Alison’s pre-school, Glencoe Junior Kindergarten (GJK) had spring break the week of March 22 and Ann scheduled a week of vacation then so we could do some things together. We had an ambitious list of things planned, from washing windows to visiting Chicago museums.

Ann also scheduled her annual mammogram for that week, on Monday, just to get it out of the way so we could move on to other things.

For the prior seven years, Nello had always accompanied her at all her mammograms and breast exams. If there were bad news, we wanted to hear it together so that we had a better chance of understanding and remembering what was said. This time, however, Alison had a morning play date with a GJK classmate and the times that Alison would have to be dropped off and picked up didn’t coincide with when Ann thought she’d be done with her appointments. Ann had been cancer-free so long that she decided she didn’t need Nello as her lucky charm any more; Ann went to the hospital and Nello stayed home to tend to Alison.

Unfortunately, there was bad news this time. Ann called Nello and asked him to join her. Nello arranged for Alison to stay at her play date later than had been planned—thank you Judy!—and he sat down with Ann just 20 minutes after her call.

Our healthcare provider, North Shore University Healthcare System (NSUHS)—formerly known as Evanston Northwestern Healthcare (ENH)—encourages breast cancer survivors to schedule their annual mammogram on the same day as a periodic breast exam. Depending on the time elapsed since their treatment, survivors have a follow-up examination with their surgical, medical, or radiation oncologist either quarterly or semiannually. Scheduling one of these exams immediately following the annual mammogram reduces the number of patient trips to hospital and provides her with better care since the physician who does the exam can integrate the imaging findings with their clinical findings and answer patient questions about both at the same time. So, Ann had scheduled both an appointment for her annual mammogram followed by her appointment with Dr. David P. Winchester, her surgical oncologist, for her semi-annual breast exam.

On this Monday, the advantage was that we didn’t have to wait for an appointment with Ann’s surgeon. We could ask questions and map out a strategy for the next steps right after the mammogram.

First, we reviewed the facts. Her mammogram revealed a single lump in Ann’s left breast that she had not been aware of. An ultrasound confirmed the lump. It appeared to be about 2 cm in size and was very close to the site of Ann’s prior tumor. Dr. Winchester suspected that the lump was malignant based on its shape and feel.

Second, Dr. Winchester laid out his recommendations:

• Schedule Biopsy: The only way to know for sure whether the lump is malignant is to take a piece of it and test it. The pathology report would be available two days after the biopsy.
• Schedule Pre-Operative Testing and Diagnostics: The testing included a chest x-ray, EKG, blood tests, and physical exam to ensure that Ann was healthy enough to endure a mastectomy. He wanted an MRI of both breasts to make sure that there wasn’t any occult cancer that either the mammogram or ultrasound had missed. He also wanted to attempt to find sentinel lymph node(s) prior to the surgery in order guide the surgical plan.
• Review Breast Reconstruction Options: The best time to do reconstruction is during the same surgery that removes the breast.
• Schedule Operating Room Time for a Mastectomy: If the lump were malignant-as he expected-then surgery would be required to remove it. With her prior tumor, Ann had the option of a lumpectomy or a mastectomy. Research shows that lumpectomies are just as effective as mastectomies in cases where lumpectomies are appropriate and when radiation therapy follows the surgery. Unfortunately, Ann’s left breast had been irradiated once already as part of her prior treatment. Since additional radiation is not recommended, a mastectomy would be recommended if the lump proved malignant.

We indicated that Ann was on vacation all week so we had a lot of flexibility fitting into any appointments that could be scheduled for this week. We were open to going to any of the NSUHS Hospitals, Glenbrook, Highland Park, or Evanston for any consultation or procedure.

Dr. Winchester’s nurse, Angie, got on the computer right away and started issuing the required orders for a chest x-ray and EKG, and she immediately scheduled Ann’s biopsy in Highland Park, MRI at Glenbrook, sentinel lymph node mapping at Glenbrook, consultation with a plastic surgeon at Evanston, and operating room time for a mastectomy at Glenbrook.

We left Glenbrook Hospital a bit dazed.

We tried to collect ourselves over lunch but we weren’t very successful. Afterward, we parted ways. Ann went to see her internist for a pre-operative physical exam. Nello went to pick up Alison and then headed to the Cancer Wellness Center in Northbrook as well as the Glencoe Public Library to research mastectomy, reconstruction, and treatment alternatives for recurrent breast cancer.

Monday was a beautiful day. It was the first day of a full week of vacation. We checked our calendar; we hadn’t scheduled a breast cancer recurrence! Nevertheless, Monday was the first day of a week of medical tests and decision-making with life-long consequences. How could so much change so fast?

Posted by Nello at March 29, 2010 6:41 PM

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