The following describes our April 13 consultation with Dr. Merkel, Ann’s medical oncologist from her 2003 treatment. It was our first time meeting him since Ann’s recurrence was diagnosed.

Sorry to Hear of Recurrence

Dr. Merkel began our consultation by expressing his sorrow at hearing of Ann’s recurrence.

Review of Surgical Pathology Report

Next, he moved on to review the pathologist’s report from Ann’s surgery. The pathologists hadn’t released it until just this morning so we had not seen it prior to this consultation. It was several pages long and very difficult to read both because it contained highly technical jargon and because it spoke in very graphic terms of slicing and dicing what had been an intimate, private part of Ann’s body. (For details on the technical portion, see the comparison of her two cancers.)

In a nutshell, the pathology report described Ann’s cancer as the most limited and treatable possible:

• No additional cancer was found. No tumors were found in the right breast. No new tumors were found in the left breast. None of the 14 nodes removed as part of the axillary lymph node dissection had metastatic disease. Of the four sentinel nodes, two had been examined by frozen section during surgery and, as we already knew, one had metastatic disease while the other did not. The new information was that neither of the other two sentinel nodes had metastatic disease. In total, 17 out of 18 lymph nodes were clean.
• Tumor biomarkers were the most treatable, namely, estrogen-receptor positive (ER+) and Human Epidermal growth factor Receptor 2 (HER2) negative.

Setting the Context of the Proposed Treatment Plan

The basic information and concepts of cancer treatment from Ann’s 2003 chemotherapy consultation continue to apply. There are four possible principal phases of treatment:

• Surgery
  Removes a solid tumor.
• Chemotherapy
  Kills cancer cells anywhere in the body.
• Radiation Therapy
  Kills cancer cells in a particular location.
• Targeted Therapy
  Interferes with hormones, proteins, or enzymes needed by cancer cells.

The surgical phase of Ann’s treatment, a bilateral mastectomy, is complete. Radiation therapy is applicable to lumpectomies only and so it would not be part of Ann’s treatment plan.

Ann’s surgery removed all known tumors. The question remained, however, whether there are any unknown tumors.

How Cancer Spreads

Tumors typically slough off cells and these cells travel through the lymphatic system, a system of drainage vessels that collect interstitial fluid, lymph, and return it to the bloodstream. These rogue cells are often caught in lymph nodes, junctures where lymph is collected from multiple incoming lymphatic vessels into a larger outgoing vessel. Lymph nodes act as the lymphatic system’s drain traps, catching and disposing of substances like bacteria that should not re-circulate in the bloodstream. The first lymph node in which fluid from a tumor collects is called the tumor’s sentinel lymph node. Sometimes, a rouge tumor cell trapped in a lymph node starts to grow into a tumor within the lymph node. This secondary tumor is lymphatic metastatic disease. Eventually, these secondary tumors slough off their own cells that travel further along the lymphatic system and the process sloughing and lodging in a lymph node continues until eventually rogue cells enter the bloodstream and travel throughout the entire body. This is a mechanism by which cancer metastasizes from the breast to other sites in the body.

PET/CT Scan Recommendation

Ann’s primary tumor was in her left breast, but the sentinel lymph nodes were on her right side—not the left side. Thus, fluid from the left breast was not draining in the usual manner. Successfully mapping sentinel nodes on Ann’s right side was good news because it meant that many of the cancer cells sloughed off by the tumor could have been trapped in these right-hand nodes. However, this contra lateral pathway is not normal and it raised the likelihood that some rogue cells may have traveled undetected in a different direction.

It wasn’t likely, but it was possible that Ann’s breast cancer had spread to one or more other parts of her body. Thus, Dr. Merkel recommended a full-body PET/CT scan to search for distant metastases.

