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Romey View Drop Down
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    Posted: Aug 22 2012 at 9:14am
Hello all, new to your forum. I was diagnosed with trip neg Breast cancer on July 30,2012. It has been a rollercoaster ride every since that day. I am currently in the gathering info part. My biopsy came back as triple negative. I had a contrast MRI 2 weeks ago to check my opposite breast. The results of that showed another 6.6 mm mass near my sternum and an abnormal looking node in the clavicle of the opposite side of my tumor (2.3 cm) So yesterday I had a PET scan to stage my cancer. I have already seen the surgeon and was orginally scheduled to have a lumpectomy last Thurs. (Aug 16). Her nurse called the day of my pre-op and said I should see the Oncologist and then get back to them?? I have seen the Oncologist and he said once the scan results are back we can decide how to proceed. I have been on the breastcancer org site and it appears many trip neg. decide to have mastectomy. Is this the norm? I have been afraid to ask either dr. since neither really gave me that option. Should I bring it up? I dont want to ASK for a mastectomy if I dont need one, but I'm afraid I may be missing a piece of the puzzle on how many trip neg women take this bold step. Does Trip Neg "mean" mastectomy? Thanks in advance
Romey 
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Natalie View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Natalie Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 10:34am
I am sorry that you had to join this particular club. Because us Triple negatives can't take the hormone blocking meds that most breast cancers can, we are at a much higher risk for recurrence. Because of this we only have chemo, surgery & radiation. Some girls choose neoadjuvent treatment and some don't.

Ultimately the decision is yours. I know 3 out of the for surgeons I consulted with said lumpectomy. I chose the Mastectomy, because I wanted to reduce my risk as much as possible. I was informed for many years that I had LOADS of calcifications, always asked if this made me at a higher risk for breast cancer. I was always told no, but this is not the case.
I also had load vitamin D levels when diagnosed, have you had your vitamin D checked? 
Also highly recommended is BRACA gene testing, it is quite expensive if your insurance does not cover the cost.

What is normal? There is no cookie cutter answer when each of us must live in our own heads and decide what is best for our individual selves. What does seem cookie cutter style sometimes are the surgeons. Most of us have had some sort of combination of ACT.

Wait for all the results to be in, do more gathering and then you can make a better informed decision.

You came to a great forum with many knowledgeable people that I am sure will be along soon.
Take deep breaths and do one step at a time. keep us updated.
All my best,
Natalie 




TNBC stage1 size 1.8, grade3 no nodes 4/11 Lumpectomy 5/11 4cycles DD A/C 4cycles DD Taxol. Double Mastectomy 12/11 BRCA all neg
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Post Options Post Options   Thanks (0) Thanks(0)   Quote CAfree12 Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 11:07am
HI Romey,
I was diagnosed last October.  I am a nurse working in oncology so I came into this diagnosis with a slightly different perspective.  My tumor was very lateral, almost on the side of my chest and my surgeon initially didn't think I needed a mastectomy, but once we learned it was Triple Negative there was no doubt in my mind that I wanted a double mastectomy with tissue expanders.  Part of my decision was influenced by how large my breasts were and with scoliosis I couldn't afford to be out of balance for six months or longer.
I agree that meeting with oncologist prior to surgery is wise because sometimes they recommend chemo prior to surgery depending on your tumor size.  If there is any question of another spot in the opposite breast, I wouldn't hesitate to have the double mastectomy done.  I have never regretted it!
Diagnosed Oct 2011 @ age 53, Stage 1c, grade 3, 1.5Cm, neg nodes;double mastectomy with TE, dose dense AC+Taxol; BRCA neg; treatments finished April 2012
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Post Options Post Options   Thanks (0) Thanks(0)   Quote *Nancy Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 11:20am
Hello Romey,
I am sorry you've had to get on this roller coaster with us. That's what it feels like, in many ways. I was diagnosed with triple negative in March 2010. I chose the lumpectomy and it was a good decision for me. There are so many factors to consider when making this tough decision. Look at family history, your age, the size of the tumor, its stage, your ability to cope with surgery, your gut feeling. The best thing you can do is what you are doing right now: read absolutely everything you can find and educate yourself. The more you know, the better you'll be able to understand options and recommendations.
Take care,
~Nancy~
Dx March 2010, age 54, 5 mm tumor, Stage Ia, Grade 3, 0/3 Nodes, Ki-67 70%,

