Monday, June 16, 2008

New girls?

Months before Linda was diagnosed, one of her good friends was also diagnosed with breast cancer. Linda's reaction at that time was "If I ever get breast cancer, I'd have them both removed, no question about it". She couldn't understand why there was even a question in her friend's mind. Why would she take the chance of it coming back?

A complete mastectomy has pretty much been the de facto outcome for breast cancer over the past 50 years. Today, there are many options in breast conservation treatment (lumpectomy) as well as re-constructive surgery after a mastectomy. There are some cases where a modified mastectomy (either one or both breasts removed) is recommended. In particular, during genetic testing, if the BRCA1 or BRCA2 gene mutation is detected (the "breast cancer gene"), then the odds of re-occurence are significantly higher and a complete mastectomy (and hysterectomy) is often the chosen course of treatment. If the tumor is large or the surgeon is unable to get "clear margins" during a lumpectomy, then the entire breast may also be removed. Clear margins simply means that when the surgeon removes the tumor during a lumpectomy, a biopsy on the mass is performed to ensure that there is a clean margin around the tumor free of disease, meaning that the tumor hasn't spread outside the margins. Another reason for a complete mastectomy is the peace of mind it may bring. Insurance will typically cover all the costs associated with breast reconstruction, or as Linda referred to it, "getting some new girls".

After several weeks, Linda had recovered enough from her last chemo, and the lumpectomy vs. mastectomy decision we had talked about 100 times was finally before us. Modern research has shown that, outside the special cases above, the long term survival odds for lumpectomy vs. mastectomy are the same and the odds for reoccurence are only slightly higher for lumpectomy vs. mastectomy. According to Dr H., since the stats are about 10 years old, before BRCA testing, 20% of those lumpectomies were probably performed on BRCA+ women and therefore the reoccurrence odds are likely skewed. If you factor that in, as well as cases where clear margins weren't achieved and cases where the woman chose not to follow up with radiation treatment, the odds for reoccurence are probably about the same.

Linda's BRCA testing came back negative, which was a huge relief, not only for Linda but also for our daughter (she wasn't aware of the test implications but luckily we can tell her the good news when it is appropriate). Even so, Linda was still contemplating a complete bilateral mastectomy at this point. It wasn't until we were told that Linda would need to wait about 1 year for breast reconstruction that she decided for a lumpectomy. You see, her follow-up radiation would end up damaging any implants that were put in during the mastectomy (something were weren't made aware of until Linda talked with her radio oncologist). So they would need to do the mastectomy, then the radiation, then let the area heal, then do the reconstruction. After everything she'd been through up until this point, and pretty much even odds, the thought of 1 year without breasts is not something Linda was willing to face.

I like boobs just like the next guy, maybe even more, but not for one second did I ever consider that to be a factor in our decision. I'd be lying if I said I didn't think about it. Of course I did. I think about boobs maybe 25-35 times a day, and sometimes they are my wife's :) Seriously, I wanted her to be healthy and happy about her decision whatever it was. As it turned out, we decided against the "new rack" and opted for the less invasive lumpectomy. The boobs I met when they were 24 were now 39 and would be coming home from the surgery which was now scheduled for May 23.

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