BREAST CANCER TREATMENT CHOICES

Breast cancer can be treated with a mastectomy or breast preservation surgery, lumpectomy, followed by radiation and sometimes chemotherapy.  These are the best ways to prevent reoccurrence of cancer.  The most common place for cancer to come back is in the same area where it was found the first time.

          The determination of which treatment is best for an individual is based on the pathology of the disease.  The initial biopsy, which is done when the cancer is first suspected, will tell what type of cancer is present and whether it is hormone receptive.  The knowledge of hormone receptors, or not, found will be part of the decision making information for an individual’s treatment.  Some types of tumors are stimulated by normal hormones found in a woman’s body, such as progesterone, estrogen, and HER-2.  A tumor may show a positive response to one or more of these hormones.  By knowing this information, a plan of treatment can be offered that will improve a woman’s chances of cancer free survival.

          The pathology from the surgery, done to remove the cancer tumor, will tell if the entire tumor was removed and if cancer was found in the lymph nodes.  During surgery the surgeon can see the cancer tumor, but not all of the cancer cells can be visualized.  So the tumor is sent to a pathologist who puts the tumor and the surrounding tissue that was removed by the surgeon under a microscope.  This way cancer cells that might be outside the main tumor can be seen.  The lymph nodes that were removed in surgery can also be looked at under a microscope and it can be determined if there are cancer cells found in the lymph nodes.  Often a Sentinel Node can be found, if a dye is used before surgery.  This dye is injected before surgery and will show which node is the main node that drains fluid from the cancer tumor site.  (The lymphatic system drains non blood fluids throughout the body.)

If lymph nodes are found to have cancer cells within them the cancer has moved from the tumor site to other areas in the body.  This movement of cancer cells away from the tumor indicates metastasis, or stray cancer cells that are traveling in the body.  The final pathology will offer much information about the type of cancer, the location of the cancer and how best to treat the cancer to provide a cancer free life for the woman.

          A woman who has been diagnosed with cancer, from a biopsy, then will see a surgeon who specializes in breast cancer.  Surgery to remove the tumor is always needed, as long as the tumor is in the breast it will grow and chances are the cancer cells will travel away from the main tumor and spread throughout the body.  These cells that move away from the main tumor will settle and grow into tumors in other parts of the body, not just the breast. The surgeon will ask questions about the woman’s health and ask about the woman’s family.  If a woman has family members that have, or have had breast cancer, this information will be included in treatment decisions.  The surgeon then will discuss ways to treat the cancer.  A mastectomy which is a removal of the breast that has the cancer in it, with one or more lymph nodes removed is one choice.  A lumpectomy which is removal of the cancer tumor and a small amount of tissue surrounding the tumor is another choice.    The size of the tumor, determined by the mammogram, will influence these choices.  If the tumor is large a lumpectomy may not be a good choice.  The smaller the tumor, the better the chances of survival for the woman.  The larger the tumor the more involved the surgery will need to be, such as a mastectomy.  Sometimes chemotherapy is needed before surgery; the chemotherapy will hopefully shrink the tumor and kill cancer cells that may have moved away from the main tumor (metastasized).  When this is done before the surgery, the hope is that after surgery most or all of the cancer will be gone and only radiation will be needed.  Chemotherapy may be needed after surgery depending on the type and stage of the cancer.

          Often the surgeon will ask a woman to see a radiation oncologist before her surgery.  This consultation will allow the radiation oncologist, another cancer doctor who specializes in radiation, to review the woman’s case and to offer choices of treatment.  The options this doctor may offer are whole breast radiation after surgery, or partial breast radiation after surgery, or no radiation if a woman has a mastectomy and no cancer cells are found outside the breast that was removed in surgery.

          One type of partial breast radiation is brachytherapy.  Breast brachytherapy has been available for some time, but not all doctors are familiar with it.  Brachytherapy of the breast is a good choice for some women.  The size of the tumor and the location of the tumor are two of the determinations if this is a good choice.  If the cancer is found out side of the breast, brachytherapy is not a choice for a woman.  Brachytherapy is radiation given to the area where the cancer tumor was.  This is where most cancers come back, in the same area they were to begin with.  Brachytherapy can be given over five days, where as whole breast radiation if given over 6 weeks.  This is an advantage for women who do not live near a cancer treatment center, women who live busy lives (most women do), or women who don’t want to prolong their treatments. When a woman chooses breast brachytherapy the applicator that will allow radiation to go right into the space where the cancer was; is placed at the time of surgery.  Brachy means close. It is another advantage of brachytherapy.   Only the tissue around where the cancer tumor was is radiated; the normal tissue is exposed either not at all or to such a low level of radiation it is not affected by the radiation.