Lumpectomy April 2010, TC x 4, Rads x 33, Treatment completed Sept 2010, NED 06/17
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 12:16pm
Hi Romey,

TN doesn't necessarily mean mastectomy.  It can be a personal choice depending on your tumor size, stage, etc.  Many times if the tumor is larger, they'll try to do chemo first to shrink the tumor and have a better prognosis.  It can also let the oncologist know if your tumor is responding to that particular chemo. 

When you meet with your oncologist after you get all your test results, ask them what stage you are.  Also ask if chemo first would be recommended and if there are any clinical trials that might fit your situation.  You might ask what type of surgery would they recommend and the benefits/risks of each procedure.

Wishing you the best.  Please keep us posted on your tests and what you decide.

Donna
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote turtle Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 1:01pm
Romey,

Before I address your mastectomy question, I want to back up to the info you have provided about your scans. If the other 'spots' that have lit up on your scans are cancerous, you may be staged differently (i.e. IV), and thus your treatment program will likely be adjusted accordingly. Your surgeon wisely put on the brakes, and recommended that you consult first with your oncologist. I suspect that once you have this meeting (which may already have taken place), your course of action may change, and you may be recommended to start chemotherapy prior to undergoing any surgery (this is known as neoadjuvant chemotherapy). As it is extremely important to choose an appropriate course regarding your chemotherapy, you may want to consider getting a second opinion from a NCCN-accredited Cancer Center. I hope that others will post info regarding second opinions in locations that would be convenient to you in Virginia. 

Regarding the mastectomy....I am not aware of any clinical studies that definitively state that the OS (overall survival) or PFS (progression free survival) of women having mastectomy is greater than those who opt for lumpectomy. It is my understanding that in the case of lumpectomy, adjuvant radiation therapy is often performed, and I don't know if this is factored in to the effects on survival when comparing lumpectomy vs. mastectomy. Incidentally, radiation therapy is becoming increasingly recommended following mastectomy in certain high risk patients (hormone receptor 'triple' negative being one of those 'high' risks). The decision to chose mastectomy can be based on many factors, including: (1) patient's personal choice, (2) location of the tumor--I can give you myself as an example: my tumor was very close to the nipple, so the nipple would have to have been removed in any surgery, and my breast are small, so it didn't really matter to me to remove them entirely, (3) size of the tumor, among others. Thus as Donna said, TN doesn't mean mastectomy.

I hope this info has been helpful. There are many well-informed folks who post on this site, so please don't hesitate to ask any and all questions. I encourage you to do the same with your doctors, particularly your oncologist. Bring a list of questions to ask your Onc, and take notes if you feel overwhelmed by the info they give you. Don't be afraid to be your own advocate!

Best of luck, and let us know how you are doing!
DX IDC TNBC 1/15/12 @ 46; MRI 2.4cm gr3 BRCA2+ 6174delT; LMX 1/31/12 2.5cm, pT2pNO(i)pMX, lymphovascular invasion present; 2/20/12 TAC X 6; 7/2/12 Rad X 25; 9/27/2012 2nd mastectomy & BSO surgery
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Romey Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 1:08pm
Thanks for your responses, I did check out the area of what to ask your doctor. OMGosh..so very helpful. I go on Friday and the poor guys not gonna know what hit him as I have wrote down so many! Donna, Maybe one day I will figure out what all the abbreviations on your post mean. I suppose it means you have survived and are well enough to guide and give others of us HOPE! Heart
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SagePatientAdvocates Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 1:21pm
Dear Romey,

Welcome and glad you found us and never be afraid to ask anything...

it is essential, in my unprofessional view, that you become as knowledgeable about TNBC as you can, as quickly as you can and become an advocate for yourself. This is about your life and the best possible treatment plan. You need to be in the hands of a TNBC savvy medical team that can properly advise you. One thing that may be suggested to you is neoadjuvant chemotherapy i.e. that is chemotherapy prior to surgery. 

