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Wade View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wade Quote  Post ReplyReply Direct Link To This Post Posted: Dec 27 2011 at 12:20pm
Hi Lee,

I don't know if my response is too little, too late, but I know of at least one woman who went to have a mammogram for a lump in one breast, and they did both breasts on a whim (according to the husband), and found the "lumpy" breast was fine, but the other one had a tumor. My wife's docs ended up going with mammo, and US, and later MRI.

I also see you're nearby - I live about halfway between Detroit and Port Huron. We ended up going with Michigan Breast Care Specialists (out of St. John Hospital in Detroit). We met with one of each of the tumor board doctors (individually - surgeon, medical onc, radiation onc, social worker and nutritionist) after the tumor board meeting. We brought a tape recorder with us, and found it quite helpful as I remembered at least one thing exactly backwards from what the doc said. My wife hardly remembered anything.

We went to Karmanos for our second opinion, and they suggested the same treatment plan - chemo first, then surgery, then radiation. My wife has about 10 rad. treatments left. She did AC first, then was supposed to do Taxol, but none was available, so she was started on Abraxane instead ( same active ingredient, but nano-sized particles and bound to albumin). There is also at least some evidence that Abraxane may work better than Taxol, due to better absorption caused by the smaller particle size. I can't cite the study, but if you nose around you may see it.  You will also want to see Steve's post re Taxol's potential for severe reaction from the carrier solvent.

So far, my wife is one of the lucky ones. The chemo treatments completely eliminated any evidence of cancer in her breast, and the tumor started shrinking within the first few weeks of starting chemo.

Feel free to pm me if you like - I'm a terrible typist and I don't have my wife's files with me today, but I'd be glad to give you any information I have...

I wish you the best of luck with your treatment.

Wade    


Edited by Wade - Dec 27 2011 at 12:25pm
Wife DX 5/2011@52 2.5x3.1cm;6/2011 DD A/C 4x,Abraxane 4x; Lumpectomy, SN biopsy 10/2011; 10/27/2011 NED; Rads start 11-22-2011, Rads fin 1-11-2012; 10-2013 NED; 07-18-2014 NED; November 2018 NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote ds21 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 27 2011 at 1:29pm
Thanks, these drug shortages are one more hassle we don't need right now.

David
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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: Dec 29 2011 at 12:08am
Hi Lee,

RE: (BTW, I started posting this reply, then hit the back arrow on my browser to read the message, and when I hit the forward arrow, what I had written has disappeared; is it floating somewhere in space?).

Think when the post that one has just written disappears.......it is gone....as if the words were never there.
Don't think one can use the forward and backward arrows.....if one does, post is gone.
Maybe some one who knows for sure might post.

Also, there is a work around that a member put on the forum about how to avoid losing one's post.....
unfortunately, I forgot what it was. Maybe that member might post again if member sees this.
If I know I will be doing an involved post, I will do it on Word and then copy and paste.....but I
think links don't transfer and I have had to do the link again.

With caring and positive thoughts,

Grateful for today.............Judy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote SagePatientAdvocates Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 6:48am
Hi Judy,

I try...and all too many times I forget to do it...especially when I am writing a long post (what’s that some of you are saying...too many times and too long..nice, no respect Smile) to write my post in word and save it
and then cut and paste it onto the thread...

I have lost so many posts...and at times I am not sure exactly why I did but early on I had written for an hour and then I lost it and I was just so angry/exhausted I had to re-group.

all I can tell you is that you are doing a marvelous job for all of us and please keep up your good work and maybe using word can help?

all the best,

Steve


Edited by steve - Dec 29 2011 at 7:16am
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 ds21 Quote  Post ReplyReply Direct Link To This Post Posted: Dec 29 2011 at 7:22am
I find the edit, grammar and spell check features of Word. If you know it is going to be a long post, fire up a real word processor and just copy paste when you are done.
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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: Jan 09 2012 at 11:06am
Hi Lee,

Would like to thank you for all your great and informative posts and articles you have
posted on several forum topics.......much appreciated.

Noticed on one of the other forum topics that you posted on 1/6 "finally able to set up my
2nd opinion trip to UCSF next week" (which would be this week).
So, sending many positive thoughts for your 2nd opinion this week.
Sincere hopes that you receive the information that will help you with your treatment
plan decisions.   You have researched information and are doing all the right things.
You will make the best decision for you.

