The medical report

Today Nadine had a core biopsy performed - the pathology report on that will be in late tomorrow or early next week. We haven't yet seen the pathology report on the slides we brought from Virginia, but we should have that by tomorrow also.

That said, everyone here seems to feel that the cancer is stage IIB/IIIA (I think they are leaning now more towards IIIA) and a bit more aggressive than the doctors in VA said - even though, as far as we know, this conclusion is based only on their reading of the pathology report submitted by the VA pathologist. We'll see what the Mayo report says.

After all of the discussions with the various doctors (the internist, the breast surgeon, the medical oncologist (who gave us a second short visit to answer some additional questions we submitted to him today), a GYN oncologist/surgeon, various nurses, and I'm sure I'm forgetting somebody) Nadine is feeling pretty sure about how she wants to proceed:

4 cycles of adriamycin/cytoxan (AC) - the biggest concern has been about the cardiotoxicity of the adriamycin. We've gone over this extensively with the oncologist and explored many various alternatives (including ones we've come up with ourselves). Nadine feels decisive that, in spite of the risk, AC is the best course of action.
4 cycles of abraxane - this will replace the original recommendation of taxol. It should enable Nadine to avoid the use of steroids (or at least minimize their use), which are bad for her eyes given her glaucoma. The oncologist has used this in the past and feels it is just as good as taxol.

4 weeks (probably) of rest/recovery

Surgery - Nadine really hit it off with the surgeon, Dr. Boughey. If there was a surgeon who could be the opposite than the one we saw at Johns Hopkins, this is the one. As much as Nadine likes the surgeon in VA who removed the lymph node, she wants Dr. Boughey to do her surgery - so we will be coming back here for that.

Some period (4 weeks?) of rest/recovery

Radiation - this is the one area we haven't really explored yet. Since the radiation has to happen 5 days a week, we will have to do this in VA. So we will need to make decisions about where to do this, and what radiation oncologist to use. But there is time to do this, and I'm sure we'll consult with Mayo as well when we come back for the surgery.

The chemo will be done in VA. We will likely stick with Nadine's current oncologist if she will concur with Nadine's decision on the chemo (she had originally recommended 4 cycles of AC followed by surgery followed by taxol, so we have two relatively minor changes that she needs to consider: doing all chemo before surgery, and changing taxol to abraxane). But we may still be able to get an appointment with one of the doctors at the Lombardi Center at Georgetown. We are considering what to do here. Since the recomendations on chemo have been largely similar everywhere, we may be fine sticking with the current oncologist. The benefit of Lombardi is that they may be more plugged into the very latest information - but I have the sense that the oncologist here is similarly plugged in, and he is the one who has helped Nadine come up with the chemo approach. Still, since we need to be thinking long-term as well as short-term, we might still want to do Lombardi.

We did have one real scare today, related to the visit by the GYN oncologist/surgeon. We thought he was seeing us to discuss the possibility of removing Nadine's ovaries as an approach to preventing recurrence, which would be recommended if she tests BRCA positive. But in fact, when the medical oncologist looked at the CT/PET scan yesterday, he saw what he called "some soft tissue mass in the pelvis" - probably the uterus, that could be nothing, could be fibroids, or could be something more serious. No note had been made of this by the VA radiologist (whether because they missed it, or because they concluded it was nothing to be concerned about, we don't know). So he wanted the GYN specialist to see Nadine. The GYN specialist reviewed the CT/PET himself, then came in, asked Nadine a bunch of questions, gave her an exam, and concluded that she is fine. What was seen in the CT/PET was entirely consistent with the fact that she is 44 and had carried two children to term. Basically, the uterus was slightly enlarged and, as he described it, a small portion at t! he top had folded over on itself so that in the scan it looked sort of thickened (if I have that right). But it was fine. I have to say that both Nadine and I were very concerned, and then very relieved!

Tomorrow we will see the genetic counselor, and then Nadine will be participated in a clinical trial of a new imaging technique (she was not eligible for the other two trials that really interested her). And then we'll be coming home, a day earlier than planned.