Also, if you have not been tested for the BRCA mutation I would suggest seeing a Certified Genetic Counselor and get tested, even absent a family history of cancer.

I would suggest you consider seeing Dr. Tanya Prowell at John Hopkins Comprehensive Cancer Center in Baltimore, MD. I believe they have their 'second opinion' clinics on Wednesdays. 


http://www.hopkinsmedicine.org/doctors/results/directory/profile/0012228/tanya-prowell?vip_doc=false&lastName=Prowell&nameSearch=Go&hch_doc=no&gs_doc=yes&jh_doc=yes&CLEARPAGECACHE=false&cp_doc=yes

I am sending you my contact info in a PM. I have some other thoughts on TNBC experts if you are able to travel. I think would be easiest to discuss on the phone. I will not give you any medical advice but hopefully a talk will be of some use to you.

good luck to you.

warmly,

Steve



I am a BRCA1+ grandson, son and father of women affected by breast/oc-my daughter inherited mutation from me, and at 36, was dx 2004 TNBC I am a volunteer patient advocate with SAGE Patient Advocates
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Post Options Post Options   Thanks (0) Thanks(0)   Quote mainsailset Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 1:36pm
I'm one of those that ended up having a mast AFTER my chemo. I was forever grateful that I stumbled upon that course because the one and only useful thing that my rotten tumor did for me was to stay in during chemo so that the doctor could use it's size and characteristics to tell if the chemo was making headway. There was something about having the onc do a physical and tell me that the tumor was softening and getting smaller that helped keep me going during all those anxious months. It was so hard to think at first of leaving it in...I wanted that sucker ripped out and tossed into outer space...but in the end, having it stay in until after chemo was very helpful.
 
So I would suggest having a discussion with your onc and/or team now about the advantages of leaving the tumor in during chemo. After chemo, it will have changed size and actually be gone and then you can have a different opportunity to look into lumpectomy vs mast. I always think of it as giving myself more control and more options. Just one woman's thoughts.
 
Last thought, please do think about the option of enrolling in a clinical trial. I did and will forever be thankful.
Best,
Mainy
dx 7/08 TN 14x6.5x5.5 cm tumor

3 Lymph nodes involved, Taxol/Sunitab+AC, 5/09 dbl masectomy, path 2mm tumor removed, lymphs all clear, RAD 32 finished 9/11/09. 9/28 CT clear 10/18/10 CT clear
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Romey Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 3:41pm
Mainy, that was my very FIRST response "Get It Out!" but I am warming to the idea of feeling it melt away and knowing wheather the chemo is actually working. I am clueless about enrolling in a clinical trial?? Steve, I will also see the genetic counselor this Friday, though it has not been approved by my insurance company as of yet? My mother died of cervical cancer on Christmas Day when she was my current age; 48 (Dont think that doesn't weigh heavy on my mind) I also have a triple negative sister who had a lumpectomy and never finished her chemo (no insurance). However she hopefully will be 5 years cancer free this January! I too have cancer prevelant through my family. My sis did not get the genetic testing due to the lack of insurance. So I don't know what will come of this Friday, it will be a big day for my PET results and meeting with the counselor.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote 123Donna Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 3:46pm
Romey,

Here's a link to clinical trials for TNBC and Virginia.  You can modify the search to include other search criteria.

