Surgery: Options and decisions

Before even meeting with the surgeon (Dr. Lal), we were made aware of the possible surgical options (listed here), but in our meeting with Dr. Lal, our tentative decisions were supported, and we were even more confident that our plan was the best for me.

All research shows that there's not a difference in treatment effectiveness whether choosing lumpectomy and radiation or mastectomy (and each doctor that I talked to said the same thing).  Obviously a mastectomy is a more intense surgery with more risky side effects.  However, lumpectomy requires that clean margins are achieved in surgery (and I know more than one person who had multiple lumpectomies due to inability to obtain clean margins) AND you must do 6 1/2 weeks of daily radiation following a lumpectomy.  Reconstruction is often more difficult to achieve balance following lumpectomy, and especially for a woman with small breasts (ahem...), it's a more noticeable change.  Radiation can mess up the reconstruction process, as it changes the tissues where the implant goes.  And we all have our baggage, and I know that my mom has been most frustrated by her changes that came about due to her radiation treatments for her cancer.  So if possible, I'd like to avoid that, thus leaning to mastectomy.

Furthermore, in addition to being Grade 3, my cancer is Ki67 positive.  The Ki67 gene codes for the Ki67 protein, which is involved in cell proliferation.  The higher the Ki67 (measured in percent of cells actively expressing it at time of biopsy), the more cells actively proliferating, and the more aggressive cancer.  Anything over 20% is considered positive.  My tumors were 62% and 55% (although the navigator told me that some women have over 90%, so not the most aggressive).  Still, enough to freak me out.  A combination of the Ki67+, Grade 3, and early diagnosis means a higher likelihood of recurrence (although there's some controversy surrounding the predictive value of Ki67, and not all labs even check it).  But it's a BREAST cancer and if there's no breast, there's nowhere for it to return to.

So I chose to do a bilateral mastectomy.  And while I like to think that I'm not the least vain person, those around me soon convinced me that I'm young (ha!) and healthy, and active, and that doing reconstruction made sense.  Additionally, it's easier to begin the reconstruction right along with the mastectomy (and I would much rather get this all done at once).   

Currently, surgery is scheduled for tomorrow--January 8th--at 2:00 pm. (There's a possibility the time might be moved up, as the plastic surgeon had a morning cancellation and would rather start earlier) It should be a 6-7 hour surgery, and I'd be lying if I said I wasn't somewhat scared.  I am not a fan of anesthesia at all, and I have never had general anesthesia.  I had hernia repair as a teenager with a local (was awake through it and remember feeling like they'd sliced me from stem to stern!); I gave birth to three children without any anesthesia--including one pitocin-induction; I regularly do dental work without anesthesia (my dentist hates that!).  Finally, I've been in the waiting room for all six of my mom's surgeries in the last seven years.  I know what the waiting is like, and none of her surgeries have lasted that long.  I feel awful thinking of Greg waiting for me for that long.

It's going to be a long day and a lot of procedures.  The "old" way to do mastectomies was to take out as many lymph nodes as they could find during surgery.  But there were a lot of issues following removal of lymph nodes, as you can imagine.  The lymph system is very important in immunity, and removing nodes disrupts the flow of the lymphatics, so any possible infection or injury in that area (essentially the whole right side of the chest, neck, arm) would be affected.  The new procedure is to only remove sentinel lymph nodes to check for cancer and if there's no cancer, no further lymph nodes are removed.  Because there are between 5 and 40 lymph nodes that drain each breast, removing the fewest number allows the best return to normal function.  In order to determine which lymph nodes are the first to drain the breast, a radioactive material is injected into the breast along with a blue dye, and then the surgeon can tell which nodes are the sentinel ones.  So tomorrow I arrive two hours before they inject me with the radioactive stuff, which happens three hours before the actual surgery starts (doing the math, that means 9:00 am arrival time).  

The surgery itself will include the sentinel node biopsy (pathology immediately examines the nodes and if no cancer, that's done; if cancer, they take the next nodes and so on until they get clean ones), placement of a port-a-cath on my left side for chemotherapy, double breast removal, and the plastic surgery.  The breast implants will go under the muscle, which lies flat against the rib cage, and so a pocket needs to be made for them to fit.  The muscle is separated and cadaver skin is sewn to expand that area.  My cells will repopulate the cadaver skin, making it my own.  A saline expander will be inserted in this pocket and it will be gradually inflated (in the doctor's office) as I heal to make room for the eventual permanent silicone implant (this is the part that can get messed up due to radiation).  The surgery to put in the permanent implant is supposed to be pretty minor.

The thing I'm most worried about after the anesthesia is the pain relief.  Not that I am worried about being in pain, but that I don't do well with pain meds.  I am horribly vomit-phobic, and even laughing gas at the dentist makes me nauseous.  My mom had issues with multiple pain meds after her surgeries (nausea and blood pressure issues) and I am so sensitive to any medications that I don't know what strong pain meds will do to me.  This is the other reason I'm opting to do it all at once--so I hopefully won't need to have surgery again!

But it's the first step in my battle, so I will do it.  And I know that I have the strength of so many people who will be with me in spirit tomorrow.

~~~

Finally, to close with some humor, I have been replaying in my mind a running gag from Arrested Development since the first meeting with the plastic surgeon.  But after yesterday, when he marked me up with the surgical lines and reality really set in, I've been thinking of it even more.  I really have this bizarre desire to pull a Kitty at least once before my surgery tomorrow: