All Clear!

Yesterday was eventful. I went to see Dr. R at Sunnybrook Hospital, in Toronto, for my second opinion dialogue. My wonderful pal and sister-in-law, M, came with me. I have been staying with M and my brother, Tom, for the last couple of days. They have been so incredibly kind and generous as hosts, inviting over friends and family, cooking marathon meals, and generally being the wonderful people they are.

In some significant way, it is M’s own cancer story, or part of it, one really important detail, that may have saved my life. M had pain in her left breast a couple of years ago that prompted her to seek a diagnostic mammogram, only then to learn that she had breast cancer. When I experienced continuous pain in my left breast this past Spring, it was the echo of M’s story that sent me on my own path to my GP seeking a diagnostic mammogram, and finding likewise, cancer in the other breast.

M and I made our way to Sunnybrook Hospital, and to Dr. R’s office in the Cancer Centre. To recap, for the uninitiated, following my surgery, there was a conflict between the cancer diagnosis at time of biopsy (microinvasion) and at the time of pathology analysis following surgery (no invasive cancer). I located, with Dr. R’s assistance, a dedicated breast pathologist who specializes in the kind of cancer that I had (DCIS) and had ALL the slides sent to her for re-analysis - a fresh and highly skilled pair of eyes. Dr. R offered to provide a consultation regarding the whole case once the pathologist had finished her work.

The important facts that emerged from my conversation yesterday with Dr. R are as follows:

-No indication of invasive cancer

-Clear and significant surgical margins (greater than 1 cm)

-Mastectomy was, in fact, my only surgical option because the cancer was not just dispersed (multi-focal) but also existed in two large and separate locations (multi-centric) which removes lumpectomy as an option.

The clinical implication for the findings is that there is no need for any further treatment of any kind, and I don’t even need to pursue any kind of follow-up monitoring.

I really appreciate the effort and commitment demonstrated by Dr. R, who organized the pathology second opinion, and offered to talk to me with no formal referral — just following contact by email. I can’t say clearly enough how wonderful it was to be able, finally, to ask my questions and feel heard.

You have likely participated in some way in my cancer story, if only as a reader of this blog, which has been, for me, a vital way to connect with a social network of folks who offer solace, wit and the critical factor of co-presence. To all of you, I need to say how very grateful I am that you have been strong enough and persistent enough to be part of my life in this strange time. With this new clarity concerning the present - my present body - I feel like I can finally take a big first step away from this grotesque disease that is cancer.

 

Diagnosis 2.0

“Patients with multifocal DCIS with microinvasion have a five-year actuarial disease-free survival of 78% compared to 98% in patients with simple DCIS.” Ductal Carcinoma In Situ of the Breast

I am the fourth woman diagnosed with breast cancer on my mother’s side of the family in the past thirty years. Both my great-grandmother and my grandmother’s sister died from metastatic invasive breast cancer. When cancer runs in families, it tends to show up earlier with each successive generation. My cousin was diagnosed with exactly the same cancer as me (multifocal DCIS, comedo carcinoma, Grade 3 with a focus of microinvasion), at precisely the same age as me (I’ll never tell).

My cousin had the same surgery as me (bilateral mastectomy), but unlike me, she did chemo and tomoxifin. My Rx post-surgery was “no further treatment”. I am getting a second opinion about my breast cancer case. If you’re an American, you may be shaking your head right now, and thinking, “What’s the big deal about a second opinion?” Well, in Canada, it’s not common to get a second opinion, and the medical system is not set up to facilitate getting a second opinion.

I have never been able to rest easy with the discrepancy between the finding of microinvasion at the time of my biopsy, and the lack of a finding of invasion in the pathology analysis after my mastectomy. There are multiple possibilities. It is possible that there was a single focus of microinvasion in the DCIS at the time of the biopsy, and that the biopsy itself removed that microinvasive section of cancer cells. It is also possible that the post-surgical pathology missed the invasive component. Another option is that the biopsy pathologist was mistaken about an invasive component. The difference matters, because there are implications for treatment.

