My girlfriend, Lisa, is 68 and is very proactive about her healthcare. She gets a yearly physical with her internist, gynecologist, mammogram screening, and appropriate colonoscopy screening.
At the end of December of 2021, Lisa had her annual mammogram. Waiting for the radiologist to come in after a breast screening can be stressful. This year, Lisa did not get her usual, “all clear.” Instead, the radiologist explained that she saw something different on the imaging that she had not seen before and suggested that Lisa have an ultrasound. The ultrasound confirmed that something had changed in her right breast. The radiologist explained that she wanted to biopsy two different spots.
Lisa agreed to let me interview her and share her journey in great detail in the hopes to help others.
I learned from Lisa that after you have a biopsy, they typically tag the spot in question by putting a small tissue marker, called a clip, into the area where the biopsy is done. The clips are made of titanium and are the size of a sesame seed. These clips enable the radiologist to mark the areas in question and check them repeatedly each year. After the biopsy and tagging, they take another mammogram to ensure the tags are in the correct place. When they did that with Lisa, the radiologist realized that she did not get the marker on the spot she initially wanted to tag. She explained that she needed to go back in and biopsy this other area.
When the biopsy is performed, you hear a click-click noise. Lisa was counting the clicks. Trying to keep her sense of humor, Lisa told her radiologist that she counted six clicks and would surely be a bra size smaller if she did not stop clicking!
It took the radiologist a great deal of time to biopsy the third spot as it was so very tiny. She persevered, thankfully, and got the biopsy completed. Lisa, then had another mammogram to make sure the tumor location was successfully tagged. When all biopsies were complete, the radiologist told Lisa that she felt that the “tiniest” spot was most concerning. It turned out that the radiologist was, in fact correct. That tiny little spot was cancerous. The others were benign.
Lisa asked the radiologist for her top 3 breast cancer surgeons (called a surgical oncologist) recommendations. She then called her internist to do the same. One surgical oncologist was on both doctor’s lists! This made Lisa’s decision much more straightforward. She immediately called that surgeon and, within four days, had an appointment.
The surgeon told her that her tumor was 6 mm, stage 1, and HR2 negative. The next step was an MRI to make sure that the cancer was localized in the breast. She also had genetic testing done. Her mother had breast cancer. Fortunately for Lisa, there was no cancer spotted in any other area of her breasts, but they did see some spots on her liver. The surgeon referred her to a medical oncologist who ordered a PET scan (positron emission tomography) to do a whole-body check. A medical oncologist treats cancer using chemotherapy or other medications. During the test, radioactive sugar (FDG) is put into a vein and travels throughout the body. Cancer cells absorb high amounts of this sugar. A special camera then takes pictures that show the areas where the sugar is collected throughout the body. A PET scan is often combined with a CT scan (known as a PET/CT scan). Lisa’s PET scan was “clear,” and her genetic testing was negative.
Lisa described her next steps as follows, “The next step was surgery to remove the tumor. My lumpectomy procedure took 15 minutes. Fifteen minutes before the surgery, they numbed my breast and did a needle localization where they put a small wire in my breast to mark the spot for the excision. In my case, they removed two lymph nodes and performed a full histologic analysis. The two lymph nodes came back benign.”
I spoke with Dr. Rebecca Rakow-Penner, M.D., Ph.D. at UC San Diego Health. Rebecca Rakow-Penner is a board-certified diagnostic radiologist and scientist whose research is focused on developing MRI technologies to improve the detection and evaluation of female cancers (breast, ovarian, cervical). She explained that there are different ways to localize tumors before surgery. At UC San Diego Health, they no longer use hook wires called wire-guided localization (WGL). Instead, they use radio frequency reflectors which are tiny things placed adjacent to the biopsy marker in the tumor. It allows surgery to be done any time after the reflector is placed, without a wire hanging out of the patient’s breast. The National Institute of Health has more info on this that you might find interesting.
After the surgery, Lisa met with her medical oncologist. He explained that he would use the Predict Model and Oncotype DX Test to help determine what further treatment she would need, such as radiation, chemo, a combo of both, or perhaps no therapy.
