day 15 one step

As a very smart man once said “the journey of a thousand miles begins with one step”.  Today, I take that one step, with my first chemo, and start on my personal journey. 

It is remarkable to me, how far I have already been brought in the past two weeks, in terms of making a picture of my disease and making a plan for dealing with it. I say brought, because I feel that at every turn there has been a guide, a doctor, nurse, technologist or staff member showing me the way. And my family and friends cheering me on. Now, I feel at least, it is time for me to also take part by accepting the treatments and doing my best to be a good patient. 

The treatment plan is as follows: first chemo, then surgery and then radiation. It is pretty certain that we will do all three, though I have not yet had a chance to discuss the radiation therapy in depth with either my oncologist or my radiation oncologist. Chemo is going to be the TFAC regimen, which is three months of paclitaxel, followed by three months of a cocktail containing 5-FU, adriamycin and cyclophosphamide.

Chemo first is the current approach at MD Anderson, and many other centers, though it is by no means universal. According to my oncologist there is no strong data showing that it matters a lot whether you have chemo then surgery or surgery then chemo. Of course, for male breast cancer there is no data at all, because it is rare, and so we are assuming, as most do, that the findings in breast cancer in women is transferable. 

Chemo first is called neo-adjuvant (http://en.wikipedia.org/wiki/Neoadjuvant_therapy). Historically the main therapy for many cancers, including breast cancer, was surgery. Then when chemotherapies were developed, they became additional therapies used to support the main therapy, surgery, and were called adjuvant for that reason. They were given after the main therapy. More recently, the supporting therapy is sometimes given first, and then it is called neo-adjuvant. These distinctions still make sense, as surgery is invariably part of breast cancer therapy, and with very early cancers may be curative. So pretty much everyone has surgery. Then, if there is local spread or wider spread, chemo and radiation are added as needed, and hormone therapy too when it makes sense. 

Why give chemo first if the order doesn’t matter? The main reason is that you can learn something important: whether the tumor responds. The thinking is that if the main tumor shrinks during the 6 months of chemo, then it is likely that the tiny groups of cells that have already spread, and are in the lymph nodes and perhaps elsewhere, will also be controlled. Since these are very hard to follow, making this inference can be helpful. It is reassuring if it happens. Or conversely, if the main tumor continues to grow through the chemo you know you need to consider different options. No chemo is currently effective enough to totally eradicate the cancer cells in the breast tissue, so it is never advisable to leave off the surgery.

Here I go!