Treatment consult, Part II

I said I'd post more about what we learned last Thursday and finally got around to it this evening. This is mostly dull, dry and boring. I'll try to weave in some math to spice things up!

We got a quick but helpful lesson on what "breast calcifications," "ductal carcinoma in situ" and "microinvasion" are. Calcifications happen when milk ducts become blocked and calcium leaks out of the duct into surrounding tissue. Cancer cells are just cells that aren't growing as they should. A breast cancer is called "in situ" if it hasn't figured out how to break out of the cells lining the milk duct. That's DCIS, and it's considered the best case. A "microinvasion" is when cells in one area learn how to break through the duct lining and into surrounding tissue. An "invasive cancer" is one that has broken through and is widespread. That's a much worse case. Here's a drawing from Dr. I. to illustrate what we've explained so far:
(Do they offer art classes in med school? Shouldn't they?!? )

Researchers don't yet know the implications of microinvasion. Intuition would be that microinvasion is maybe a little worse than DCIS but better than full-blown invasion, and some studies have shown that to be true. At worst, microinvasion has implied spreading in only a small percentage of patients. One of the problems of microinvasion studies is that the definition of microinvasion varies, so there's some controversy about their conclusions. Dr. I. said that from what he sees on the pathology reports there's some suspicion about whether there's a microinvasion in FrogRev's case. Dr. I. places FrogRev's cancer on the high end of DCIS, but on the low end of the larger cancer spectrum, at stage T(0).

In any case, what we're after now is local control to prevent the FrogRev's cancer from spreading. The first step is adequate surgery, which has already been accomplished. What's next? Radiation is recommended next. We're looking locally for a radiation oncologist now.

We talked a bit about the idea of cancer spread. There's no way to detect spread, apparently. We can only look at the probability of spread. Dr. I. places FrogRev in the extreme favorable category of not spreading, with a probability of less than 0.1 of spreading. One option for the next step after radiation is to do nothing. Evidence shows, however, that we shouldn't just do nothing. There's a risk of recurrence, and there are several options to cut that risk.

The ways of eliminating some of that remaining risk are hormonal therapy and chemotherapy. Chemo carries a much higher risk of side effects, so, in FrogRev's case, it's not a potential option. Hormonal therapy is relatively non-toxic and low-risk compared to chemo. There are benefits and they may only slightly reduce the risk of recurrence slightly, but the risk is also small. Hormonal therapy seems like a small step compared to chemo, but there's not a large increase in benefits gained by chemo over hormonal therapy in FrogRev's case. Hormonal therapy is still a big step compared to doing nothing.

Tamoxifen appears to be the Selective Estrogen Receptor Modulator (SERM) for FrogRev. Raloxifene has been in the news lately, but those study findings are related to postmenopausal women. Raloxifene isn't even approved for use in FrogRev's case. Tamoxifen cuts in half the risks of new cancers and reduces the risk of spread to other areas. It's also good for osteoporosis. Studies have shown that the benefits of taking Tamoxifen for five years last at least 20 years, but there's no added benefit if it's taken more than five years. Looks like FrogRev has five years of Tamoxifen ahead. Tamoxifen has some side effects, with hot flashes being the most notable. It also doubles the inherent risk of uterine cancer, blood clots and stroke, but FrogRev has almost no risk for those to begin with. Doubling almost nothing is still almost nothing. If Tamoxifen doesn't work, treatment will need to become much more aggressive. So we're rooting for Tamoxifen to do its job.

Things slowed significantly this week. FrogRev's only doctor meeting was for the infection in the surgery area. She doesn't have any more consultations for a couple of weeks, so we're back to waiting. The time between FrogRev's diagnosis, surgery and first consultation apparently happened in record time, so there's no rush in getting to the radiation step. We'll post more when we know more, or when FrogRev needs an outlet.