Over this past month I've learn that -- pretty much my entire team -- has "oncology" or "oncologist" or "oncological" attached to their speciality (eg surgeon vs radiologist). It means that they are all "cancer doctors". And, there are so many doctors that make up a person's cancer team. My cancer surgeon is an oncological surgeon. She takes the cancer out -- hence she is the person who performs the mastectomy. My reconstruction surgeon specializes in oncological reconstruction -- he sews you back up after the mastectomy and starts the process of reconstruction which takes about a year. The radiologist also is an oncological radiologist. Mine happens to specialize in cancers of the breast. The radiation oncologist is the person who, in this tag team, administers radiation.
But the one we generally think of as the cancer doctor (even though these all are cancer doctors) is the medical oncologist. Dr. Link is a cancer doctor.
Dr. Link is famous for many reasons. But among the reasons is the fact that he was one of the first doctors who said the medical field is over treating cancer patients with a one size fits all approach in regards to chemotherapy. About 20 years ago he performed studies which eventually showed the medical community how a chemotherapy can be tailored to each persons unique biological profile. And he is a proponent of both hormone therapies and therapies guided by genetics. He also ran track (for USC) and with his three team mates broke the 2 mile relay world record the year I was born -- the year Mexico hosted the Olympics. Two weeks after that relay, his beloved coach died of cancer; hence, his initial interest in this field. Dr. Link is amazing in person and in writing. His books are informative and paradigm shift changing with great results.
In the past it used to be that doctors were guided by the following three main categories of each cancer:
1. The type of cell where the tumor originated such as in the mammary ducts (tubes) or the mammary lobes (milk production bulbs attached to the tubes). Hence the names ductal cancer (ductal carcinoma) or lobular cancer (lobular cancer).
2. how different the cancer cell was from the original normal cell
3. how the surface of the cell appeared in terms of unique receptors
Because of genetic research and microarray analysis, a new classification emerged in which the genetics of the cancer tumor guides diagnosis and treatment. This genetics classification system is completely different than that of the hereditary type (eg BRCHA genes -- this is a different analysis; this test simply uses a saliva sample). The genetics classification discussed by Dr. Link is that of the way the tumor looks and behaves genetically. The genetic test used on, the Agendia Mammaprint, actually samples the biopsy tissue called a core. And, based on many years and cases, they now have 4 distinct patterns to place breast cancer tissue. This tells the doctors whether a patient will respond to chemo or radiation or hormone therapies -- or a combination of these, or none.
The four classifications of a tumor based on this genetics test are the following:
1. Luminal A
2. Luminal B
3. Basal Cell a.k.a. triple-negative
4. Her2-positive
For the sake of simplicity, I'll only talk about Luminal A and Luminal B cancers since these apply to me.
Luminal A cancers are the most common. These don't respond to chemotherapy. The hormone receptors of estrogen and progresterone are positive. The rate of cell division or mitosis is slow. The grade -- or ugliness -- is also low. The tumors classified as Luminal A tend to be less than 2 cm (the size of a quarter). Mine was more than 2 cm. However, the Agendia Mammaprint result given prior to surgery put me in this category despite its size and quantity.
Luminal B cancers act more aggressive than Luminal A cancers (Luminal A would be my first choice if I had one). Luminal B divide at a faster rate. Whereas a Luminal A cancer would go through division, or mitosis, at a rate of about once per three months, a Luminal B goes through one roughly at about 30 days. Mammograms tend to underestimate these cancers; MRI's are better. Complete removal is tricky. Sometimes a second surgery is needed to clear the margins (mine were clear in the first). Luminal B cancers enter the lymph system and bloodstream. Treatment decisions (eg chemo, radiation, hormone) depends on many additional factors and additional testing.
One of the controversies with Luminal A and Luminal B cancers is that some argue that, based on evidence, a Luminal A can morph into a Luminal B. This is what Dr. Link's book states. It just so happens that prior to my surgery, my Agendia Mammaprint came out as a Luminal A cancer type. But, after surgery, once the surgeon was able to remove my tissue, my cancer was what was described as a heterogenous one with both Luminal A and Luminal B areas.
In other words, my tumor sample -- the actual tissue taken out of my breast during the biopsy that happened after my series of mammograms and ultrasounds -- came out as Luminal A on the Agendia Mammaprint. But once that tumor was completely extracted, it behaved like both Luminal A and Luminal B. I asked is it like taking out an item the size of a quarter (mine was roughly bigger) and some of that quarter had Luminal A behaviors and some had Luminal B behaviors but when they sampled they only sampled the part that had Luminal A behaviors. I was told this was correct thinking. So, cells are heterogenous in which the Agendia Mammaprint worst result of the two (in my case Luminal B) trumps Luminal A. This is really only known at surgery. Mine is now categorized at a higher grade cancer -- it acts more aggressive than one once thought; it also is aggressive at a faster rate. And it metastasized to the lymph system. Thankfully, only the sentinel node was affected in the sample removed.
In terms of node testing at surgery, this is what typically happens: surgeon removes breast, then looks for blue dye injected the previous day that marks the sentinel node -- the first node in the network of all other nodes. They test it there in a roughly ten minute test performed by the pathologist. If it has cancer, the theory is that other nodes may also have cancer. If nodes have cancer, then this is the entry way to the bloodstream. In any case, if the sentinel node has cancer then the surgeon removed a chunk of tissue around that node. Kind of like fishing in a pond where you see one fish -- you then cast a larger net to see how many lymph nodes appear in that mass that also then gets biopsied. Sometimes only a few lymph get caught, sometimes more. Mine happen to be two sentinel nodes and 13 lymph nodes for a total of 15 nodes. Most of them, in my case, which explains why I have no sensation under my arm. Imagine numbed cheek after a dental procedure. That's what my underarm feels like. Doctor said this numbness is for roughly 7 months or more or indefinitely. Small price for bigger goal.
So, my cancer is controversial. Luminal A doesn't respond to chemotherapy; depending on tests, Luminal B does respond to chemotherapy. In my case Luminal B trumps Luminal A. But it's not simple in saying 'ok, she needs chemo'. From here there are other considerations that guide the doctors to the right 'chemo cocktail' of which there are many these days.
In my next post I'll talk about the chemo cocktail chosen for me. I'll go through four chemotherapy rounds starting Tuesday, March 26, 2013.
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