Tuesday, March 8, 2016

Something bright for your day

We drove back from Charlotte Sunday night. We took off Monday from work because we had an appointment with my OB and then with the breast surgeon. Kevin's mom Debbie came with us to both appointments, which was particularly nice since she went through so much of this process with a close relative a couple of years ago. Despite being worked in and triple-booked, we had just a short wait to see Dr. Khouzami. His nurse didn't know what was going on, so when she saw me on an off week, she was confused, then stunned. I got the full treatment at my appointment: pee in a cup, measure my uterus, listen to the heartbeat. Debbie got to hear the baby's heartbeat, which was a perk I hadn't planned on but found exciting. So did she.

Then we went into Dr. K's office to talk about what was going on and what we might expect. Thanks to help from friends who have been on the cancer boat, I had a long and pretty thorough list of questions prepared. (side note: always write down questions for doctors, especially for complicated appointments. It's something I've been doing for a while anyway, but I spent a lot more time on questions for these appointments. I keep a running list on my phone using the Notes app, and it's really helpful. I'd forget half the stuff I wanted to ask about if I didn't do it.)

Gestational breast cancer isn't common, but Dr. K has seen a handful of women with it over his career. He's also treated a number of patients who became pregnant sometime after fighting cancer. The first thing he said, and the first thing I have heard from nearly every provider I've seen, is that the baby is going to be fine. Dr. K had a copy of my pathology report, which he gave to me before I left, even though it didn't mean much of anything to me. He said I'd definitely need chemotherapy, surgery, and radiation; the radiation would come after the baby is born, since that would harm the baby. Chemo, he reminded me, is remarkably safe to use during pregnancy after the first trimester, since the particles (?) are too large to pass through the placenta. Surgery is also safe.

As for timing, he wanted to plan to deliver Baby Brotzman around 36 weeks, at the end of May/beginning of June and just 13 weeks away. Because chemo attacks all fast-growing cells, it also destroys white blood cells, so I would need to stop chemo between three and four weeks before delivery so that my body could recover and be ready for birth without the risk of complications from infection.

Then he told us about the surgeon. First, he said, she is excellent, one of the best and he always recommends her. Second, you should know that she is hard for some people to take. She has a bit of a foul mouth. Laughing, I said we'd get along just fine and I liked her already. He was pretty amused.

So we made our way through the hospital to the breast center. I completed the paperwork for the office and gave my mom a quick call to update her; we were still talking when we were called back to the exam room. We met first with the nurse practitioner, Angela, who gave us an idea what to expect for the appointment and then did a brief physical exam. (By the end of the day I'd remark that it felt like more people had seen my boobs in the past week than in my entire life. It was a little disconcerting...and it was only the beginning.) Angela told us Dr. Schnaper would explain everything to us and said that Dr. S would even take notes so that I could just listen and take it in. She said the doctor would be fine with us recording as long as we asked.

Dr. S came in a couple minutes later. She did another exam, feeling the lump and checking for any others. She thanked us for asking if we could record and then pulled up my ultrasound films. She was incredibly thorough, explaining what she could see in the images and what they meant. She was good at it--the blobs and shadows started making more sense to me, and I felt like I could even see some of what she was talking about. She left me to get dressed again, and we met in her office a minute later.
Sitting at a round table, she pulled out some note paper and the pathology report, and began explaining what she knew about my cancer and how we were going to address it.

She started with the different ways cancer is classified and how those classifications determine how it's treated. My tumor is an invasive ductal carcinoma, more specifically known as Triple Negative Breast Cancer. That means it does not have receptors for the Estrogen or Progesterone hormones, nor for the HER-2/neu factor. Typically, she said, it's less good if a tumor is ER-/PR- as it eliminates hormone therapy as a treatment option. However, since I'm pregnant and my hormones are going crazy, it's probably quite a good thing. A HER2- status is good; as I understand it, it plays a role in the aggressiveness of the tumor. The cell differentiation is high, which is less good. It means that, despite the HER2- status, my tumor is more aggressive. She said she wouldn't be surprised if I had had no lump two months ago. I admitted I was not very good about checking my breasts every month, but that the lump definitely was not there four months previous, which was the last time I remember doing a check.  It also wasn't there (or at least big enough to feel) when I had my first prenatal appointment with Dr. K; he checked then, too.
As for size, my tumor measured 3.4 centimeters under ultrasound, putting it in the T-3 range of 3-5cm. There appeared to be no nodal involvement, which is very good. That means they don't think any of the cancer has left my breast via my lymph nodes. Sometimes they'll do an MRI to check for other spots, but since I'm pregnant, and they don't have reason to suspect it's traveled to the nodes, no MRI for me right now.