With caring , positive and hopeful thoughts,

Grateful for today................Judy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 09 2012 at 4:55pm
Hi Judy
Thank you for your kind thoughts.  I feel I have a personal connection with many on this forum already!
I am hoping my second opinion will give the same recommendation -- golly, what to do if two disparate opinions? None of us have the proverbial looking glass...reminded of Steve Job's Stanford commencement speech in 2005 (http://www.youtube.com/watch?v=D1R-jKKp3NA) -- (a very inspiring one for those who haven't heard it).  He gave the speech a year or so after his diagnosis of pancreatic neuroendocrine cancer. Basically one of the important messages of his speech is to live each day like it's your last and ask yourself if you want to be doing today what you are doing if it is the last day of your life. It's given me a lot of pause for thought especially since my diagnosis.
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 12 2012 at 11:09am
Hi everyone

I had my 2 nd opinion yesterday at UCSF and they couldn't have come up with a more divergent recommendation from the one from U of M. UCSF strongly recommends neoadjuvant whereas U of M recommended lumpectomy first. Both agree the order will not affect survival; but as you all know neoadjuvant will provide prognostic information on chemo sensitivity. 

UCSF says I would be a candidate for the ISPY-2 trial but U of M is not a participant and I would rather stay local for my treatment than drive 6 hrs to Chicago the nearest site.

 It seems like it comes down to two points 1) UCSF believes in the MRI sizing of my tumor at 3 cm which is almost twice the size seen by ultrasound that U of M is basing their recommendation on ( it seems that pre-op MRI is controversial although I don't think there is disagreement about the relative accuracies of the different modalities).  Not shrinking the tumor down would result in substantial removal of tissue. UCSF doesn't think a mastectomy is indicated.  2) the prognostic importance of neoadjuvant therapy.

I am not sure I have time for a third opinion - it's been more than a month since my surgery and more than two months since the onset of symptoms (discharge).

I know that people on this forum have experience with either approach.  This has been discussed elsewhere in other threads but sometimes it is hard to pick up on those.

I would really appreciate your input on this to help me with my decision.  Why did you go with the approach you took ? Did it work for you? Do you have regrets?


12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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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: Jan 12 2012 at 11:48am
Lee,

Thank you for sharing the info from your 2nd opinion.
Do you feel comfortable sharing:
        Has either UCSF or U of M advised you the time frame within which to make your decision?
        What is the chemo protocol in the ISPY-2 trial?
        Was there another chemo protocol option recommended by UCSF (or U of M)
              with the pros and cons of ISPY-2 vs other chemo protocol offered?   
       
Will be out for the afternoon and will post later tonight.

From your posts, it is clear you know how to research things and make excellent decisions.
With empathy, I acknowledge the importance and challenge of the treatment decisions.
One realizes that with the same information........the best decision for each person could
be different and still be the best for them.
There is no doubt in my mind that you will make the best decision for you.


With caring and positive thoughts,

Grateful for today.....................Judy
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 12 2012 at 12:10pm
U of M didn't provide a time frame although I am scheduled for surgery next Thursday ; UCSF says within 3 weeks.
From my recollection, the ISPY trial has the standard therapy of taxane x 12 weeks followed by 4 weeks of AC and an investigational drug added to 4 of the 5 arms ( randomized trial with mammoprint profiling) during the taxane component.
There was mention of another trial at a site closer to home (I don't remember the name) which included Avastin but neither the surgeon nor I an a fan of Avastin in this setting (significant morbidity).
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wade Quote  Post ReplyReply Direct Link To This Post Posted: Jan 12 2012 at 12:23pm
Good morning, Lee

I'm glad to hear that you were able to get a second opinion quickly - I'm sorry it diverged  from the first.

My wife also had mammogram, ultrasound and MRI. The mammogram showed a lump 3.5 x 3.9cm, and on the same day the ultrasound report says it was 3.1 x 2.5 x 3.1cm. A fine needle biopsy was done on the same day as the US and mammogram. There was some swelling (both the radiologist and surgeon's opinions) caused by the needle biopsy. We didn't go for the MRI until 14 days later, at which time the report sized the lump at 3.6 x 3.2 x 3.5cm. So we don't really know if this is a growth,swelling, or measurement difference from using a different technology or ?

