Monday 19 September 2016

The Plan

My first appointment at the Cancer Agency was with the medical oncologist who would be governing my chemotherapy treatment plan. He started off by discussing what we knew and what had happened until this point: how I first got diagnosed, surgery, results, etc. The lump removed was 4cm when initially thought it was only 2.5cm and the type of breast cancer I had showed characteristics of both ductal (cancer beginning in the milk-carrying ducts) and lobular (cancer beginning in the milk-producing lobules) carcinomas; however, it seemed to show more lobular than anything. Ductal carcinoma is the most common type of breast cancer found in about 80% of cases, whereas lobular is the second most common type found in about 10% of cases. The cancer was also estrogen and progesterone positive, but HER2 negative which was a good thing as it was more common and treatable. The concern however was that 3 out of 4 lymph nodes removed tested positive for cancer. He told me there was the possibility of having more surgery to remove additional nodes which the radiation oncologist would discuss with me further.

The oncologist then went over the plan in terms of chemo. Since I was young and healthy, they wanted to put me on the “best of the best” treatment which was also the worst of the worst on the body. I would be on chemo for a course of 16 weeks with each treatment cycle occurring once every 2 weeks (8 treatment cycles in total). It is called Dose Dense because whereas normally they would give the treatment once every 3 weeks, it would be given once every 2 weeks so that the cancer cells don’t have an opportunity to divide. By giving it so frequently, though, the body’s white blood cell count is depleted and cannot replenish itself before the next treatment. In order for my white blood cell count to come back up again, I would require 7 days of subcutaneous Neupogen injections after each treatment cycle. The Neupogen helps stimulate the bone marrow to produce more white blood cells. This stuff isn’t cheap either at $1400 for 7 days’ worth of injections. Thankfully, it would be covered under my extended health benefits; however, there is also a relief program that assists those who don’t have coverage so that they don’t have to pay for this out of pocket.

Chemo would be starting quickly. I was advised that if I couldn’t get into the cancer clinic in Nanaimo right away, we may be looking at doing 1 or 2 cycles in Victoria to get things going as quickly as possible. I was grateful that I could do the treatments in Nanaimo as it would mean less of a commute for me. In the meantime, the oncologist was going to order some further tests including an MRI of my liver and a bone scan to see if the cancer had spread further. The thought of what the results may show made me nervous. I could handle battling breast cancer, but what would I do and how would I react if it had spread? I would also need to get a heart function test done to see how healthy my heart was as one of the chemo drugs could have temporary or permanent damaging effects on the heart. If my heart wasn’t strong enough, I wouldn’t be able to take this particular type of chemo drug.

I was also being referred to a genetic counsellor to determine whether I carried the BRCA1 or BRCA2 gene mutations, two mutations that, if carried, increases a person’s risk of developing breast cancer. In my case since I already had breast cancer, they wanted to see if I carried the gene mutation as I would be at a high risk of breast cancer recurrence and recommendations would likely be put in place for a bilateral mastectomy (removal of both breasts) in order to lower or eliminate that risk. There was also a possibility of having to undergo an oophorectomy (removal of the ovaries) as I would be at an increased risk of ovarian cancer as well. It was a lot to take in, but at this point I was ready to do what I needed to do to get rid of this thing.

I got the call from a clerk at Nanaimo hospital the following day after my appointment with the oncologist with a list of appointments for the following week: check-in appointment with the GP Oncologist on Tuesday at the Cancer Clinic in Nanaimo, heart function test on Wednesday, bloodwork Thursday, chemo on Friday, MRI of the abdomen and liver on Sunday, and then a bone scan in a couple of weeks. I never had so many tests done in my life!  I was grateful though that I could do everything so close to home rather than have to travel the extra distance to Victoria.

Three days later, I went to see the radiation oncologist to discuss the remainder of my treatment plan. She discussed the importance of having more surgery to remove additional lymph nodes as there were concern there could be residual cancer cells in some of the lymph nodes. She explained that studies found that if 2 out of 4 lymph node tested positive for cancer, there was no benefit to additional surgery. However, when 3 out of 4 tested positive for cancer, it was highly recommended to remove additional nodes as a precautionary measure. I already had 4 sentinel nodes removed from below my armpit and this surgery would be to remove the axillary nodes which are located to the right of the breast. The surgery would take place 4-6 weeks after chemo to allow for the chemo drugs to be completely out of my system and for my blood counts to revert back to normal.

