Port

I'll be getting a chemotherapy port on Monday. It's a little titanium gizmo that has a shape much like Apollo Command's re-entry module, although (obviously) in miniature. It will go just under my skin in my upper chest, below the collar bone, and will be attached via a little tube to a major vein for easy blood stream access. The idea here is to facilitate both blood draws and chemotherapy infusions. From what I understand, there are fewer nerves there than in the arm or other places that health care folk might think to stick a needle. I wonder if they could insert a second port for coffee infusions. And maybe a third for wine! A tawny port port, perhaps? I'm thinking the insurance wouldn't pay for that, though.

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.

Today's PET-CT Results

Clear! PET-CT was CLEAR. No metastasis. C-L-E-A-R clear. The cancer is actually in four lymph nodes, not two, but still... This is good news. This puts my final pre-surgery staging at T2N2M0. That is, (largest) Tumor = 2.1cm, (lymph) Nodes affected = 4) (and 3-5 earns the classification 2), and Metastasis = 0. I believe that the cut off between stage 2 and stage 3 is three lymph nodes, so I guess that puts me at a stage 3a. But the devil (or mabye the grace?) is in the details.

BTW, my primary care physician here in Mahomet called me personally with the news, knowing I would not have wanted to wait until my appointment tomorrow at 1:00 with the radiological oncologist to find out. I am so grateful.

"Radioactive, radioactive"

As I write this, I'm prepping for my PET CT scan with Grace. The nurse just injected radioactive something-or-other along with glucose into my body. Imagine Dragons' song springs to mind:

   Welcome to the new age, to the new age
   Welcome to the new age, to the new age
   Whoa, oh, oh, oh, oh, whoa, oh, oh, oh, I'm radioactive, radioactive
   Whoa, oh, oh, oh, oh, whoa, oh, oh, oh, I'm radioactive, radioactive 

:-)

Triple Positive

OK, here's a post for those of you who are interested in some of the medical specifics: Craig and I met today with the oncologist (who is simply wonderful, by the way), and we got the pathology back on the cancer: Estrogen Positive (ER+), Progesterone Positive (PR+) and Human Epithelial Receptor 2 Neu Positive (HER 2 neu +). This is basically a triple positive, which in the breast cancer world is a lot better than a triple negative. From what I understand, this is a highly targetable cancer with chemotherapy, of which I will be getting a healthy dose. If any doctor or nurse friends or family reading this wish to provide more insights or thoughts on this, feel free to comment and elucidate. I am viewing this as a slice of good news in a broader "series of unfortunate events." Tomorrow, PET-CT scan. Stay tuned!

Introducing Grace

Meet Grace. She is a little fluffy dog that easily fits around my finger or in my pocket. My friend Zanne gave her to me last night: A new companion as I begin what will certainly be an unpleasant series of treatments. (See my post "on strength and grace," and Zanne's and Jim's comments, for a bit of context here.) She will go with me to surgery, to chemo, to doctors' appointments, and to radiation. She will sit by my bedside, both when I'm calmly dreaming of not having cancer, and when I'm quietly weeping. I will wrap her paws around my finger when I feel sad or scared. And I will train her to growl at adversity. I wonder, can I train Grace to deliver a bitch slap?

Those of you who have dogs or are dog lovers know that they can be warm and fuzzy, but also messy and smelly. They may lovingly lick your chin and nuzzle your check, and then turn around and poop on your carpet. Your dog will wag its tail excitedly when you come home, and when she arrives on your lap, you may get a whiff of the pile of dead stuff she just rolled in, having spruced herself up for your arrival. Such is Grace--many forms, at times messy, but always welcome.

Like me, Grace may not always look or smell pretty during this process. She may take on a rough and weary appearance at times. But while treatment won't be easy on either of us, I can now say that I will be going through all of this "with Grace."

On "Strength" and "Grace"

Those of you on Facebook may likely have already seen this, as it's making the rounds through the social networking world, but I find that so much of it rings true for me right now, and how I'm trying to go about this: 13 Things Mentally Strong People Don't Do. But I have some other thoughts on this...

On "Strength." It is a no-brainer that no one is mentally strong all the time, and if anyone leads you to believe otherwise, they are lying. 'Nuff said about that. But I do have a few concerns about what appears to be a standard of strength that people might strive to live up to (lots of people, not just cancer patients). When Skyping with Craig in between my mammogram and the biopsy, I told him, "I don't know how to do this. I want to do this with strength and grace." His simple and amazing response was, "Why? Why do you think you need to do that?" Indeed, why? Why did I want to do that? Why did I (correction, do I) feel the need, even the expectation to do that?

I have nothing against strength, mental or otherwise. In fact, I do aspire to it. However, I'm quickly learning that it is a standard that is simply unfair to impose on people in unchecked ways. While I find friends' comments about my supposed strength helpful (e.g., "You are strong and you will get through this"), "strength" in its soundbite form, as a cliche, is in itself weak.  Strength takes so many more forms than the link above would suggest: Everyday forms, teary forms, micro-forms, forms that sometimes don't appear fully controlled. Curling up in a ball and crying before getting out of bed in the morning: one last bout of sobs to send the remaining night demons packing. Taking a sleeping pill at 5:00 am to get just a couple more hours of sleep. Slapping an extra helping of whipped cream on a latte.... Close your eyes and visualize these events. They may not match the standard of "strength," but how are these not strong?

On "Grace." I have this image in my mind of Craig's mother, Jan, with cancer, near the end of her life. Her words to her friend, "Don't cry for me, Lois, I've had a good life," ring in my ear. Her perpetual lack of complaint, and her willingness to still do things for others before herself. Even when she was in pain. Smooth lines through life. Giving. Laughter. Softly putting others first, and smiling all the while. Jan really was amazing, and I continue to admire her grace. But let's be clear: That was Jan being Jan. She was always like that. It was not a false grace that she took on because she had cancer. 

My high school friend Kathleen, a military woman, recently offered to put on her fatigues and cammo paint and "open up a can of whoop ass" on my cancer. Close your eyes and imagine it: It's rough, it's abrupt, it's fierce, it's hard. It's a loud and welcome complaint and threat against my cancer. No smooth lines there. But how is that not also grace?