The basic question that needs to be answered with a reasonable degree of confidence is, “Did the cancer (DCIS), prior to the surgery, already progress to the point where some of the various tumour segments included invasive cancer cells that could have travelled beyond the confines of the ducts?”

Certainty in this matter of the diagnosis is not on the cards, because all of the methods for the identification of the kind and grade of cancer cells, and the degree or not of invasion, involve probabilistic techniques. No pathologist has the time to look at every cell, nor does the technology to do so even exist. So what pathologists do is based on a cost/benefit ratio acceptable to most parties, that goes something like, “If I slice up the tissue and make slides that I examine carefully from ten or so of the possible thousands of slices, then I will have a representative sample of the total population of material that could be examined.” And there are disagreements, of course, to pile on to what statisticians call, “standard error of measurement”. So if your life depends on getting the correct answer, then adding a second look to the first opinion is a very solid place to begin to improve the accuracy of the total diagnostic picture.

I was very surprised when I asked my surgeon what was the consensus about the error rate for pathology analyses, and she nonchalantly ventured that the generally accepted error rate was about 10%. Imagine that your life depends on the accuracy of a given diagnosis, and that in ten percent of the cases, a second-look would reveal that the facts were actually different. There is a decent body of research on the rate of disagreement amongst pathologists, like this study, by Canadian oncologist, Dr. E. Rakovitch, of Sunnybrook Hospital in Toronto. If you saw the news reports about Stronach’s DCIS and mastectomy back in June, you will have seen Dr. Rakovitch interviewed in just about every report. Dr. Rakovitch’s research shows that when you get a dedicated breast pathologist to provide a second opinion on pathology slides, a significant percentage of errors show up from the first opinion, resulting in a change of treatment plans in many of the cases (29%).

I searched out a breast pathologist, and an expert oncologist who specializes in DCIS, and together, they have agreed to provide a second opinion. I am really glad that I followed my gut feeling about the complexities of my case, and my family history. I am incredibly grateful to the doctors who helped me to find the right people to provide the second opinion. I’ll know more when I meet with the oncologist in about ten days. I am really nervous about opening up the space of uncertainty again. However, in fact, the space has always been open. All I am doing is gathering more knowledge with which to interpret the various uncertainties.

After my visit with the new team, I’ll update you. When I know, you’ll know.

 

Death by Numbers, or, the Patient From Hell

“We found that elevated pre-operative serum marker values were correlated with early replapse and death from disease. Possibly, the release of tumour associated antigens at the time of diagnosis proves blood supply respectively vascularization of the tumour and by consequence the possibility of already existing micrometastases and bad prognosis from the beginning.” F. Ebeling et a;. (2002). Serum CEA and CA 15-3 as prognostic factors in primary breast cancer. British Journal of Cencer, 1217-1222.

I am reading a really cool book at the moment — The Patient from Hell, by Stephen Schneider, a professor of Biological Science at Stanford who has documented his extraordinary and highly atypical strategies for informing himself at an expert level about a rare form of cancer, and using that knowledge effectively to significantly alter his medical care. Some days I try to be the patient from hell. I read all the information in my medical charts. I follow up by reading articles in the medical journals. I formulate questions based on my research and try my best to articulate a reasonable dialogue with doctors. It kind of works, sometimes. And it often falls flat. Schneider’s characterization of medical reasoning helps to shed light on several key factors that explain why it fails. Basically, doctors are trained to follow particular protocols, and a line of reasoning that isolates one or two findings in an If, Then logic. Add to the deficiencies in reasoning produced by this kind of linear thinking is the simple but devastating impact of economics on medical protocols. The kind of care you get is based on a cost-benefit analysis that is modeled on whole populations. There are particular shortcomings to this form of reasoning. Like, that it could kill you.

