testing for BRCA 1 and 2.  She also suggested that I have an MRI of both breasts done to make sure there was nothing going on in the left breast.  Lastly, Tamoxifen would not be an option to help prevent recurrence because my pathology report said the cancer is estrogen and progesterone receptor negative.

The last to visit us for the afternoon was Dr. Kavanagh, my surgeon.  She calmed my nerves somewhat, saying that an affected area measuring 5 cm would not be unusual for DCIS and the estimated oblong shape was consistent with ductal travel.  However, the area size in combination with my young age (again, <50) did make her suspicious of invasion, and she said that she would be performing a Sentinel Lymph Node (SLN) biopsy during my mastectomy.  In an SLN, the cancerous area is injected with a radioactive substance or dye;  the lymph nodes first detected with those substances are removed and promptly checked by a pathologist. If my first lymph nodes are clear (no cancer), that is very good news.  If not, they’ll have to remove several more lymph nodes and that changes my post-operative treatment and prognosis.

She sized up my situation roughly as follows:
50% probability – pure DCIS (noninvasive, Stage 0)
40% probability – DCIS with microinvasions (invasive cancer) present
10% probability – DCIS with tumor(s) >1 mm involved, Stage ???

Interestingly, Dr. Kavanagh said that  it can take 9 years for one mutated cell to turn into a 1 cm lesion.  This cancer has been in my body for a long time.

It had been a long, emotionally volatile afternoon but we were not yet finished.  It was time to go home and tell the kids.

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