I would then be moving onto radiation therapy everyday (Monday to Friday) for four weeks in Victoria at the Cancer Agency. Radiation therapy would entail using high energy external radiation of the lymph nodes and breast to kill any remaining cancer cells. The radiation can cause damage to normal cells including the skin which can suffer sunburn like damage from the rays. It can also cause lung problems, particularly blood clots, so it was important to watch for any redness, swelling or discomfort in my legs while undergoing radiation therapy. Since it would be awhile until the radiation started, my oncologist encouraged me to just focus on one thing at a time and not think too far ahead into the future.

Now onto the next step in my journey, chemo!

Monday 5 September 2016

A Trip to the Fertility Specialist

I got a call from the BC Cancer Agency the day after hearing the results from the sentinel node biopsy and surgery. They had an appointment for me three weeks later. My initial thought was 3 weeks! Why so long?! I was expecting to get in within a week or so based on my conversation with the surgeon. I tried contacting my surgeon to no avail and then called the cancer agency back to explain that the cancer had spread to the lymph nodes, surely they must want to get me in sooner? The receptionist assured me that my file was reviewed by the oncologist and that was the soonest he would see me. I was devastated and that’s when I really broke down since I was first diagnosed. I felt helpless, like I wasn’t in control anymore of my fate. I was angry that they didn’t want to get me in sooner when they knew the cancer was in my lymph nodes and had to be stopped before it went any further. And I was even more upset and worried that my cancer was spreading while I was sitting here playing the waiting game. It took me a few days to get past the flurry of emotions and then I finally decided that I needed to switch things around and get my mind focused on something else before I started driving myself crazy.

Can I have children after cancer treatments?

There were a couple things I wanted to get in order before I started chemo including getting referred to a fertility specialist. In speaking with the surgeon and others who had been through a breast cancer diagnosis, I knew that my body would likely be put into temporary menopause during chemo and could have long term effects on my ability to get pregnant. Although my husband and I didn’t have plans in the near future to have kids, we wanted to keep the door open and know what our options were should we decide to have kids later on.

My family doctor put in an expedited referral and I was contacted by the Victoria Fertility Clinic within a week to discuss my options with a specialist. As my appointment with the oncologist was quickly approaching, there was some urgency in seeing the specialist in case I decided to look at fertility options pre-chemo. I was required to fill out a lengthy questionnaire asking about my family history, any fertility issues, medical issues, etc. prior to my appointment. When I arrived at the clinic the following week, the specialist reviewed all of this information including how my current diagnosis came to be and how it would impact my ability to get pregnant. Chemo kills fast-dividing cancer cells and can be harmful to the ovaries which also contain rapidly dividing cells that produce eggs. Some people’s ovaries will recover after chemo and others will not. Age can factor into this as well as what types and dosages of medications you have.


We then reviewed both of my options, neither of which would be covered under my extended health benefits. The first option was in vitro fertilization (IVF) which involves egg retrieval, sperm retrieval, fertilization, and then freezing the embryo. However, it would also mean taking hormone pills to stimulate estrogen production which is exactly what my body didn’t want right now. My breast cancer was fueled by estrogen. This procedure is also very expensive (in the thousands) even at a reduced rate for cancer patients and is not guaranteed to work. The second option was to start taking an experimental drug immediately which may help preserve my ovaries throughout chemo with the hopes that they would function normally after treatment. The drug was experimental though which meant they didn’t know whether it was effective, if it would counteract with my chemo drugs, and would also set me back $400 per month during chemo.

Seeing my hesitancy with both the options discussed, the specialist decide to conduct an ultrasound to see how well my ovaries were functioning in order to get a better idea as to whether they may “wake up” and function again after treatment.  Once finished, I returned to his office and he let me know that my ovaries were functioning normal to above normal and felt that I had up to a 75% chance of my ovaries waking up again after chemo. That was great news; however, he also advised that after all of my cancer treatments were finished, I would be placed on a hormone therapy drug called Tamoxifen which shuts down the ovaries’ production of estrogen, taking away my ability to get pregnant for at least five years. So, even if I froze my embryos or took the experimental drug, I wouldn’t have the ability to get pregnant until I was 40.

It was disappointing to think that the opportunity to have children was being ripped away from my husband and I. It was no longer a personal choice anymore. We wouldn’t have the opportunity to have a child in a couple years or possibly ever, depending on whether my ovaries started working again after all of the treatments. The doctor asked me what option I was leaning towards. It was too much of a risk to take either option and both had no guarantee. My health was my top priority as this point and I would rather wait and see what happens then have either option potentially affect my treatment or growth of the cancer. The doctor agreed and told me that my number one goal and focus was to beat this thing.