I have not been able to rest easy with my breast cancer surgeon’s decision that I should not see an oncologist following my mastectomy, and in the same vein, that I should not have any form of adjuvant therapy (like Tamoxifen, or radiation, or chemo). I am not comfortable with the biopsy finding of micro-invasion. That tells me that cancer cells could well have escaped the confines of the ducts. Yesterday, a new piece of information on my diagnostic profile blew me away — the micro-bomb. I was being a good “patient from hell” and reading my chart while waiting for my family doctor. I learned in a letter from my initial gyne surgeon consult to the internal medicine doctor who was in charge of my case while I was resident at UBC Hospital, that at the time of my breast cancer diagnosis, my CA 15-3 cancer marker was elevated, whereas it had significantly decreased post-operatively. My breast cancer surgeon had never disclosed the fact that CA 15-3 was elevated at diagnosis. And the implications are chilling.

CA 15-3 is one of the “tumour marker” blood tests that are typically done at the time of diagnosis. CA 15-3 is a cancer antigen - a protein that is shed by breast cancer cells. There is a lot of research on the prognostic value of levels of pre- and post-operative CA 15-3, and it’s not at all good news, in my case. A 2002 study reported in the British Journal of Cancer by Ebeling and his colleagues shows that amongst early breast cancer patients, “elevated pre-operative serum marker values were correlated with early relapse and death from disease.” Shering and colleagues (2000) report that amongst early stage breast cancer patients, “the probability of disease free survival at 5 years was 44% in patients with high CA 15-3 levels compared with 65% in patients with low CA 15-3 levels”. YIKES!!!

I know as a somewhat educated (in this domain) person that it would be erroneous to make huge assumptions based on one test result, but imagine not having known this upon making the decision to pursue no adjuvant therapy for breast cancer. It sure doesn’t make sense to me. Now what? Arrange for a second opinion, collect up copies of all the test scores, make a list of the key questions, go back into cancer world, keep fingers crossed, and so on, and so on… That’s my hope — to be another patient from hell who survives and thrives.

 

Can you come home, again?

I am home, again. “What’s home got to do with it?” ask Biddy Martin and Chandra Talpady Mohanty, a brilliant feminist, critical race theory duo. Good question. Can you come home, again? I am uneasy and remain in what I think of as, “Code Blue” mode. High alert. What could go wrong, will go wrong. Can you rest easy? Can you ever relax again? Can you trust your body? Martin and Mohanty ask us to question the politics of comfort and of some idealised notion of origin connected with the construct of “home”. This is hardly relevant to my present situation, where surely, after having endured two major surgeries in 5 weeks, and two encounters with the “medical cancer complex”, I can presumably afford to “take it easy”. I can let go, right? I suppose that just one of the tasks at-hand is to relearn a relationship to my body as something other than a disaster area - a site of catastrophic failure.

Perhaps I should start with the good news. I spent 11 days in the hospital awaiting surgery that quickly escalated into a scenario where ovarian cancer was high on the list of possibles and ended up with a more or less clean bill of health and a much less drastic surgery. Or perhaps I should relay an adequate account of the events of the past 11 days spent in two of Vancouver’s hospitals and dispersed across a veritable phalynx of doctors, surgeons, nurses, caregivers, friends, family and others. It’s hard to know where to start with this new episode. “Another chapter for the book” was my maternal grandmother’s favorite phrase deployed in order to decompress a tragic event and re/present it as simply another event in a busy life. Maybe that is how I should think about the recent spate of unfortunate events - another chapter for the book.

How about a simple chronology of events, as a way to begin.

July 3 Bilateral Mastectomy

July 20 Follow-up appointment at BC Cancer Agency for mastectomy, where unexpectedly, I run into my gyne oncology doctor, Dr. M, in the hallway - I had gone to see Dr. M for many years of colposcopic examinations of the cervix as a monitoring procedure because my mother had been given DES when she was pregnant with me, and DES daughters have a high risk for cervical cancer.

