Return to Work

  First week complete. It felt great to be back. I didn't feel overly fatigued and really liked returning to using my brain. Being in a hospital setting, I will have to watch myself with my potential for a lowered immune system.

 While I didn't really look into many return to work materials prior to my return, I found this website which may be helpful for both employees and employers when returning to work after cancer diagnosis/treatment: https://mariekeating.ie/back-to-work-after-cancer/.

  I think the one that resonates with me the most is "Returning to work after cancer, or while still undergoing treatment, is an achievement in itself. Don't expect too much too soon."

 For now, I'm rested up and

KADCYLA is a go!

  Here we go again! Day 1 of KADCYLA was able to start today. I feel more settled knowing I’ve started and can get a handle on the scheduled doses moving forward. 

 I have a loading dose for 90 minutes today and then every 30 minute infusions from there on as long as everything goes well. 

 I do start work on Monday. I’m very much looking forward to it. I can’t wait to get back to helping others navigate their medical needs and continue to improve quality in the world of healthcare. 

Playing the waiting game

  Currently still waiting for insurance authorization for my KADCYLA. I’m really hoping it gets approved in time for me to have my first infusion tomorrow, as I’ll have to plan for ongoing infusions every three weeks with my return to work. 

Understanding a breast cancer pathology report

  I had my follow-up with my surgeon who did the lumpectomy and sentinel lymph node biopsy. I came out of that appointment more positive than I had been after reading my pathology report right after my surgery. I thought it might be good to go over how to understand a pathology report for anyone who must have one, but first, the good things that came from my neoadjuvant targeted and chemotherapy treatment to date:

1. While I did not get a pathologic complete response, my neoadjuvant chemotherapy of Taxotere, Carboplatin, Herceptin, and Perjeta (TCHP) DID kill 90% of my cancer cells, leaving only a measly, ornery 10% of live cancer cells. This is the only reason I need to have targeted chemotherapy in the form of KADCYLA, rather than just targeted therapy of Herceptin and Perjeta.
2. While my tumor size does put me into stage IIA, it is only due to 0.2 cm or 2 mm. Even just a tad less and I'd be stage I. It is just a positive that I'm not on the larger side of a stage II which is up to 5 cm.
3. NONE of my lymph nodes were positive which shows the TCHP stopped it in it's tracks, and kept it in my ducts.
4. My overall Grade changed from a 2 to a 1. This is better explained below, but my granular/tubular and nuclear differentiation both decreased by one point making my overall histologic grade a 5 instead of a 7.

 That is worth a bit of celebration!

Rather than recap some of the terms above, here is the link to my past post about stages and grades and bears, oh my!

 Here is the link to the site describing all things pathology. I have tried to explain it in more regular terms as I would like this to be a powerful moment for anyone who has to know what the pathology report means and have the ability to ask questions about their unique situation. I would recommend taking time to read right from the link above if you are reading through your pathology report.

 I think it is important to say that each pathology report can look very different, but all should have various sections that outline the findings from the samples.

 From oncolink.org, you will find the following sections on a pathology report:

• Some information about you, like your health history.
• Diagnosis (suspected or known).
• The procedure that was done to get the tissue sample.
• What the tissue looks like to the naked eye (called gross description).
• What was seen under the microscope (microscopic description).
• A pathologic diagnosis (a diagnosis based on what the pathologist saw under the microscope).

For breast cancer, the report will also have:

• The type of cell the cancer comes from.
• The tumor size and grade.
• Whether cancer cells are in the lymph system or blood vessels.
• Information about surgical resection margins (the edge of the tissue that was removed).
• Hormone receptor and HER2 status. 

 For my pathology report, I was looking to see if each tissue sample (labeled as A, B, C, D, etc.) was positive or negative for carcinoma (cancer) and if the margins (edges of the removed tissue) were negative (all cancerous cells were removed with none remaining). They all were negative. Woo hoo!

 I was also looking for the cancer type to see if it remained the same, and it did - invasive ductal carcinoma. Interesting to note, there was findings of ductal carcinoma in situ (has not yet spread to surrounding tissue) but there were negative margins, so that was all removed as well. 2% of my overall remaining cancer was in situ.