The brachytherapy treatments are given two times a day, at least 6 hours between treatments, for a total of ten treatments. This type of radiation requires special equipment and knowledge, many cancer centers now have both the equipment and the radiation oncologists that are specialized in this treatment.

           The other type of partial breast radiation is accelerated partial breast radiation.  This type of treatment also requires that the tumor is small and no cancer has been found outside the breast.  This type of radiation can be given over a shortened time, days instead of weeks.  The equipment to give these treatments is IMRT, which most if not all cancer centers have.  This is external beam radiation that goes from the outside of the breast to the inside of the breast and radiates all of the tissue in the area.  The advantages to this treatment are it takes less time, although it is also two treatments a day at least 6 hours apart, and it only radiates the portion of the breast where the cancer tumor was.

          Whole breast radiation has been around for a very long time and is what all women received until the past 15 years or so.  This type of radiation involves one treatment a day Monday through Friday for 6 weeks, a total of 30 treatments.  It is external beam radiation that goes from the outside of the breast to the inside of the breast and radiates all of the tissue in the breast and surrounding area, not just the area where the tumor was.  This type of treatment is favored when the tumor is larger or the cancer cells were found outside of the breast, such as in one or more lymph nodes.  The lymph nodes can be included in the whole breast radiation.  Some women will choose whole breast radiation because it has been used for so very long.  Partial breast radiation has shown the same effectiveness in studies, when the woman is a candidate for brachytherapy.

          Chemotherapy and biological therapy or hormone therapies are needed in specific cases.  These treatment choices should be discussed with the surgeon, the radiation oncologist and a medical oncologist.

What ever choose a woman is given they need to be well understood before she makes her decision.  Asking questions of her doctors and talking to her loved ones will be helpful.  If a woman’s decision is thought out it will probably be the best choice for her.  Prayer always is beneficial.

God Bless you.

DEALING WITH DEATH

Every person will die.  All of us are mortal creatures. Many of us don’t deal with this fact, but it is true.  None of us are in any hurry to die, but the sooner we face our own mortality the better this life will be.

          This is a talk I give to the student nurses I work with.  It is after I have spent some time with each of them, one on one.  This talk is one I wish I had been given in my youth.  I was fortunate to attend a Catholic nursing school.  It was a special experience, especially since I am not a Catholic.

          I went to nursing school thinking nuns were angels sent to Earth by God to help people on this life’s journey. (I had seen nuns only in movies such as the Bell’s of Saint Mary, and the movie nuns were ever so sweet and pious and kind.)  I found out nuns are very human women who can be very determined and a bit rigid at times.  The nuns at my nursing school meant for the nursing students to walk a very narrow path and to follow the rules strictly.  Yes, I bristled at this; it was 1970 a tumultuous time in America.  Surprisingly I found myself liking the structure and doing well in school.  The discipline and study hours, along with morning prayers were just what I needed. So I learned much about the workings of the human body and how to care for its needs in a Christian environment.  This Christian atmosphere included the emphasis of treating each patient as a child of God; not just the gallbladder in room 402.  The Holistic approach was stressed, treating the whole person “mind, body and spirit”. 

          I am saying I grew a lot in the three years I lived at nursing school.  My faith deepened in the Lord and I learned to accept and respect a religion different from my own.  This is a big part of who I am today.

          When I speak to nursing students today I openly tell them I am a Christian and I believe this life is just the beginning of what is ahead for me.

I also tell them I am not preaching to them.  I am telling them my beliefs so they know I have thought of my own mortality.  I say that until each of us considers our own mortality we can not accept or deal with another person’s death.  In nursing, as in life, I have dealt with death.  Sometimes it had been very up close and personal.  Caring for some one who I have become fond of, caring for them and their family as that patient dies, I have shed many tears.  If I didn’t have a sense of my own mortality I would not have been able to continue working as a nurse.  I would have been devastated by each and every death I witnessed.  I have seen many nurses who have left nursing “because it is too hard” or the honest “I can’t handle this”.