As to the decision on whether to go with lumpectomy first, or chemotherapy, my wife went with the chemo. She "checked out" after the diagnosis, and left most of the research up to me. I read many of the arguments here, and we met with the surgeon first (Dr. Cheryl Wesen), who suggested neoadjuvant therapy. I said  something like "You're a surgeon, and you're sending us away - why?"

She said that in my wife's case there were two reasons. One was cosmetic - with the size of the lump so large in comparison with her breast size, if she performed the surgery first, she would have to do a mastectomy. If she were to do chemo first, the tumor might shrink, and if it shrunk enough, she could then safely perform a lumpectomy.

Secondly, as you mention, doing chemo first allows the oncologist to see if the tumor is shrinking. If it does, great. If not, try another cocktail. Obviously, if the surgery is done first, you lose this indicator of efficacy. It seemed to me a very compelling argument. I wasn't the one taking the treatment, so it wasn't my decision,but the thought of going through the chemotherapy process and not knowing whether it had done any good sounded terrible to me. What if it actually made the tumor grow, as some have reported on one of the drugs (Taxol) recommended for my wife? Would I have been better off NOT doing chemotherapy at all, and just having the surgery and radiation? Why did I put myself through chemo, if it didn't do anything?

It seemed the only upside to surgery first was to "get the darn cancer out of my body". According to our tumor board team, they said that by the time you have a detectable lump, the cancer has likely been in your body for years, and even in stage 1 cancers, micrometasteses have been found in bone marrow. This made it seem even more important to keep the indicator of efficacy (the tumor) around until you found the drugs that worked. We found these arguments the most compelling

I am not questioning anyone else's decision to do surgery first.  I can't imagine having to make the call. I was only a spouse, and I found it tough.

It is still early days, but it looks like my wife's choice was right for her. The first cocktail shrunk the tumor, there was no evidence of cancer found in the subsequent surgery, and she just finished radiation yesterday. I should also say that my wife's response is not necessarily typical. Her medical oncologist (Dr. Carrie Dul), said that her response to chemo was one of the best she had seen. We still took comfort in knowing that if the first drugs hadn't worked, she could have switched to a different regimen.

Anyway, that's my two cents, I'm sure you will hear from more knowledgeable and better informed people here. Good luck with your decision. It sure seems to me that you are doing the best you can to inform yourself. I wish you all the best.

Wade

   

  


Edited by Wade - Jan 12 2012 at 12:28pm
Wife DX 5/2011@52 2.5x3.1cm;6/2011 DD A/C 4x,Abraxane 4x; Lumpectomy, SN biopsy 10/2011; 10/27/2011 NED; Rads start 11-22-2011, Rads fin 1-11-2012; 10-2013 NED; 07-18-2014 NED; November 2018 NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 12 2012 at 11:28pm
Wade thank you for sharing your wife's medical timeline. I told U of M the recommendation from UCSF and they are reviewing again my case.
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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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: Jan 13 2012 at 1:42am
Lee,

Reconfirming what we all know, one needs an individual plan for one's individual situation made
with one's physicians. With the same clinical information, the best plan can vary with the
varying factors one brings to the treatment plan.

This was my experience.
Diagnosis: Normal mammogram 2009. Normal MD breast exam summer 2010.
                     Felt right breast lump end of Sept 2010.
                     Initial size varied by 10/10 clinical exam/mammogram/ultrasound.                   
                     Right breast mass core biopsy: IDC. Invasive ducal carcinoma, grade 3. Ki67:80%   TNBC.
                     FNA: positive malignancy.
                     Clinical:   T2N1 M0
Treatment plan:
    Initial treatment plan consult:
        Advised I could:   Do standard plan of care: dose dense AC q 2 weeks x2. Taxol q 2 weeks x4.
                                             either neoadjuvant (before surgery)   or   adjuvant ( after surgery)
                                       Participate in a clinical trial.   4 arms: one standard DD ACT.
                                             other ACT and carboplatin.   other ACT Avastin.
                                             other ACT and carboplatin and Avastin.
       Due to my concerns of increased risk of serious side effects if I was in the ACT/carboplatin/Avastin
                 arm, I did not do the clinical trial.   I felt if the ACT was not working, another chemo could be
                 tried.
       For me, pros of neoadjuvant were:
                                  If ACT did not decrease tumor size, chemo could be changed.
                                  Surgery would take care of local mass.
                                  I wanted to ensure no distant spread with chemo ASAP.
                     cons of neoadjuvant were:
                                  The possibility that while trying ACT the tumor could grow and /or there
                                        could be cells going to distant organs IF ACT did not work.
                     pros of adjuvant were:
                                  Not allow the tumor to grow and not give any more time for cells to
                                  possibly travel to distant organs.
                     cons of adjuvant were:
                                  If the tumor was removed, then there would be no way to know if the following
                                  chemo was the chemo my tumor was sensitive to (in case there were any
                                  residual cells)
   2nd opinion:   Same as initial
   When I had a complete clinical response before the end of ACT, was glad I had neoadjuvant.