 I then looked at the histologic type (type of cancer) and histologic grade (predictive of how aggressive tumor cells are). The three scores (nuclear grade, mitotic rate, and tubule formation) are then combined for a total score between 3 (1+1+1) and 9 (3+3+3). You may see the three values and total score, or just the final grade.

• Score of 3, 4 or 5: Well differentiated or low grade (Grade 1).
• Score of 6 or 7: Moderately differentiated or intermediate grade (Grade 2).
• Score of 8 or 9: Poorly differentiated or high grade (Grade 3).

 Overall, the lower the grade, the less aggressive the breast cancer. Conversely, higher grades indicate a more aggressive breast cancer.

Nuclear Grade: A score is given from 1 to 3, based on what the nucleus of the cancer cells looks like compared to normal cells. In nuclear grade 1, the nucleus of the cancer cells looks more like normal cells, while in nuclear grade 3, it looks the least like normal cells.

Mitotic Rate: Describes how quickly the cancer cells are multiplying or dividing using a 1 to 3 scale: 1 being the slowest, 3 the quickest.

Glandular/Tubular Formation: This score tells you the percent of cancer cells that are formed into glandular or tubular structures consistent with normal breast tissue.

• A score of 1 means more than 75% of cells are glandular or tubular structures consistent with normal breast tissue.
• A score of 2 is between 10 and 75%.
• A score of 3 is when less than 10% of cells are glandular or tubular structures consistent with normal breast tissue.

 For comparison, my pre-neoadjuvant chemotherapy histologic grade was a 7. Nuclear grade and Glandular/Tubular formation were both a 3 and Mitotic rate was a 1. Post-neoadjuvant chemotherapy, my histologic grade was a 5. Nuclear grade and Glandular/Tubular formation both decreased to 2 and Mitotic rate stayed a 1. This shows the impact that TCHP had on my cancer cells.

  My hormone receptor and HER2 status stayed the same. Triple positive. This was not expected to change, but I finally found a good visual to share.

  TNM Classification:

Clinical (pre-treatment):

 cT2N0M0

Pathologic (post-treatment and surgery):

 ypT2N0M0

 

 

Reset

 

 KADCYLA is a go. Due to the targeted approach of the chemotherapy, I can start it as soon as my insurance approves it. I’m hoping that is tomorrow. My wounds should continue to heal and I shouldn’t have more hair loss since it targets the cancer cells directly.

For now, I’m doing a reset for the good things ahead. 

More Chemotherapy but More Targeted

 

 Just when you thought I couldn't possibly add any new terms to the list, I introduce to you, KADCYLA (kad-SY-luh). Due to my non-pathologic complete response (which means there were still cancer cells in my tumor that was removed), I need a different medication instead of Herceptin and Perjeta. 

 KADCYLA is essentially Herceptin (a monoclonal antibody) and Emtansine (a chemotherapy). More specifically, it is an antibody-drug conjugate consisting of the humanized monoclonal antibody trastuzumab covalently linked to the cytotoxic agent DM1. Here's the technical visual:

 Unlike my poor attempt to explain chemotherapies in a previous post, I like that the Kadcyla website actually provides the information on how KADCYLA is thought to work.

 Currently, my doctors have differing views on when to start this new infusion. They will be discussing it today to balance the need for wound healing from surgery with continuation of chemotherapy to kill any lingering cancer cells that may be anywhere in my body. 

 Here we go again. I will receive KADCYLA every 3 weeks for 14 cycles. I did the math. That is 42 weeks. There are 52 weeks in a year. I'm in this for the long haul.

 This patient brochure is very comprehensive, in case you wanted more light reading on this topic.

Week 2

 

 This week continues my focus on healing. All of my steri-strips were removed today! Boy did that feel good! I have a few small areas that are open and need to heal before I can continue on to my next steps. Fortunately, being a board certified wound specialist pays off here.