July 21 Notice left ovary pain for the first time

July 27 Left ovary pain has been increasing all week, so I call my GP, who recommends that I go to UBC Hospital Urgent Care in case it is a ruptured cyst. UBC Urgent Care is amazing - great doctors and diagnostic technologies. I get a CT scan and it shows a huge left ovarian complex cyst (10.5 by 8.6 cm, or grapefruit size) as well as a diverticular attack in the colon. I get a couple of prescriptions for antibiotics and leave expecting to consult back with my GP about the cyst. The pain gets worse over the next two days, as well as omnipresent nausea.

July 29 I go back to Urgent Care because I am feeling extraordinarily awful. The cyst pain is not getting better and the nausea is considerably worse. The doctor who is on-call in the Hospital recommends admitting me. I think that she is unusually kind and attentive because she is a school buddy of my friend B, who accompanied me back to Urgent Care. Dr. C is very concerned about the shape of the cyst (irregular/complex) and the link between ovarian and breast cancers. There is much talk about how to get in to see a surgeon about the cyst sooner than later. The tone, it is impossible not to notice, is getting that dire quality that stretches itself over the scenario like a taut netting. It’s disconcerting. My gown is not coming off this time. I am being wheeled into a hospital room. I have a tag on my wrist. I am here to stay.

July 29-August 6 I am resident at UBC Hospital where the amazing Dr. P tries every known combination of pain and anti-nausea medication to control my symptoms. He is one of many incredibly kind people who treat me during this period. Exactly as in the breast chronology, three days later I am let out of the hospital for a few hours to go to VGH to see the gyne oncological surgeon, Dr. McA. She is no nonsense about it all and schedules me for surgery August 7. The senior surgeon who will be overseeing the operation is my gyne oncology doc who I had run into at BC Cancer Agency, Dr. M. I really like Dr. M. I can’t believe that I am heading into another surgery where cancer is the overly determined backdrop.

August 6 I am transferred from UBC Hospital to VGH. I am on the gyne oncology surgery ward. It’s a very serious place. The nurses are very matter of fact about everything and not at all — what’s the right word here — kind? They do their job competently and don’t actually want to know how you are doing, when they ask “How are you?”. I have an amazing team of friends who come to visit from morning until night. They make me laugh. They go out and get broth and jello when the cafeteria brings the wrong meal and I am not allowed to eat anything but fluids. They push for me to get medication when the pre-surgical bowel prep meds I had been given created an explosive reflux problem that was burning a big hole in my throat. They give me hugs and take funny pictures with cell phones. My friends cradled me with love and care. The evening of August 6 the surgical resident, Dr. S, came to talk to me about the surgery scheduled for the next day. The dialogue was surreal. She walked me through a procedure where the surgeon biopsies the cyst and sends a frozen section to pathology for immediate diagnostics. While they wait for pathology’s response, the surgeon would remove my pelvic lymph nodes on both sides. OMG. At this point in the description of the forthcoming events I was freaking out. WHAT?!? Why start harvesting body parts before they even know whether or not the cyst is malignant? I start playing “Let’s reorganize this surgery” with the resident. How about they wait until they find out about the frozen section before they begin organ removal? I am emphatic that I must now revize the Surgical Consent Form. Sanity is disintegrating all around me even as I very rationally talk about the procedure with the resident, who reassures me that Dr. M will visit me before the surgery tomorrow and that I can “discuss this” with her. F*CK.

