day 205 – more positive nodes, an upgrade to my tumor grade & I start the big T

I’ve been chewing on this for a few days before getting to a point where I can write about it, but soon after the operation my surgeon shared the path report with me, and it wasn’t really good news.

I had mentioned previously, that because we knew there were 3 positive nodes before surgery, she would not do a stepwise surgical dissection of the nodes to see how far the cancer had gotten, and adjust the node removal during surgery. Instead, she would assume that it was past the sentinel node, and so would take all the nodes in the anatomic field, in my case 31. These would then be analyzed by pathology for the presence of cancer, and this information would help the radiation oncologist design the appropriate field.

Well it turns out I had 6 nodes that had cancer in them. I guess the 3 new ones that we discovered didn’t have enough cancer burden to show up as enlarged on ultrasound, or to show up as having higher metabolic activity in a PET scan either, so that is good. Also my surgeon emphasized that the positive nodes were all in the first line, not the second line, meaning that the cancer had not yet moved from one node to another one further along the chain, again good news. However the fact that they were there is just not great. In fact, it earns me an immediate upgrade of my tumor grade from stage IIA to stage IIIA because I no longer fit the description that

” […] the tumor is 2 centimeters or smaller. Cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes […]”

but am now described by

“[…] the tumor may be any size. Cancer is found in 4 to 9 axillary lymph nodes […]”.

More details and pictures on staging here: http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient/page2

I realize these are arbitrary-sounding distinctions. What’s a node between friends, after all? But it is based on quite a lot of science, and stage underpins clinical research in turn. It is a major factor in estimating prognosis and can also influence eligibility for trials. It gives everyone involved some information about what kind of tumor it is and so what to expect.

The nodes of course are so important because they tell us about systemic spread of the cancer. That spread is what you need to worry about for long-term survival. The local disease is very effectively treated with surgery and radiation. The cells that have left tumor-town and are hiding out along the rivers and streams of the lymph and blood system and in the organ-countryside beyond are the ones that can threaten your life, if they acquire the ability to grow there. They are the reason we do systemic therapy: chemo and hormone suppression.

That brings me to the other not-so-good news in the path report: there really wasn’t a lot of evidence that the chemo had had major impact on the tumor. We had been monitoring tumor response with ultrasound, which gives you only a rough measure of the size of the tumor, during chemo. In fact, my tumor was growing, albeit slowly, during the taxol, which is why we dropped this 1 week early and moved on to FAC. During FAC the tumor at least stopped growing, and maybe even shrank a tiny bit, but again we didn’t have any idea of what was going on inside. I had hoped that there would be at least some cell death in the tumor – that the center would even be necrotic – but it didn’t happen. So the nearly 6 months of chemo didn’t do much to the main tumor. I don’t consider it wasted time though, because as my doctors quickly pointed out, it is possible and even likely that the cells out in the body are more sensitive to the chemo and so we may have gotten some significant benefit.

The other interesting thing is that insensitivity to chemo is often found in tumors that are very strongly hormone-dependent. My tumor, like most male breast cancer, is highly ER/PR positive, and so the good news (yay! good news!) is that it should respond really well to tamoxifen. With 95% positivity for the hormone receptors, this should work well. And since it has proven it doesn’t respond well to chemo, I am hoping that it holds true for me that response to hormone deprivation will be effective. Of course, with the main tumor now gone, we won’t know how well it worked until I live to be 100 🙂

For that reason I started tamoxifen this week, rather than waiting until after radiation therapy, which is what I had expected. There is no reason to wait, and since benefit is to be had, let’s get started. And that is good news indeed.