As for treatment, the standard of care for Triple Negative Breast Cancer (TNBC) is chemo followed by surgery followed by radiation. She'd initially thought that she would want to operate first for me since I was pregnant, but during a consultation conversation with the oncologist she is referring me to, she decided there was no reason to treat me any differently just because I was pregnant. The greatest risk with this cancer is its aggression, so we need to treat that first. The way to treat it is with a whole-body treatment, or chemotherapy. Once I've finished chemotherapy, which she said would take about six months, I'll have surgery to remove the lump and margins. She explained the options for surgery and said that there is no indication for me to have a mastectomy. Lumpectomy and sentinel node biopsy followed by radiation has a 3% chance of same breast recurrence. Mastectomy has a 2% chance of chest wall recurrence (it couldn't come back in the same breast, since the breast is no longer there). Since a mastectomy is a much more in depth and difficult surgery, she highly recommends against it in most cases. I quite like this idea. No drains, no reconstruction, easier recovery (with a newborn!)? Definitely.

Dr. S wanted me to have a mammogram and more systematic ultrasound on both breasts to look for any other suspicious areas; she said that while she understands why they didn't do the mammogram when I was in last week, the radiation from a mammogram is about what a person receives during a flight to California, which is certainly permitted in the second trimester of pregnancy. She had me scheduled already for the radiology procedures, and it gave us enough time to go get some lunch and call my mom to update her.

We had a brief wait before I was called back for my scans. While we were waiting, Dr. S and another doctor, who was very, very pregnant, came through the lobby. Dr. S greeted me like an old friend and not at all like we'd just met a couple hours ago and only because she is going to operate on me in a few months. She introduced me to her partner (we joked about how almost all maternity clothes were stripey) and told me she had some things for me in the office if I'd just go back and ask for her secretary. I thanked her and went on back. I found the woman, who led me to a conference room and gave me a copy of the notes Dr. S had taken, some additional reading material, and the appointment card for the oncologist (this Thursday afternoon). Then she handed me a small bud vase with a pink rose and some baby's breath in it, tied with a pink ribbon. Dr S wanted me to have this so I would have something bright for my day. My eyes filled with tears; I don't have the words to express how comforting and kind the gesture was, and I thanked her before heading back out to wait.

Mammograms, of course, are not fun procedures. However, my person was excellent and we had some fun talking about differences living in Maryland versus living in the Carolinas, where she also grew up and lived until a few years ago. Still, that is a cold and squishy machine.

My ultrasound tech was the same as I'd had for the biopsy, and again, I really liked her. She is also pregnant, but several weeks ahead of me. We talked about the temptation to sneak a peek at the babies since all the equipment is right there, but blah, blah, blah, it's against the rules. She said she was so sorry to hear that the mass was cancer; she had really hoped it'd be benign. I agreed. She commented about how much she liked Dr. S, and I told her about the rose. She said she didn't remember seeing anyone else with one, and I was struck again with how lucky I was to have such a caring doctor, not to mention her skills. And Baby Brotzman kept reminding me how it was all going to be okay by kicking me throughout the procedure.

The scans took longer, since they were looking in much more detail and checking both breasts. She finished, said she would go talk to the radiologist to see if there was anything else she wanted, and be back soon. A few minutes later, she came back in with the radiologist, the same who had called me on Thursday, and Dr. S. The tech and the radiologist went right to work rescanning my right breast while Dr. S explained that she was there to check on me and that there was one spot that the tech was unsure about and that they were just going to recheck it. I thanked Dr. S for coming and for the rose. I told her I maybe cried a little. She said, Oh, I'll be sure not to do that again! I told her how much it meant to me, and that I was grateful .

After several minutes of the radiologist looking, and then the tech, they found the spot, and the radiologist confirmed it was just a shadow and nothing to be concerned about. I was relieved; I don't think I'd realized how nervous I was until they said it was nothing.

Finally done, I changed back into my clothes and went out to meet Kevin and Debbie so we could go home. It was a long and exhausting day, and I was ready for a nap.

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