          This is a shame because many of these nurses were very good at caring for patients.  They were well educated and knowledgeable, kind and caring, but “people aren’t supposed to die”.  One nurse told me this and I was flabbergasted.  Nurses don’t become nurses to watch people die, this is true.  We become nurses to help them recover their health.  We study and read the scientific journals to keep up with all the new fancy things that are here or are coming, to help in caring for and curing patients from their diseases.  We keep up with the evidenced based research in nursing. We are willing to work night shifts, weekends, holidays and 12 hour shifts to be there for the patients.  We are willing to endure the back aches, the running around, the anger of patients and their families, when we can’t be every where at the same time, and the over time, spent finishing our charting.  But unless we can accept mortality we just can’t keep working as nurses.  It hurts too much.

          The human body wears out.  This is a fact.  It may wear out from disease or from old age but it wears out. Some experience a trauma that can not be overcome; the damage is too much to heal from.  Each of our bodies will eventually give up the ghost.

          I suggest to the student nurses, and to each of us, to take some time and think about what happens to you when you die.  We all have a soul, some call it a spirit, and this is the essence of who we really are.  This soul or spirit is the most important part of our being.  Yet so often in our day to day lives we ignore it or don’t give it a thought.  I ask you to ponder your true existence, that of your soul.  At least figure out that you have a soul, you may call it a spirit.  I want you to know that your soul doesn’t die when your body dies.

          I listen to the radio on my way to work and often find Sister Ann Shield’s program “Food for the Journey”.  (Yes, I’m back to those Catholic nuns again.)  Her program is only 15 minutes; she reads from the Bible and talks about how to enrich life each day by drawing nearer to our Creator, God.  This reminds me of morning prayers back in nursing school and it helps me start my day in a very positive way.  Strengthened for whatever will come my way during the day.

          You may not be a Christian, but believe me you have a soul and a spirit that needs tending too.  How you go about this is your own business, of course.  But I ask you, for yourself and for your patients, to consider what will happen to you (your soul) when you die.  The time you give to this important matter will aid you in your nursing career, I promise.  You will probably still shed some tears along the way, I do.  Once you figure out your own mortality and deal with that fact, all of life will be easier.

HAVE CANCER....GET ORGANIZED

When you have cancer you will be going to many different doctors.  Each time you see a specialist this doctor will need to know your specific diagnosis and specifics about you.  Oncologists need to know everything they can about you and your individual case, so they can offer the best possible advice and treatment plan.

You probably started with your primary care doctor, and then were referred to a surgeon or urologist or medical oncologist or radiation oncologist or all of them.  Each time you meet a new doctor they will need to review all of your tests and procedures that you have had done.  The doctor’s are supposed to send all of this information to the next doctor before you arrive.  Sometimes there are delays in transferring your information to the next doctor.  This is a delay that can be avoided, and you can help.  I know you are feeling overwhelmed by your diagnosis of cancer but by getting organized you can feel more in control of what is happening to you. 

Every cancer patient has a team of doctors, nurses, pharmacists and others that are working for you and towards your cure.  Being a part of that team will help you feel that you haven’t lost control over your body or your life.  A patient often feels like they have become an object rather than a person.  You can feel like you are just following instructions: take this pill at such and such a time, be at the hospital for this test at this time, show up for chemo on time, don’t be late for your radiation treatment, etc.  Yes it is important to do all of the above things.  But you can have influence on your care by becoming a true member of this team that wants to help you get well.

One of the ways you can do this is to start a notebook or file containing your journey through cancer.  You can request and receive copies of your test results as you go along.  An example is to ask for your pathology report.  This where the whole journey starts, the diagnosis of cancer.  Each doctor you visit will need to see the pathology report to know exactly which type of cancer you have. Not all breast cancers are the same type of cancer and the type of cancer you have will determine the type of treatment you will need to have.  The same thing is true of prostate, lung, brain, colorectal, leukemia, lymphoma and other cancers.  So the pathology report is key information.

          Other things that will help determine your treatment are your diagnostic imaging reports and films.  These may include X-rays, Cat scans, Pet scans, Pet/CT scans, MRIs, and Mammograms, among others.  When you go for these tests you can ask for your own copy of the report and a CD of the images themselves.  You should be able to get a copy of the CD at the time you have completed the test.  It will take awhile for the radiologist to read and review your test so the report won’t be available immediately after the test, but may be sent to you if you request this.

          Your blood work, laboratory tests, are also important for each doctor to know.  A PSA level is essential in prostate cancer.  Blood work such as your blood counts and electrolyte levels are important when you are having chemotherapy or biotherapy.  You can ask which ever doctor orders these tests to give you a copy of these results.