Surgery:
I decided on a unilateral mastectomy.   ALND (due to prior FNA + of one axilla lymph node)
       This was a difficult decision for me. Intellectually, I knew mastectomy was the best choice
       for me. But I would go and forth about what to do.
       I was aware that OS (overall survival) was the same for lumpectomy/radiation or mastectomy.
       When I asked for the study or numbers for OS for TNBC re: lumpectomy/radiation or mastectomy
       no one could give me any (and I could not find any).    I choose the mastectomy knowing that
       in the future it may be proved that for TNBC OS is the same whether lumpectomy/radiation or
       mastectomy. I preferred this rather then having future studies show OS for TNBC better with
       mastectomy (or mastectomy with radiation) then lumpectomy with radiation.       
       (As it turned out, there was the Canadian study referred to elsewhere on the forum that did
        look at lumpectomy/radiation or mastectomy....but not mastectomy with radiation which is
        what my final plan included)       
Unilateral mastectomy. ALND x 2 levels.   Path: ypT1cN1a
Radiation x 29 treatment days.
             Right chest wall. Scar bolus every other treatment day.
             Adjacent lymph nodes/high tangential field.      (not full axillary field due to ALND)
             (Internal mammary nodes field not included)
             Right supraclavicular lymph nodes area.
              
Think there is the possibility that since you told U of M the recommendation from UCSF and they are reviewing again your case........and now U of M has the MRI result of a possible 3 cm tumor.............
U of M recommendation might now turn out to be the same as UCSF.

Again, you have done such great research work.
You will make the best decision for you.

Sending lots of caring and positive thoughts,

Grateful for today................Judy

                  
                                             
       


     

Edited by Grateful for today - Jun 01 2012 at 2:20am
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wade Quote  Post ReplyReply Direct Link To This Post Posted: Jan 13 2012 at 7:11am
Hi Lee,

It struck me after my post that I sounded pretty strident - I guess this is all a little too close in time for me be dispassionate...

There must be sound medical reasons to do surgery first, else why would they still recommend it? I hope others who have heard the arguments for surgery first will post as well. It would be very interesting to hear the reasoning for it.

Please let us know what the people at U of M say.

All the best,
Wade
Wife DX 5/2011@52 2.5x3.1cm;6/2011 DD A/C 4x,Abraxane 4x; Lumpectomy, SN biopsy 10/2011; 10/27/2011 NED; Rads start 11-22-2011, Rads fin 1-11-2012; 10-2013 NED; 07-18-2014 NED; November 2018 NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wade Quote  Post ReplyReply Direct Link To This Post Posted: Jan 13 2012 at 7:18am
Wow, Judy!

Your post was very informative. It's clear you did your homework. Thank you for explaining your thought process so well.