Chemotherapy Recommendation

The remainder of our discussion focused on the chemotherapy portion of Dr. Merkel’s proposed treatment plan. Some of the factors Dr. Merkel considered in making this recommendation included:

• Recurrence vs. New Primary Tumor
  The new tumor is located very near the old one and its characteristics (ER+, HER2-) are similar to those of the 2003 tumor. It is possible that this tumor is a relapse of the 2003 tumor but it also might be a new tumor, independent of the old one. It would be very difficult for a pathologist to decide which it is. Fortunately, the treatment plan is the same for either.
• Recurrence Despite Estrogen-Deprived Environment
  Ann’s lab tests showed that her ovaries were no longer producing estrogen, which would have stimulated the growth of this ER+ tumor. Moreover, the Femara she was taking should have eliminated other sources of estrogen. The fact that this ER+ tumor is growing in an estrogen-deprived environment is another reason that chemotherapy is necessary.
• Special Case
  There is much less clinical evidence upon which to base a treatment plan for recurrrent cancer. Much more than an initial breast cancer, treatment of a recurrent cancer depends on the oncologist’s judgment.

Ann’s Chemotherapy
	Initial (2003)	Recurrence (2010)
Name	TAC	TC
Drugs	Taxotere (generic: docetaxel) Adriamycin (generic: doxorubicin Cytoxan (generic: cyclophosphamide)	Taxotere (generic: docetaxel) Cytoxan (generic: cyclophosphamide)
Frequency	Once every 3 weeks	Same
Rounds	6	4

Dr. Merkel recommends that Ann complete a chemotherapy regime referred to as “TC”; her 2003 regime was “TAC.”

The differences between the two regimes are:

• No Adriamycin in 2010
  Dr. Merkel said that he was not recommending Adriamycin because it is not appropriate for cases with only one metastatic lymph node. Moreover, Adriamycin is toxic to the heart and Ann’s 2003 treatment exposed her to the maximum lifetime dosage.
• Fewer Rounds in 2010

This chemotherapy recommendation left us both relieved and anxious. One the one hand, we expected that fewer drugs and fewer rounds would result in less hardship on Ann. On the other hand, we wondered if fewer drugs and fewer rounds would be sufficiently powerful to defeat her cancer.

Managing Chemotherapy Side Effects

Like all chemotherapies, Ann’s regime of Cytoxan and Taxotere is a rather blunt instrument that kills cancer cells by attacking all cells that are dividing quickly. Unfortunately, malignant tumors are not the only tissue with rapidly dividing cells. Many perfectly normal tissues also have rapidly dividing cells and her chemotherapy will attack them too.

Normal, healthy tissues that will be attacked by chemotherapy include:

• Lining of the digestive system
• Hair follicles
• Bone marrow stem cells

Thus, side effects of chemotherapy include:

• Nausea
• Hair loss
• Lower levels of red and white cells in the bloodstream, resulting in anemia and susceptibility to infection.

Most of these side effects will be managed with the same treatments used in 2003. Nausea and other digestive discomforts are treated quite effectively with drugs. A cranial prosthesis (wig) takes care of the hair loss. White cell production is stimulated with an injection of Neulasta (generic: pegfilgrastim). However, if Ann becomes anemic, her treatment will not be the same as in 2003. During her 2003 treatment, Ann’s red cell count dropped to an anemic level after her third round and it was treated with a drug in her fourth round. This drug, Aranesp (generic: darbepoetin alfa) is a hormone that stimulates bone marrow to produce red blood cells. This time, however, if she becomes anemic during her upcoming chemotherapy she will not receive Aranesp. Apparently, cancer treatments were not as successful for patients who received Aranesp. Thus, the only treatment that will be offered for chemotherapy-induced anemia will be a blood transfusion.

Chemotherapy Will Require a Port

Both of Ann’s arms are at risk for lymphedema and infection since she’s had an axillary lymph node dissection on each of them. Consequently, neither of them should be used for intravenous drugs, including chemotherapy infusions. Ann will use a portacath for her infusions. Port installation is an ambulatory surgical procedure

Next Steps

Chemotherapy cannot start until Ann’s surgical wounds are completely healed.

In the mean time, we have to do the following:

• Once the drains are removed, get a PET/CT scan to confirm that there are no unknown metatheses.
• Get a port installed.
• Complete whatever research and second opinions we feel we need to be comfortable with going forward with Dr. Merkel’s chemotherapy plan.

Posted by Nello at April 13, 2010 4:38 PM

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