August 7 My surgery is supposed to be at 2pm. It’s a long day. I haven’t eaten now for 48 hours. Dr. M did come and see me and agreed to hold off on removing body parts until seeing the results of the pathology. I am feeling a little more confident. I am also terrified. I have a lot of pre-surgical angst. Just before they wheel me into pre-op a nurse comes in and tells me that the medical student has ordered an anti-coagulant shot. I can’t believe my ears. Who the heck would expect a shot of anti-coagulant just before an operation. I imagine bleeding to death on the operating table just because I foolishly agreed to a shot ordered in error by a fledgling doctor. So despite my intense desire to be a “good patient” I refuse the shot. Down in pre-op the nurse there tells someone else that I had “refused” the Heparin. I try to locate a doctor who can tell me whether or not I should actually be getting the shot. Everyone asks me the same litany of questions about allergies as if no one person shares their information with another and there is no central record keeping. It’s a zoo. We wait. And we wait some more. And my pain level increases intolerably because I have had no pain meds for hours now. There is someone else in pre-op also scheduled for the gyne oncology team, who I have come to think of as the “Dream Team”. And at 2:30, my time, the other person gets wheeled in. Dr. M tells me I might not have my surgery today if the other procedure takes too long. And we wait some more. I meet my anaesthetist, who turns out to be the same wonderful guy who was my angel of sleep for the mastectomy, Dr. B. How weird is that? Two surgeries within 5 weeks, and I get the same brilliant and kind anaesthetist, who goes to great pains (ha ha) to clarify for me the critical difference between “anaesthetist” and “anaesthesiologist”. Cool. Dr. M shows up and it’s time to wheel me into surgery at about 5pm. I try to chat with the OR folks for as long as I can to put off the “procedure”. I hate the”going to sleep” part of it all, cuz the “waking up part” is too soon after that moment, and then, the pain comes.

But wake up I do, and as soon as I can focus, look down to my abdomen to see what kind of incision I have — laparoscopic (maybe not cancer) or vertical abdominal (cancer for sure, all parts out). WOW. It’s laparoscopic — just three sections of steristrips. A nurse comes by. Someone tells me that they didn’t take out anything other than the cyst, which they think is benign. Only the pathology report will confirm this critical detail, but apparently with cysts, appearance is a reliable diagnostic tool. They didn’t even bother sending off a frozen section to pathology during the procedure. And it wasn’t, in the end, an ovarian cyst either. A fallopian tube became walled off and cystic, and expanded to grapefruit size. The sheer weight of the cyst and the fact that it became separated from the ovary and was swinging around and pressing on my colon and bladder is what had produced all the pre-op pain.

My friend P asked me if I “felt like I dodged the cancer bullet for the second time”. And oddly, I don’t. Maybe I should feel “lucky”. Perhaps in time all of this will settle somewhere, and might exist as some version of my grandmother’s “other chapter for the book”. But for now, I just want to feel the comfort of being “at home” - at home in my own body, in my domestic space, in the world. And once again, I am bowled over by the kindness of strangers — all the amazing people in the medical institutions that I travelled through who went out of their way to be helpful and empathetic — and by the kindness and generosity of friends and colleagues. SO much love.

 

Life stuff…

Since I want to enjoy the sun and my family today, this entry will have just the basics with no frills, no theory, and no clever commentary. So I haven’t updated my blog because for a week now, I have been in hospital. Yeah, I know. It’s f*cking unbelievable. But that’s also just the way it is. I am currently at home for a few hours on a day pass. Like a good inmate. Then, back to the institution. A week ago I ended up at the ER because I had been trying unsuccessfully to cope with intense abdominal pain for about a week. Something sure wasn’t feeling right. And it turns out that is because I am sharing my abdomen with a 10.5 by 8.4 cm mass on my left ovary, and maybe a diverticular attack as a chaser. The higher risk factor that I now carry for ovarian cancer pushed me to the top of the list, more or less, and I have been fast-tracked for surgery on Tuesday, Aug. 6. I know and like the surgeon who will be operating Tuesday. She may elect to take what few bits are left out (both ovaries and fallopian tubes), or I may just lose the mass and one ovary. It all depends what has chosen to take over my body. Many of you have helped to pass this time joyfully and have been incredibly supportive. I love all of you, whether you are one of those folks or not. People in the hospital have been extraordinarily kind. I am terrified and also not alone, so it’s almost bearable. I will have more to say when I get back. That’s a good motto I guess — yeah — more to say when I get back…

