Treatment Plan

It's taken me several weeks to be able to write this post. I needed to wrestle with and eventually make peace with my oncologist's recommended treatment plan before I could post about it publicly.

One thing that was communicated to me early on in this process by my medical team is that a treatment plan is not formally decided upon until after the final pathology results are received, which is typically a few weeks post-surgery. The plan takes into consideration age, overall health, menopausal status, stage of the cancer, grade of the cancer, the tumor’s genetic profile, and its hormone receptor status.  

My situation is complicated by the fact that I have bilateral breast cancer, so I’m processing each test result twice. Some of the key factors in developing my treatment plan included:  

• The tumor in the left breast was stage 1A and the one in the right breast was 2A; both are considered early-stage cancer and have a very good prognosis, meaning treatment is often highly effective.  
• Both tumors are Grade 2 which means the cells are “moderately differentiated” which indicates a faster-growing cancer than Grade 1 but slower than Grade 3.  
• My sentinel lymph node biopsies were both negative, which significantly lowers the chance of regional lymph node spread; although, it's not an absolute guarantee that the cancer has not spread elsewhere in the body.  
• The hormone markers for both tumors are estrogen and progesterone positive and HER2 negative, meaning that hormone therapy will be an effective and importatnt component of my treatment plan.

Where the tumors differed was in their Ki-67 and Oncotype scores. The Ki-67 score indicates how quickly a tumor is dividing while the Oncotype score predicts the risk of distant recurrence and the potential benefit from adjuvant (post-surgery) chemotherapy. 

I was thrilled to find out the left tumor had an Oncotype score of 10 and Ki-67 of 5% meaning that surgery, radiation and hormone therapy would be considered sufficient treatment and there would be no additional benefit to having chemotherapy.  

The right tumor, on the other hand, fell into a more intermediate level with an Oncotype score of 21 and a Ki-67 of 20-25%. Because of my age this score puts me in a gray area. Research has shown that for women over 50 with this score, chemotherapy does not provide any additional benefit. But, for women under 50, with my score, research has shown that chemotherapy is likely to provide a modest benefit (6.5%) in reducing recurrence risk. 

Over the last few months, I remained hopeful that after surgery my treatment would include only radiation and hormone therapy. Because my tumors were small and caught early, I wasn’t anticipating my oncologist’s recommendation for chemotherapy as a part of my treatment plan. While she unwaveringly recommended chemo, she also said I was the captain of the ship, and the decision was ultimately mine. Her advice was to listen to my gut and to ask myself whether I was ok knowing that there could be a 7% chance of distant recurrence without doing chemo, or did I want to do everything possible now to aggressively treat the cancer? If I decided to not do chemo and the cancer recurred in another part of my body down the road, she asked if I would regret my decision to forgo chemotherapy now?  

I’m not a risk taker by nature, so I of course want to do everything in my power to avoid recurrence. At the same time, because I don’t feel sick, it feels counter intuitive to introduce poison in the form of chemo into my body with the hope it will kill some stray cancer cells that may or may not be there while also killing a significant number of healthy cells in my body.  

I've also had a hard time accepting chemo as part of my treatment plan because it already feels like this process has been going on for so long. I was anticipating starting radiation a month after surgery and having everything wrapped up after 4-6 weeks of treatment. Now chemo will take place in four rounds over 12 weeks, followed by 4-6 weeks of radiation. My oncologist said I could expect to feel back to my current baseline in about a year.  

Everything up until this point has been hard, but it's been manageable. Chemo on the other hand feels downright daunting. I’m struggling to find the mental fortitude to prepare for this next stage. I don’t think there has ever been anything I’ve wanted to do less in my life. As I prepare for the chemo start date of 9/8, I try to remind myself of the end goal and that as hard as the next three to twelve months may be, this is simply a tool to give myself the best shot of preventing the cancer from returning somewhere else in my body in the future.