Predict is a tool that helps show how breast cancer treatments after surgery might improve survival rates. Characteristics of the patient and their cancer are inputted for analysis. Predict then shows how different treatments would be expected to improve survival rates up to 15 years after the diagnosis. Their model incorporates data from similar women in the past.
The Oncotype DX Test tells you what % chance you have of reoccurrence. The Oncotype DX process is performed using a tiny sample of the tumor tissue removed during the core biopsy, lumpectomy, or mastectomy.
The Oncotype DX is a test that may predict how likely your breast cancer will return. It can predict whether you will benefit from having chemotherapy in addition to hormone therapy. The test results can help you and your doctors make a treatment plan that’s right for you. If you score 25 or above, they suggest you have chemotherapy. If you score 25 or lower, you may not need chemo. You can read Margret’s journey and how the Oncotype Test determined her after surgery protocols in this Menopause Mondays® Hot News Flash: Chemotherapy or no Chemotherapy- Learn About the Oncotype DX Test.
After reviewing the results of these two tests with her oncologist in detail, it was determined that Lisa needed radiation but not chemo. The next step was to determine how the radiation would be administered. Lisa began her radiation treatment 30 days after surgery.
Lisa made an appointment with Dr. Robert R Kuske, a radiation oncologist at the Arizona Center for Cancer Care who has sub-specialized in breast cancer treatment to determine what type of radiation was best for her specific situation. Dr. Kuske is the inventor and pioneer of “accelerated partial breast irradiation,” (APBI), a five-day alternative to conventional six weeks of external beam whole breast irradiation in select early-stage breast cancer. In 1991, a Venezuelan businesswoman flew to New Orleans and insisted on shorter radiation treatment for her early-stage breast cancer. By treating only the affected part of the breast with a radioactive seed, Dr. Kuske could shorten her therapy to less than one week. The success of this novel idea led to the first trial at the Ochsner Clinic, then to the national Phase II and III trials that Dr. Kuske wrote and directed. He also invented a technique to treat breast cancer in women with breast augmentation that does not cause hardening of the implants.
Lisa fit the ten guidelines that enabled her to be a candidate for Brachytherapy. Brachytherapy only targets the actual area of the breast where the tumor occurred. The radiation only reaches a small area around the surgical site. It does not treat the entire breast, so it is called “partial breast” radiation therapy or partial breast brachytherapy. Three different types of catheters can be inserted. Your doctor will determine which one is best for your breasts. These catheters are inserted the day before you start your treatments. They implant radioactive material through a needle that goes into the catheters. For Lisa, 23 tubular catheters were inserted in her breast where they inserted her treatment. She said it was painless. She had 8 – 15 min treatments. Lisa had one treatment at 9 AM and one at 3 PM for four days. On the 4th day, after they completed her treatments, they pulled out the catheters. She was surprised that the removal of the catheters was painless. It was explained that this was because the body creates fluid around the catheters, which helps them slide out.
Please note that Brachytherapy is only one of the many types of radiation used for breast cancer. The American Cancer Society has a list of the options your specialist may discuss with you.
The next step was to determine if Lisa needed an estrogen blocker. Her oncologist laid out the risks vs. benefits of the estrogen blocker. Then together, they decided that she should go on Anastrozole. Anastrozole is a nonsteroidal aromatase inhibitor. It works by decreasing the amount of estrogen the body makes. Estrogen blockers can help slow or stop many types of breast cancer cells that need estrogen to grow.
Her next visit with her oncologist will be six months after her radiation. She will have another mammogram and ultrasound before her appointment.
Before we wrapped up the interview, I asked Lisa what her best advice was for someone diagnosed with breast cancer. She said, “Take control of your journey. From the moment I heard that I had a tumor until I finished my radiation, I became my “best” personal health advocate. I focused all my energies on finding great doctors by reaching out to other trusted doctors and friends who were breast cancer survivors to get a consensus. When booking appointments, if you do not hear back – keep calling until you get the help you need!”
When Lisa and I met in college, I was always amazed by her stamina to get things done! From the moment she found out that she had breast cancer she became her own fabulous health advocate. I am and continue to be in awe of her determination to get the best medical care possible while at the same time maintaining her sense of humor and incredibly positive disposition. She is a role model for all of us.
Remember: Suffering in silence is OUT! Reaching out is IN.
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