 

MRI’s, Breast Cancer, and Screening Options

Major Announcements Bolster Use of MRI Screening for Women Deemed to be at High Risk for Breast Cancer

So I will likely post quite a few things concerning screening and breast cancer. Don’t forget that my own breast cancer was missed across multiple mammograms whilst I was already enrolled in a program for women at high-risk. There is nothing particularly odd about this, since mammograms are unreliable screening tools for women under 50 and/or with dense breasts. I may even repeat myself on this topic. Let’s just call that, education. MRI’s are far from perfect, but they ARE going to be more likely to detect cancer. The weakness of the MRI from a clinical point of view is that it over-detects — produces false positives which then result in unnecessary biopsies. Oh, and as far as the state is concerned, MRI’s cost too much. Yes, that’s right. Even if you are high-risk, you can’t get a breast MRI unless you pay for it yourself. What is a woman worth, these days?

 

Living in Prognosis

It’s amazing to read something that seems to speak directly to you when you are in the grip of an extraordinary trauma. I can imagine getting really flaky, which I could not have envisaged pre-cancer. Yesterday my friend Stuart gave me a paper by Sarah Jain called “Living in Prognosis: Toward an Elegaic Politics” (Representations, Spring, 2007). It’s a funny thing, coincidence. I met Sarah Jain last year, having exchanged articles by email sight unseen, as folks commonly do these days. And then I discovered that another new email friend, Kris, from the University of Chicago, knew Sarah Jain, as does Stuart. How odd is that? And now this incredibly smart woman who teaches at Stanford and whose work I have been getting to know is writing about uncertainty, risk, discourses of temporality and breast cancer. Wow. I am almost ready to start talking about angels.

Everyone wants to know when I will get my pathology report and it concerns them greatly that (a) I am not sure, and (b) I don’t seem to be motivated enough about reading the analysis of the evidence from the diagnostic work on the breasts following the mastectomy. These folks who are concerned about my apparently lackadaisical attitude don’t have cancer. Well let me correct that. They are not “living in prognosis” - to use Jain’s elegant formulation. Prognosis is a very inexact set of practices. The reassurance that my well-intentioned friends think will be provided by a set of statements about the tumour and the presence of absence of cancer cells in the two lymph nodes removed in the sentinel node biopsy is actually a pipe dream. In fact, someone working in a lab will look at slices of the breast tissue and the lymph nodes, and provide a set of descriptive statements that, as a collective set of facts, will link up with another set of aggregated probabilities. The relationship between the population statistics and what the pathologist notices, and between these two sets of relations and treatment options - well, it’s just a big huge open field of uncertainty.

Tumour size, single or multi-focal, cells in the lymphs or not, estrogen and/or progesterone positive or not, age on diagnosis, micro-invasion or not — yes they all translate into slots in an actuarial chart — but no, there will be no moment of clarity and comfort in this clinical picture. Chemotherapy yes or no, radiation yes or no, hormone therapy or removal of the ovaries or both. Any and all are possible elements for my treatment and I am rather glad that at this point, today, as I am riding the waves of post-anaesthetic nausea, that there is a lot that I still don’t know.

 

Dancing on Knife’s Edge

I have wondered how to start this blog. Just thinking about writing my cancer onto the screen is way too real.

I have been living with a breast cancer diagnosis for three short weeks - days that have been filled to bursting with specialist appointments, blood tests, MRI, and hundreds of desperate and sometimes awkward conversations with friends and family. And I have cried. I have never cried so much as I have over the past 21 days. Buckets. I never know when the tears will start.