http://www.clinicaltrials.gov/ct2/results?term=triple+negative+breast+cancer+and+virginia&recr=Open&no_unk=Y
DX IDC TNBC 6/09 age 49, Stage 1,Grade 3, 1.5cm,0/5Nodes,KI-67 48%,BRCA-,6/09bi-mx, recon, T/C X4(9/09)
11/10 Recur IM node, Gem,Carb,Iniparib 12/10,MRI NED 2/11,IMRT Radsx40,CT NED11/13,MRI NED3/15

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Post Options Post Options   Thanks (0) Thanks(0)   Quote mainsailset Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 6:35pm
Romey, there is a small window here for you where time is on your side. Getting a 2nd opinion and maybe even a 3rd will give you: 1) a bit more of an education into what's available for you, each doctor has something to offer, 2) not every doctor and every clinic has all clinical trials available to them. They pick and choose and some actually don't have access to a trial for TN, so good to ask 3) try and get as many tests as you can:  get your D tested, get your cholesterol, thyroid, adrenal levels etc all done so that you have a starting score to judge by, it will also give you and your doctor a better understanding of where your body may need some extra help.
 
Get a 3 ring binder to hold your collection of test and scan results, get a business card holder for everyone's card on your team, get a couple of water bottles (I like the ones that have filters in them so that I can fill up wherever I'm at and get good water) get a blood pressure cuff, a body temp gauge and a spiral notebook with a calendar so you can start keeping a diary. You're under more stress than everyday people can even imagine. So do your mind a favor and keep the diary, use the calendar, and don't rely on your memory to keep yourself safe. 
 
Mmmm, I gotta go to you tube...here you go,   http://www.youtube.com/watch?v=MUBnxqEVKlk


Edited by mainsailset - Aug 22 2012 at 6:37pm
dx 7/08 TN 14x6.5x5.5 cm tumor

3 Lymph nodes involved, Taxol/Sunitab+AC, 5/09 dbl masectomy, path 2mm tumor removed, lymphs all clear, RAD 32 finished 9/11/09. 9/28 CT clear 10/18/10 CT clear
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SagePatientAdvocates Quote  Post ReplyReply Direct Link To This Post Posted: Aug 22 2012 at 8:02pm
Dear Romey,

The National Comprehensive Cancer Network (NCCN), an alliance of 21 of the world's leading cancer centers
promulgated new rules earlier this year that state that any woman under the age of 60 who has TNBC, even absent a family history of breast cancer, should be tested for the BRCA mutation. This ruling, I have been told has been followed by the overwhelming majority of insurance companies who now pay for the testing.

Would be happy to give you some more guidance if you can call. Please ask your Certified Genetic Counselor about the ruling.

And I hope you test negative. But knowledge is power and a positive test result wouldbe important on many levels.

warmly,

Steve
I am a BRCA1+ grandson, son and father of women affected by breast/oc-my daughter inherited mutation from me, and at 36, was dx 2004 TNBC I am a volunteer patient advocate with SAGE Patient Advocates
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Romey Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 9:26am
Okay, so I saw that my insurance still had not pre-authorized my Genetic Counseling and Testing as of 4pm yesterday, so I called my Onc. office and the lady I talked to told me I have to request the testing through my insurance company?? I told her the Oncologist never mentioned that I would need to begin the process. I was confused and she agreed to find out and call me back before end of office day or today. Since my PET scan results should be back, she said we might be able to code it as a PET consultation but also do the genetic stuff? My insurance requires 3-7 days pre-auth. or they don't pay! After all these high co-pays we have had over the last 2 weeks I can't afford another HUGE bill. I don't want to cancel but I also cant foot the bill. I just want to have my PET scan results and get a plan in place!Disapprove
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Post Options Post Options   Thanks (0) Thanks(0)   Quote turtle Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 10:52am
Romey,

In my case, I received a referral to a genetic counselor from my oncologist. This referral was based on the fact that my cancer was TN, my age of presentation was below 50 years (as in your case), and I was of Ashkenazi Jewish descent. Upon running my family history thru their (the genetic counselor's) statistical program, it was determined that I had an approximately 70% chance of having a BRCA mutation. I believe it was this high statistic, when presented to the insurance company by the genetic counselor, that resulted in their paying for the testing to be done. It may be that when you proceed similarly, that the insurance company will end up paying for the counseling visit as well as any subsequent testing. Your particular insurance coverage would of course dictate any copays though. 