          If you have had surgery, a copy of your operative report is helpful to have.  You can ask your surgeon for this when you go for your first appointment after your surgery.

          A list of all of the medication that you are taking or have taken in the past few months is essential for all of your doctors to have.  This list should include prescribed medications, vitamins, minerals, supplements and any other over the counter medicine such as pain relievers (Tylenol, Advil, Motrin, Aleve etc.) and allergy or cold pills.  Keeping this list up to date is important, so if you stop taking a medication please put a line through your list so the doctor will know you were on this medication but aren’t now.  Also if you are taking recreational drugs, it is important to tell this to your doctor.

          By having a file or notebook in which to keep all of this information, you are ready at all times to see a doctor, who with this information can be up to date with your case with a reading of your tests and results.

          Another good idea is to have a calendar to help you coordinate your life.  Since you will probably be busy with appointments relating to your cancer and hopefully you will still be able to live a real life, a calendar will help you plan.  By checking with the calendar you can find time for friends and activities that you enjoy.  It will help you organize better.  If you have an appointment, which you will be done with just before lunch, perhaps you will want to meet a friend for lunch at a restaurant in the same neighborhood where your appointment was.  Or if you get tired after chemotherapy, you may want to plan a nap before your meet with friends or family, or you may wish to reschedule meeting with loved ones until the next day.  Keeping track of appointments and planning ahead is a great way to maintain control of your life.

          Many people, but not all, find keeping a personal journal of there cancer experience helpful.  This may be a good way to help deal with the stress of cancer.  You may wish to do this in a private diary or you may wish to share your journey with friends on the web.  There are some free sites on the web that help with this such as: CaringBridge and CarePages. 

          These are some suggestions that I hope will help you to feel more a part of the team that wants to cure your cancer.

SYMPTOMS OF COLON CANCER

Symptoms of colon cancer can be sneaky, because we all have some of these symptoms once in a while.  The time to be concerned is if the symptoms persist for two weeks or more.  We all have bowel movements and it is alright to talk to your doctor about your bowel habits.

Changes in bowel habits can be a clue to the fact that our colon is not healthy.  This doesn’t necessarily mean there is a significant problem, but if these changes continue over a couple weeks, it is time to talk to the doctor. A change is anything that is different for us.  It may be constipation when this has never been a problem for you before or it may be diarrhea that lasts for two weeks.  The first thing to consider, of course, is what have you been eating?  We all have bouts of constipation, if we aren’t getting enough fruits and vegetables; so the first thing we should do is increase or start eating fruits and vegetables.  Diarrhea hits if we eat too many fruits and vegetables, or too much greasy food, or if we eat something that has spoiled.  You should decrease the amounts of fruits and vegetables, and or the amount of fried foods, when you develop diarrhea.  A bacteria or “bug” that is going around can gives you diarrhea and, in and of itself, isn’t a cause to panic about symptoms of colon cancer.  But if these symptoms go on for 2 or more weeks, then it is time to call your doctor.

Diarrhea is when you have loose or liquid stool or increased number of stools in a day.  Constipation is when you have hard stools or you haven’t had a bowel movement for 3 or more days.  Everyone’s bowel habits vary from time to time and what is normal for one person is not necessarily normal for the next person.  It is changes that you should pay attention to.

Bright red or very dark red blood in your stools is another sign not all is well.  The most common cause of blood in stools is hemorrhoids. These are tags that form in the rectum that can fill with blood and then break and bleed.  The bleeding from hemorrhoids should not last for more than a day or two at the most.  So when you continue to have blood in your stools this is a symptom that needs to be reported and checked by your doctor.

Narrow stools or stools that are pencil shaped are another sign that the colon is not healthy.  Again if this continues it is time to call your doctor.

Another sign of trouble is increased and persistent gas pain, bloating, a feeling of fullness with or with out decreased appetite and abdominal (tummy) cramping that continues for 2 weeks.

Again symptoms of colon cancer are not that uncommon to us.  We all go through times that our colons aren’t healthy, but when these changes go on for 2 weeks, it is time to go to the doctor and find out why things aren’t normal.  Symptoms of colon cancer can be caused by other things, so why worry?  Go get checked out if you have:

          Changes in your bowel movements

          Constipation         

          Diarrhea

          Blood in your stools

          Stools thinner than normal

When you are aware of what is normal and what is not normal you are better prepared to talk to your doctor about your body.

So eat your fruits and vegetables and have your colonoscopy when you are fifty and every 5 years after that.

Wishing you good colon health and God Bless you.