Best regards,
Wade

Wife DX 5/2011@52 2.5x3.1cm;6/2011 DD A/C 4x,Abraxane 4x; Lumpectomy, SN biopsy 10/2011; 10/27/2011 NED; Rads start 11-22-2011, Rads fin 1-11-2012; 10-2013 NED; 07-18-2014 NED; November 2018 NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote christina1961 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 13 2012 at 9:03am
Lee, I had neoadjuvant chemo. My prechemo scans included a bilateral MRI, mammogram and ultrasound.  I was originally thought to be node negative, but one of the ROs actually thought two nodes looked a little big in the MRI and I turned up, after surgery, to have two positive nodes.  The neoadjuvant chemo only gave a partial response but I had such a good clinical response, the oncologist thought I had gotten a pcr.  I was very disappointed. I am still glad to have received neoadjuvant chemo but I would have, in my case, gone on a clinical trial of neoadjuvant in retrospect because I could have received "standard of care" chemo afterward if the first round of chemo did not work-- or I would have insisted on ultrasounds or some type of scan during my neoadjuvant period.  Clinical exams just don't cut it and I questioned that in my mind the entire time and didn't speak up.  That is probably my biggest regret. I had a unilateral mastectomy. My oncology surgeon prefers that after neoadjuvant chemo - and I had a full ALND, two levels.  I followed up with elective radiation, four fields, with a boost.  I have no regrets having the mastectomy because the regional recurrence rate is less, and I'm glad that I went ahead with the radiation.  It is hard to lose a breast, however.  I saw the plastic surgeon yesterday and it looks like I will have to have a lat flap due to the radiation, but his photos are absolutely amazing.  I feel so much better after having the consultation.  I do not have the BRACA gene but due to the presence of colon, prostate, and esophageal cancer on my father's side of the family, I believe there is some problem that has been passed on.  I may elect to have the other breast removed at the time of reconstruction.  I am beginning the research process soon for that issue. 
2.5 cm TNBC, BRCA-, diag. 2/11, neoadj chemotherapy, uni MX, y2cm,2/16 nodes, RCBII, tumor retested 5-10%ER+,PR-,Her2-, rads, clin trial eribulin 10/11-2/12, tamox.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 13 2012 at 10:09am
Thank you Judy, Wade and Christina for sharing. I will be seeing a med oncologist at U of M on Monday who will be re -presenting my case to the tumor board.
I will also posit the same question over on the "chemo before surgery" forum to see if I can grab more responses.
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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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: Jan 13 2012 at 12:03pm

Addendum to my earlier post today.....the part about the mastectomy decision:

Already mentioned about one's individual situation.......same info.....different decisions.......

Would like to share:    I am 67 and single.
Would I have made a different decision if I were in my 20's or 30's or married/had a partner.......
..........don't know.
Do know others (67/single and all others) and with same info could choose lumpectomy/radiation
and that would be the very best decision for them.

With caring and positive thoughts to all,

Grateful for today..............Judy
    

Edited by Grateful for today - Jan 13 2012 at 12:13pm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wade Quote  Post ReplyReply Direct Link To This Post Posted: Jan 16 2012 at 3:33pm
Hi Lee,

I've been going through my binder and found an article you may be interested in.

The first is from ONCOLOGY, volume 25, #9 (August 2011, I think) "The Changing Field of Locoregional Treatment for Breast Cancer". I found it on www.cancernetwork.com. There are several articles referenced at the end of this article as well.

Good luck with your decision - and your treatment!

All the best,
Wade

ps - I forgot to put in the title of the article in the original post...  


Edited by Wade - Jan 17 2012 at 7:33pm
Wife DX 5/2011@52 2.5x3.1cm;6/2011 DD A/C 4x,Abraxane 4x; Lumpectomy, SN biopsy 10/2011; 10/27/2011 NED; Rads start 11-22-2011, Rads fin 1-11-2012; 10-2013 NED; 07-18-2014 NED; November 2018 NED
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Lee21 Quote  Post ReplyReply Direct Link To This Post Posted: Jan 16 2012 at 9:50pm
I met with my medical oncologist for the first time and decided to go with the neoadjuvant route (DD AC-T) to start in two weeks to the day. I hope I will be able to tolerate the drugs.  I still have my sentinel node biopsy to do this thursday.  I guess it is out of order because I had originally planned surgery with SLNB but at this late date we decided to go through with the node biopsy part.

The only thing that I found a little disconcerting is that no imaging will be done until the end of therapy unless by physical exam they find the tumor is growing.  However, since the tumor is not palpable waiting for the tumor to be physically detectably growing before intervention is a little unnerving to me.  But that is the standard of care at my cancer center. So, unless I want to move to SF, I guess I will have to go with the flow.

Wade, thank you for the reference.
12/9/11 @59,IDC,grade3, TNBC,3cm(MRI),SLNB0,stage IIA, BRCA1 variant
1/30/12 DD AC-T, 6/7/12 Lumpectomy, ypT1b(0.8 cm), 7/9/12 Rads x 30
11/9/12, clinical trial cisplatin/rucaparib, cisplatin-only arm
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