No Further Treatment

… maybe.

I met with my medical oncologist, Dr. Jeske, yesterday afternoon.  Earl recorded our conversation so that I could concentrate on comprehension rather than on note taking.  She first went through the pathology report with us and then proceeded to a physical examination.

Dr. Jeske was very happy with the pathology report because of the negative nodes and the “microscopic” size of the invasive tumor.  She told us that when she first met us at the breast cancer clinic (see Time to Meet My Oncology Team) well before my surgery, experience led her to guess that not only would they find invasive cancer within my extensive DCIS, but that it would be on the order of T1b or T1c (0.5cm – 2cm) or even much bigger or in the nodes.  She admitted to being a pessimist, which is key to remember for the following.

Dr Jeske:

“It’s true [that your cancer is Her2+], but I’m not sure there’s a lot we can do a lot about it.  The cancer is so small, that the risk of recurrence is incredibly low, and so then you start to weigh risks and benefits, and the risks of treatments against the benefits of treatments.”

“When the recurrence rate is as low as this kind of a cancer’s recurrence rate is, which is probably on the order of 10%, then the benefits of treatments like chemotherapy and Herceptin start to become minimal.  And the risks, of course, are real.  These treatments all have side effects, all have toxicities.  And so there is no real meaningful expectation that there would be enough benefit from treatment to undertake it.”

“We are left with sort of an uncomfortable position ’cause we’d love to have something we could do.  We’d love to use some hormonal therapy, we’d love to use something … But the reality is your cancer is too good to use any treatment because the benefits of the treatment really don’t outweigh the risks of the treatment.”

“Now you’ve done a mastectomy on this side.  So you’ve dramatically lowered your chance of this cancer ever coming back on this side, by nearly 100%. There is no such thing as 100% in medicine, but nearly 100%.  The other side though is a real risk.  That’s where your age really plays in.  You know, the reality is we do have to watch that other side very closely over time ..”.

“If you were going to recur and we were playing the odds, where are you going to recur.  By your path report, the most likely place for you to recur at this point is with a noninvasive cancer under that [superficial/skin] margin.  That we’re going to take care of.  I mean, I’m not comfortable with that just being the way it is right now.  We either have to radiate it or we have to, which I think is reasonable, just take it out with the reconstruction.  And then it’ll be gone, too.  And there may be nothing in there.  They may take it out and find no cancerous cells, which is a very common phenomenon.  Especially because when you have cancer right at the margin, even for a positive margin, and you cut there, the inflammatory response of the healing process can often eliminate any residual cancer.  So it’s very possible that when they do the reconstruction we won’t find anything …”

“That [mastectomy site] is probably, as we’re looking at that path report, your bigger chance of recurrence risk [which] would be a local recurrence, rather than a systemic recurrence.  There isn’t anything thankfully [in the path report] to suggest that a systemic recurrence is likely.”

So there you have it.  She encouraged my seeking a 2nd oncology opinion if I wanted, and at my request she also sent in a request for another pathologist to look at all of my samples (not just the invasive portion – there were two pathologists looking at that).  I have set up not one but two additional appointments for the second week of July.  One is with another Kaiser oncologist in Walnut Creek, at the other large Kaiser breast cancer center in Northern California (besides Santa Clara).  The second appointment is with a medical oncologist at UCSF whose research specialty is actually Her2+ breast cancer, Mark Moasser [a].

Dr. Jeske said my overall risk of recurrence is in the single digits, citing a recent Kaiser Permanente study [1].  Remember that she is a pessimist but still recommends no chemo, no radiation, nothing (aside from removing some extra skin during the reconstruction).  So that makes me feel better about taking no additional action.  However, I will be analyzing data from the Kaiser and other studies to further evaluate my risk in the next week or two before gathering recommendations from the other oncologists and then making a more educated decision about future treatment.

BTW, Dr. Jeske said that the incision area looks fantastic, and that I am “well above the curve” in healing.  She said that whatever I have been doing is working and to keep it up.  (This includes my self-mandated 5-6 mile a day walk.)

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