One alternative would be to submit samples directly to a clinical trial for genetic testing (see below, the trial is being conducted at Georgetown University, which may be convenient for you):


Others have posted about the King lab on this forum that is conducting its own screen, to whom you may be able to submit a sample and have it tested completely free of charge. I would add though, I am not sure if this would end up changing your treatment (chemotherapy) protocol; in my case, my oncologist indicated it would not. So it may be that if this is something that would be financially overwhelming right now, you may be able to delay this one piece of the puzzle, but again, another question to ask of your oncologist.
DX IDC TNBC 1/15/12 @ 46; MRI 2.4cm gr3 BRCA2+ 6174delT; LMX 1/31/12 2.5cm, pT2pNO(i)pMX, lymphovascular invasion present; 2/20/12 TAC X 6; 7/2/12 Rad X 25; 9/27/2012 2nd mastectomy & BSO surgery
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Post Options Post Options   Thanks (0) Thanks(0)   Quote mainsailset Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 11:31am
Romey, what you have just run into is unfortunately pretty common. And it's important for your health that you learn to navigate this stuff to your own satisfaction. So here's some ideas
  1  do start writing in that diary I suggested. When you talk to anyone regarding your health, document your conversation, the time and date, and who you talked with. Take your time, get names spelled etc and take your time making sure you understand the conversation as well as the person on the other end.
  2  do you have anyone you can tap to help you as an advocate? If not, start asking in your conversations for help, often the onc's office will have a 'social worker' or in the financial dept there will be an experienced person who can help you cut some corners in the process
  3  it's ok to ask the professionals to bear the burden of being in the driver's seat. In this instance, the onc wants you to have the tests so he/she can do his job so his office should be with you in the drivers seat. In my case, I couldn't get an onc to agree to my BRCA testing so I was sunk. But for all other things, I've noticed they write the script, they pre clear payment through insurance, they make the appointments. I have a friend in the financial sector who has been doing this for years and to watch her on the phone with the insurance folks is sheer magic, NO ONE gets off hte hook and she knows better when they pull the 'ooohhh we've never cleared t h a t   for payment before'  What would take me forever, takes her minutes.
 
Also, if you can sneakily get your onc's email, and anyone else's go ahead and get them. They're not given out for the purposes of chatting, but sometimes we just need to get something into the right hands.
 
Diaries are our friend!
M
dx 7/08 TN 14x6.5x5.5 cm tumor

3 Lymph nodes involved, Taxol/Sunitab+AC, 5/09 dbl masectomy, path 2mm tumor removed, lymphs all clear, RAD 32 finished 9/11/09. 9/28 CT clear 10/18/10 CT clear
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Grateful for today Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 12:13pm
Romey,

Just a thought on the BRCA testing.

If not helpful, just disregard.

Consider:
1. Confirm with onc office where's things stand.
     Review plan with office:   what they will be doing.
                                                  what you plan to do.
     Confirm correct person is handling BRCA testing matter in onc office.
          Who usually does insurance BRCA test auth and is that person working on it?
2. if BRCA testing auth not given, consider calling your member service phone number and ask:
             Would you please assist me to get a review and approval for BRCA testing for tomorrow?
                     ( Ask to speak to a supervisor if needed. )
             If member service cannot help me with this, what is the number for Consumer Grievances
                  (Consumer Affairs/Consumer Complaints or similar dept)     
3.   Call the Consumer Dept. if needed.
4.   Try to remain pleasant and calm on the phone.
       Explain......this a cancer diagnosis.   Result of test MAY effect treatment plan.
       Acknowledge it would have been better to have started this earlier but you thought MD office
             was doing this.
       Ask if the insurance company has an "expedited process" to get an answer by tomorrow.    

