9/19/19: (~1 Month Post-DMX) Medical Oncologist Appointment - I Need Chemotherapy

I really like my medical oncologist. She was just the right balance of knowledge and caring. A nurse sat in on the entire meeting, and she will be the person helping me navigate upcoming appointments and procedures.

So much information to process.

I will be getting chemotherapy.

I cried a bit at this news, but actually I am on board with the recommendation; I feel my oncologist really gave my case a lot of thought, and is giving me the best treatment for my unique situation. Going into this appointment, because I was in a grey area, I was most worried that the doctor would not be able to confidently recommend a clear course of treatment. She said my case is indeed unique. Two tumors in my right breast, one tiny tumor in my left, two different types of cancer.

The two tumors on the right were ER-positive, PR-positive, and HER2-negative. The larger of these two was sent for Oncotype DX testing, which predicts the likelihood of recurrence and whether or not the patient would benefit from chemotherapy. The result came back "intermediate to low risk", which is basically another grey area with no clear recommendation in terms of chemotherapy. The actual number was 18. The above link gives this not super helpful explanation of results: "If you have a score of 16 or above and are aged 50 or under, your specialist will discuss your test result with you to help decide if you’re likely to benefit from chemotherapy."

The tumor on the left was ER-positive, PR-positive, and HER2-positive. Usually, a HER2-positive cancer is treated with Herceptin in conjunction with chemotherapy. But since this tumor was so small (4 mm), it wasn't clear if Herceptin and chemo are still necessary.

My oncologist brought my case to 3 additional oncologists at the main hospital in the city. All 3 oncologists said that yes, I should be treated with Herceptin. Moreover, they all agreed on administering it via chemotherapy with Taxol, which interferes with the growth of cancer cells. My oncologist said their agreement is noteworthy; in a non-straightforward case like mine, it's more common to get differing opinions. I do find it very reassuring to know that even though I started in a "grey area", my course of treatment was actually recommended by 4 oncologists, including my own.

Ultimately, my age played a large factor in the decision. Because I am considered young, the likelihood of recurrence is high. Since I am healthy and have no other health issues, I should be able to handle the chemotherapy.

My medical oncologist said my regimen will be like "chemo lite". My treatment will last a year total. For 12 weeks, I will get Taxol and Herceptin once a week. Then I'll get a maintenance dose of Herceptin every 3 weeks for the rest of the year.

Before starting chemo, I need to get a baseline echocardiogram. I also need to get a port placed in my upper chest, which is how the chemo will be administered. Both these appointments will happen next week.

I will also be getting hormone therapy.

All 3 tumors were ER-positive and PR-positive, which means the cancer's growth is fueled by estrogen and progesterone. I'll be getting both Tamoxifen and Lupron. Tamoxifen is a pill that blocks the estrogen receptors in the cancer cells. Lupron is a type of ovarian suppression. It's an injection that stops estrogen production in the ovaries. I'm not entirely clear on this, but it sounds like I may need to take Tamoxifen and Lupron until menopause.

I do not need radiation.

Mainly, I think, because I had clear surgical margins and my lymph nodes were clear.

All my treatment moving forward is to prevent recurrence. Chemotherapy and hormone therapy are both systemic treatments, and as this video explains, they are needed to address any cancer cells that already escaped from the breast and may grow into cancer later.

Finally, we discussed my variants of unknown significance in my BRCA2 and PALB2 genes. BRCA2 is also linked to ovarian cancer, and PALB2 may be linked. Ovarian cancer is very difficult to detect, and tends to already be late-stage when it's found. If I had known mutations in BRCA2, an oophorectomy (removal of ovaries) would be recommended. Since my mutations aren't known to be problematic, they're not sure if there is enough reason to worry about ovarian cancer. My medical oncologist said she would confer with the genetics specialist, and I should also discuss this question with my OB/GYN. (I have an appointment in October.) There seems to be a lot of negative side effects when getting ovaries removed pre-menopause, so I hope I can avoid it.

On Monday morning Ken and I will meet with the oncology nurse to review my entire treatment plan. It'll also be a chance for us to ask questions.

Incidentally, at the start of this appointment, I had a blood draw. In retrospect, I'm sure it was to get a baseline before I start treatment.

It's all very overwhelming. I really feel like I'm just being carried along on this river. I don't know where it's going. Whatever comes up, it is what it is. I just have to do whatever I have to do.