The beginning of this story probably involves a minimum of three combustive elements: queer love, a tattoo and cancer. I could start this account 17 years ago, when I had fallen desperately in love with a woman called Ange. She seemed like a heroic figure to me at the time. When I met her, Ange had just been through surgery for colon cancer. She had “the bag”. And she had a poster on her bedroom wall of an Amazonian woman with an amazing floral tattoo that wound its way across her double mastectomy scar. Ange died of cancer about six months after getting the all-clear from a doctor at the B.C. Cancer Agency. And now, today, I am quietly waiting for my own bilateral mastectomy (double) which is scheduled for the day after the day after tomorrow. And the tattoo that I have so proudly sported for the past seventeen years - a floral wreath that winds its way across my breasts in Ange’s honour - will itself be severed, and distorted; brutally cut short, just like my love of Ange.

I wanted to start this blog right away - back then - in the early days - but I just couldn’t bring myself to do it. I didn’t have the energy or perhaps, the courage. So this first entry will be a retrospective on the first three weeks.

June 8 - a mere three weeks ago - I got the call from my doctor with the results of my core biopsy. I was sitting in the Edmonton airport, waiting to fly back to Vancouver after having done a couple of really good research interviews. I am working on a project where I am looking at media, sexuality, communities and knowledge. When I saw my doctor’s name flash across the call display I knew before I even clicked the little green button that the news wasn’t good. After all, why phone me with good news? “Are you sitting down?” she ventured. My doctor told me that the biopsy of the right breast had revealed DCIS (ductal carcinoma in situ). “We’ve found it very early,” she exclaimed buoyantly, “and it’s totally curable. 100%” She then told me that she was heading out of town herself, but that she had set up an appointment with a surgeon. I remember that I couldn’t hear the surgeon’s name, and that I was utterly at a loss for words. I couldn’t metabolize the information at all.

It was a Friday, which meant that I couldn’t get into the doctor’s office until Monday to read the radiologist’s report on the biopsy. So I read whatever I could get my hands on about DCIS. Monday, I knew what to look for in the report. And when I finally got to see the report, I couldn’t fathom the intention of my doctor’s good cheer. The DCIS was multi-focal, grade 3 comedocarcinoma, and with a focus of microinvasion. Not good. But my doctor wasn’t around, and the next step was to get in touch with the surgeon, and to see what I could find out about her.

Dr. C works at VGH and is an oncological surgeon. So far so good. I found published papers she had authored. I didn’t find anything awful, although I am not sure what I was expecting to find. When I called Dr. C’s office, her secretary set up an appointment the very next day. I was just four days post-biopsy news, and heading into the oncological surgery floor of a major hospital. I didn’t take that as a very reassuring sign although, of course, I was also really grateful.

Dr. C’s office manner was a breath of fresh air for me. She took one look at my page crammed with notes and questions, and asked me what I thought about the situation. I remember thinking, “Wow. How novel. A doctor who wants to know what I think before even giving me her opinion.” So I ventured forth with my impression of the biopsy report, outlined my family history of bilateral breast cancer, and ended with the notion that I would probably be more comforted with a simple mastectomy of the right breast than a lumpectomy, despite the equivalent survival rates, because the fear of recurrence would likely prove untenable for me. My presentation felt oddly clinical - like I was an extra on House who had just nervously stumbled her way through a case presentation during Rounds. I thought Dr. C would vigorously disagree. After all, how hopelessly old fashioned of me to suggest a mastectomy for DCIS when I could opt for lumpectomy and radiation - or what we call, “breast conserving” treatment. But instead of trying to persuade me to keep my right breast, Dr. C steered us right down the path of deciding the fate of the left breast, and about 60 seconds later, I had settled on a bilateral mastectomy. There wasn’t a whole lot left to talk about at that point, save for a discussion of the sentinal node biopsy - a technique for testing the cancer status of the lymph node closest to the cancer and that is designed to reduce the risk of unnecessary lymph node removal. Then came the date for the surgery. July 3. 3 days from today.

I don’t know how to accommodate to the fact that I have cancer, nor to the fact that in three days, my breasts will be removed. Some days, the loss of my breasts seems like the really bad thing that I have to somehow get used to. And then, cruelly, comes the realization that after all, what’s the loss of breasts in comparison to the very real possibility of metastatic cancer?