Today we met with the plastic surgeon to discuss reconstruction. What once would have been awkward having digital photos taken of my chest now is routine. Based on his assessment given my girls are even and not sagging he recommended direct to implant reconstruction even with the radiation. He would perform the surgery once my surgical oncologist (Dr Gadd) finished the mastectomy. Assuming the tissue has good blood flow we would do the implant. If it did not, they have an alloderm "sling" that could be implanted that the skin would adhere to and help take pressure off the healing skin. Since alloderm is synthetic skin it can better tolerate radiation as well. And if the tissue was in really bad shape he would put in tissue expanders with the alloderm that would allow time for the tissue to heal while gradually filling the implant before the start of radiation. Tissue expanders have to be filled before radiation as the skin will harden and scar tissue (capsular contracture) will occur. With the alloderm hopefully I would be able to handle the scarring and damage from radiation. If not, they can go back in, remove the implant, and cut through the scar tissue to provide relief. But typically it's not a good idea to have surgery on a radiated breast due to difficulty with the skin healing. No one said this road was easy. Whether he did one side or both sides it didn't matter to him from a reconstruction perspective, he could do the girls at the same time or in separate procedures. Obviously the risk with doing one vs two is double the chances of complications and a longer recovery time.
My medical oncologist (Dr Peppercorn) called this week to discuss some of my concerns following the unsuccessful surgery. He confirmed I am stage 3 given tumor size and lymph node involvement, but that it wouldn't have changed the treatment plan in anyway. We discussed the ER+ vs triple negative concern, his response is that the tissue has consistently shown some ER+ and I did have a good response to chemo so he wants to keep ER+ responsive drugs in the treatment plan. We discussed more IV chemo vs pill chemo, his response was that there have been studies on 4 vs 6 rounds of Taxol but found the 6 rounds provided no additional benefit for the additional toxicity exposure. And while I'd read that some people had 12 rounds of Taxol, it was low dose, not the dense dose stuff I took. He also shared that there was a study for AC vs Xeloda, Xeloda being viewed as potentially "kindler gentler" version of AC particularly for elderly patients, but Xeloda couldn't beat the performance of AC. That said, Xeloda still shows good statistical response for residual cancer so will be part of my treatment plan. I will start low dose Xeloda during radiation then high dose for 6 months after radiation. Will be two weeks on, one week off. This is still chemo, not Advil, so I will have to get my blood count checked during my off week. Side effects of Xeloda are diaherra, rash to the hands and feet, and low blood counts. The good news I will get to keep my regrown hair. Should the rash get bad they will lower my dose to allow my skin to heal. Frying from the inside out! The next major decision will be on endocrine therapy following Xeloda. I can take standard endocrine therapy or take part in a clinical trial with endocrine therapy plus a drug called palbociclib. But won't have to make that decision until next summer.
In front of me now is the decision to do a unilateral or bilateral mastectomy. Unilateral has better short term benefits - less invasive, less recovery, less risk, and would still be able to move my right arm. Bilateral has better long term benefits - less risk of cancer recurrence and better cosmetic result keeping the girls even. What matters most to me is chance of recurrence, which is 15-20% in the left and 10% every 10 yrs in the right. So at 60 yrs old it will be 20/20, at 70 it will be 20/30, and 80 it will be 20/40. Since the surgeons have to coordinate calendars, it is likely my OR date will change. That gives me a few more days to think about it. I will be one happy camper when this is behind me!
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