My Treatment Plan

I've often heard people say that a cancer diagnosis is incredibly difficult, but once you have a plan for treatment, it gets easier. I have always responded politely to such assertions, but quietly doubted them. Well, I'm still in the shitty situation of having breast cancer, but I now have a treatment plan. And yes, it does make things seem a bit more manageable, at least for the time being. Knowing the course of treatment is better than sitting around not knowing anything except that you have cancer, and I have a high degree of confidence in the care I am receiving. So... fasten your seatbelts, people. Here we go:

A "neo-adjuvant" approach

I have decided on a neo-adjuvant course of treatment, rather than adjuvant. What this means is that instead of starting with surgery and moving on to chemotherapy and radiation (adjuvant approach), I will begin with chemotheraphy, followed by surgery, then more chemo, followed by radiation. My oncologists here in Urbana, as well as the oncologist I have consulted with in Seattle, have all agreed that there is no statistical difference in outcome between these two approaches based on clinical trials. They are equally effective in that regard. However, based on what cancer researchers are learning about my kind of cancer, which is a nasty and aggressive kind, but also very responsive to chemo- and hormonal-therepies, there are some strong theoretical supports for a neo-adjuvant approach over a standard adjuvant approach. There are several reasons for this, but two reasons that really hit home with me are:

1. Considering that it is a fast growing cancer and that it is in my lymph system (and therefore knows how to live outside the breast), it may be smart to blast it at a more holistic or whole body level to kill any cells floating around in my blood stream, as well as my established tumors, to get rid of it before any rogue cells have a chance to form metastatic tumors.
2. We will be able to see the chemo working pretty quickly and see the tumors shrink up and (hopefully) go away. In other words, you know if it is or isn't working. With the more standard adjuvant approach, one gets the satisfaction of removing the breast and lymph nodes right away, which provides more information for final staging and the oncologist in charge of managing my later targeted radiation. You then get chemo; however, you don't REALLY know if it's working because you don't get to watch the tumors shrink. They've already been removed.

To be clear, the doctors have all agreed that either approach would have been fine for me, but almost all of them leaned slightly toward a neo-adjuvant approach for my cancer: ER+/PR+ and HER2+. The HER2+ part is what makes me a good candidate for neo-adjuvant care. In the end, they advised me to go with my gut, and my gut said neo-adjuvant.

The plan

• Begin chemotherapy on Dec. 9th: A cocktail of three different drugs, two of which I will have infused once every three weeks, and one of which I will have infused once a week. This will last for 4 cycles, or 12 weeks, which will bring us to early March.
• Re-imaging to determine the extent to which the cancer has gone into remission. If I have only partial remission, then proceed with a different cocktail of chemo prior to surgery. If it has pretty much done the trick, then move on to surgery.
• The surgery will be a modified radical mastectomy, which means removal of the right breast and all of the axillary lymph nodes (those in my arm pit), but leaving the muscle in my axillary intact. This will likely occur in mid-late March.
• After a few weeks of recovery from surgery, I will begin another round of chemotherapy, this time for 8 weeks, I believe. 
• In June or July I will have several weeks of daily targeted radiation to the areas around the breast and armpit.
• I think I will be on Herceptin, a drug meant to target my particular cancer, for a year, but I'm not sure about that. 
• I will then be on hormonal therapy (Tamoxifen or an aromatase inhibitor) for several years (I think 5-10) to help prevent recurrence.

A final note

I have had some interesting conversations with doctors about my particular cancer, ER+/PR+ and HER2+.  It seems that this kind only accounts for about 15-20% of invasive ductal breast cancers, and it has only become widely treatable in the last 5-6 years with the development of targeted hormonal therapies. I have a good prognosis, but had I gotten this 8 or 10 years ago, it would have been a very different story. I am so grateful to the goddesses and gods of science who have moved the field forward so rapidly in the past few years. I am now on that train, and while I am not a part of any clincal trials, I feel the train pushing forward. Should be an interesting ride.