Romey, you may decide to just deal with the PET scan results on Friday as you said in your post.....
and then deal with the BRCA testing issue. You know your situation best.

With caring and hopeful thoughts,
Grateful for today..........Judy

Addendum:
Romey, in addition to the great thoughts/considerations noted in above post. -
You mentioned you have a list of questions for your onc appt tomorrow - great.
      You may want to consider the following:
             Let your physician know at the start of the visit that you have many questions.
             Maybe ask sometime during the visit.......if there is not time for all the questions at
                 the visit - or if you have questions afterwards, do you call or email?
             Look at your list of questions.........maybe * the one most important ones....the ones
               that you want answers to before you leave the office.
      You may not need to consider the above as your physician will answer all your questions.
      Questions.........consider if not already on your list:
               What are the pros and cons of each of your treatment options?
                             Chemo vs surgery first?
                             What are the various chemo options for your situation?
                                   (or your physician may recommend only one chemo plan)
               Can the physician print out your path report and PET report for you?
                             (SOMETIMES, there is a computer in the room and the physician can easily
                                print you a copy of your reports)

    There is a thread on the abbreviations used on the forums that may be helpful:
                  http://forum.tnbcfoundation.org/abbreviations-on-forums_topic9524.html

Edited by Grateful for today - Aug 23 2012 at 12:35pm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Natalie Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 3:13pm
Romey,
The Brca counseling is not an emergency at this time,as it is for information to if you have the gene. If you do then we are at a higher risk for other girly cancers. If you test positive you can address that down the road.

I know I went for the counseling and they worked at the insurance. You might look into going that route too. A phone call wouldn't hurt. People are generally helpful.

Take Care,
Natalie
TNBC stage1 size 1.8, grade3 no nodes 4/11 Lumpectomy 5/11 4cycles DD A/C 4cycles DD Taxol. Double Mastectomy 12/11 BRCA all neg
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Romey Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 3:32pm
Thanks again for all the helpful info. Judy excellent idea on ordering my questions. All this info really gives a sense of some control in what feels like an out of control situation. Wish me luck tomorrow -Romey
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Post Options Post Options   Thanks (0) Thanks(0)   Quote debB Quote  Post ReplyReply Direct Link To This Post Posted: Aug 23 2012 at 4:02pm
Hi Romey,

Welcome! I am coming in to the conversation a little late here. You have gotten lots of advice on the BRCA testing. The only thing that I would add is that some + women seem to not respond well (or at all) to Taxol, and it might be helpful to have that info.

As for the lumpectomy vs. mastectomy, I was told that there is no statistical advantage to doing the mx. I am smallish breasted and they said if the tumor was much larger than it was, I could still do the lumpectomy but would likely want reconstruction afterwards. They also said if my scans showed a secondary tumor or if it recurred, they would recommend a mx.

The surgeon that I originally met with (but he was not able to do my surgery for insurance reasons) seemed to be very up on TN and it was an interest of his. He said he thought that TN especially was headed in the direction of doing chemo first and surgery afterwards so they would know how it responded to the drugs. You are also in a great position of looking into some of the neoadjuvant studies that are out there which could potentially improve your response as well.

Best of luck navigating the insurance and with your appointment!
Deb
Dx 4/29/11, 46 yrs old, 3.9 cm tumor, Stg 2 Grade 3 chemo 4 rounds DD AC, 12 weekly taxol, finish. Lumpectomy, 2mm residual tumor. 37 rounds rads completed. Cisplatin/PARP trial
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