 As I learned early on, all things are fluid. Radiation will be 8ish weeks (possibly up to 12 weeks) from surgery rather than 6 to ensure complete healing. Once I start radiation, healing slows again. Radiation will be 6 weeks long with 15 minute sessions Monday-Friday. They have it so targeted, it really focuses well on the involved area, but it’s not completely without potential side effects. These are minimized by a diligent team and state of the art equipment. 

 I hope to know more about my continued targeted and/or chemotherapy plan after an appointment with my medical oncologist tomorrow. Minimum 8 weeks until I can begin chemo if it is still warranted. 

 

 

More Healing

  I had a great first check-up with my plastic surgeon. All my incisions are healing and there have been no areas of excessive swelling causing alarm. I do have to back off and strictly abide by no reaching over my shoulders or lifting more than 5 pounds, however. This is due to my oncoplastic portion of my surgery, not my lumpectomy or sentinel node biopsy. 

 Being the PT that I am, I do want to share a valuable resource that if you have only a lumpectomy and/or sentinel node biopsy and if cleared by your surgeon to do so, this is a great list of exercises to perform to prevent scarring or adhesions and get back to full range of motion of your arm.

 

  From what we currently know from my pathology report, I will have restrictions based on my surgery healing to when I can begin my radiation and further targeted therapy with likely chemotherapy. While all the known cancer was surgically removed, radiation and further targeted and chemotherapy will help to ensure there were no cancerous cells elsewhere in my body looking to grow and wreck havoc.

 As of what we know today, I will have to wait 6 weeks from my surgery day to start radiation and 8 weeks from my surgery day until chemotherapy. This will ensure my incisions have healed and we will not have wound complications which would put a wrench in all the works. 

 What is still pretty amazing is that my case will be discussed next Friday with all my involved physicians sitting at the same table to come up with my plan. I can't ask for a better medical care team and plan of care than that!

Happy Anniversary and Navigating Relationships after Cancer Diagnosis

 Happy 7th Anniversary to me and my hubs! I can't think of a greater gift than for him to continue to be by my side as I continue this fight.

 I found this article from Outcomes4Me about Navigating Romantic Relationships straight and to the point. It is true that a cancer diagnosis can make or break some relationships. Fortunately, ours has been made stronger and stronger. I always enjoyed watching the couples come into the oncologists office together, showing support for their significant other.

"Here are four considerations to keep in mind to help you prioritize your own mental health and self-care, along with your relationship:

• Find the right time to disclose
• When you do decide you’re ready to share, it can be helpful to approach the conversation in a calm and confident manner. Allow the partner you’re in a relationship with to ask questions and provide reassurance and support as needed. It’s important to remember that not everyone may be comfortable with the realities surrounding your cancer diagnosis, and that’s okay. The right person for you will accept and support you, regardless of your cancer story.
• Communicate openly
• A study published in the Journal of the American Medical Association (JAMA) found that caregivers of cancer patients are at a significantly higher risk of suffering from anxiety and depression disorders. Be honest about how you’re feeling and what you need from your partner, and also encourage them to share their own thoughts and feelings about your diagnosis with you. Open communication is hard work but it’s so worth it to learn how to best support each other during this challenging time in your relationship.
• Be patient with yourself
• Give yourself time and space to heal, and don’t push yourself too hard. Breast cancer can affect a person’s body image and self-esteem. It’s important to talk about these concerns and find way to connect that are comfortable for both of you.
• Take care of yourself
• Investing in self-care after a breast cancer diagnosis can benefit your relationships. When you prioritize your own well-being, you can develop a stronger sense of self-esteem and self-worth, which can improve your communication and connection with others. Self-care can help reduce stress and improve physical health, which can have a positive impact on mood and energy levels, leading to more positive interactions with others. Additionally, taking time for self-care can provide a sense of control and empower you to approach your relationships with confidence and a renewed sense of purpose. Self-care can look different for each person–e.g. it could mean taking a walk, watching your favorite show, doing yoga, or cooking–but the goal is to engage in activities that bring joy and a sense of balance to one’s life."