Radiotherapy progress

It' been 1 and half week since the Radiotherapy(RT) started. Out of 28 sittings, 8 have finished. 4 more weeks to go as it happens only on the week days. The 2 days gap every week is given to give the healthy cells some time to recuperate.

Until now no side effects except some redishness in the exposed area. No other problems.

There is some pain in the breast occasionally which is unrelated to the therapy and is more likely associated with the surgery.
For that Mom has been prescribed a pain killer, Tryptomer (10 mg) daily before going to bed.

One word for the Manipal hospital RT staff . They are exceptionally polite, helping and professional led by a very caring Dr. Sanjiv Sharma. It's been worth travelling 30 kms (15 one way) daily for the treatment.

Cost of treatment until now

Over the past month I've realized the fact that cancer treatment is a costly affair and made me think how difficult it would be for poor people to get through it. It has also re-emphasised the importance of proper and adequate insurance coverage.

The following are the details of the treatment cost in Mom's case:

- Diagnostic tests - Rs. 15000/-
- Surgery - Rs 65000/-
- Radiotherapy - Rs 102000/-
- Hormone therapy 5 yrs (1 Arimidex tablet daily) - 5 * 365 * Rs. 233/- = Rs. 425225/-

My corporate insurance with United India Insurance has covered the first 3. But there is no approval on Hormone therapy as yet and I'm very skeptical that it would come.

Another patient whom we had met during Mom's surgery in Rangadore hospital suggested us to get the cancer medicines from the Kidwai Memorial hospital drug store. It's a government hospital and they sell the medicines there on discounted price and not on MRP. I checked there and got the Arimidex tablet at a discounted price of Rs. 173/-. So the total cost for this medicine would be:

5 * 365 * Rs. 173/-  = Rs. 315725/-

I'm amazed how much money the drug companies make on these drugs. Read somewhere that Astra Zeneca, the Arimidex manufacturer has sales of around $2-3 billion from just this drug annually.

Besides it made me realize that how much margins the pharma retailers make on medicine sales and state governments in India are doing their bit at providing these at lower costs.

Radiotherapy

For Radiotherapy we were reffered to the radiation oncologist Dr. Sanjiv Sharma of Manipal hospital. Since he was on leave for a week we thought of meeting couple of other radiation oncologist to get some information and clear our doubts about this therapy. Besides I wanted to explore the option of getting the therapy done in Apollo hospital which is very close by.

I got the following info on Radiation therapy after the meetings:
1) It is done to kill any cancer cells in and around the tumour area remaining even after the surgery.
2) It is must after breast conservation surgeries(lumpectomy) but not essential post mastectomy.
3) It has minimal side effects. These are mainly skin darkening and peel off in the treatment area besides some itchy feeling. These normalise after the treatment.
4) The risk of radiations impacting heart and lungs is very less owing to advance technology.
5) Mainly external radiotherapy is done. Internal is not that common and anyways it is relevant more for very small tumours < 2 cm.
6) Two techniques of external radiotherapy are available: 3D CRT and the newer IMRT. These use X-Ray beams using medical linear accelerators. Differences in the techniques:  http://www.pamf.org/radonc/tech/imrt.html.
7) 25 to 36 sittings are required. This happens daily 5 days a week. First sitting takes few hours as the radiation exposure area is marked and other planning is done along with CT scan. Subsequently 10 mins. is sufficient.
8) The radiation oncologist himself doesn't do the therapy. His role is more in consulting and planning. There are other specialist in his team who operate the equipment.

As far as Im aware the following hospitals in Bangalore have the ccapability:
1) Manipal hospital, Old airport road
2) Bangalore Institute of Oncology
3) Apollo hospital
4) Kidwai Memorial hospital

We met Dr. Sharma eventually on 29th November. He gave us the details of the therapy, cleared all the doubts we had and reiterated the fact that the risk involved was negligible specially at Mom's age. I found him far more confident and convincing than the couple of others I had met.

He did a clinical examination of the operated breast and subsequently mentioned the following treatment for Mom:
- 28 sittings of radiation for 5 1/2 weeks
- Forward IMRT (This is latest)
- 5 days a week.
- The Hormone therapy tablet Armidex have to be stopped during this 5 1/2 week period.

We have to first get a CT scan done. Post that his team would require couple of days of planning and then the therapy would start. For the scan no fasting is required unlike as mentioned by previous doctors.

The team at Manipal is very trained and experienced and the equipment is latest. I found the treatment cost also fairly less than the other private hospitals.

I decided to go ahead with the treatment in Manipal hospital under Dr. Sharma.

We got the scan done the same day. The RT team also tattooed few markings(spots) on Mom's chest area for accurate radiation exposure regularly.

The therapy started 2 days later on 1st Dec 2011.

Chemo or no Chemo

In cancer staging terminology Mom's breast cancer stage is described as PT2N0M0, where,
P is Pathological stage i.e post surgery on pathological examination of the tumour rather than C, clinical examination.
T2 - Grade II tumour
N0 - Lymph nodes un-impacted
M0 - No metastasis i.e no further spread in the body

Next couple of days as I met couple of medical oncologists it became clear to me that this wasn't a bad state to be in. This is considered early stage and is amongst rare detection in India but is common in the west where the awareness of Breast cancer is high.

We met Dr. Shekhar Patil 2 days later on 14th Nov. at Bangalore Institute of Oncology. This hospital has couple of branches, one on Double road Shanthi Nagar and other on Miller's road. The consultations happen in the later branch. Since the appointments of Dr. Patil were full for almost a week we went there in the walkin batch which gets a chance post 4'o clock in the evening.

Dr. Patil explained in detail on the course of treatment for patients with Mom's stage and age (She is 62 yrs. of age). Radiation therapy is mandatory and so is 5 yrs. of Hormone therapy. For the later he prescribed Armidex(Anastrozole) tablets. These are newer estrogen suppressors than the popular Tamoxifin tablets with lesser side effects.

As for Chemotherapy he mentioned that there were both lines of thought equally prevelant, those who favour Chemo and those who don't at this age and stage. But recently there are couple of new tests that have come up on which the judgement could be based. These are:
1) Oncotype Dx - Details http://www.healthsearches.org/Categories_of_Q&A/Diagnosis/1326.php
This is a very effective indicator. But this is very expensive, approx Rs. 1.6 lac and conducted only in US.

2) A lesser comprehensive and inexpensive test is Ki-67 tumour marker test. This also gives reasonable indication. This is conducted in Bangalore as well.

He makes his judgement on the basis of one of these and asked us to choose.

I decided to go with the later. Since I already had some idea of this test I had brought with me the tumour tissue block that was given after surgery and histopathology tests. The BIO lab verified the block and found it good enough for the test. The results were expected in 3 days.

We waited with bated breath for the same. 18th Nov we got the report which mentioned that the "Ki-67 proliferative index was around 5%". Met the doctor the same day and he mentioned that the value is very low. If it's around 50% then only Chemo is recommended.

Hence no Chemo for Mom. We were happy.

Future course of treatment

Post surgery the only discomfort Mom faced was some pain and stretchy feeling in the operated area and in the underarm. She was on a painkiller (Ultracet) for that, taking couple of those daily.

On 8th Nov 11 we went for a checkup. Dr. Praveen who is the assistant doctor to Dr. Srinath and an amiable personality, did a fresh dressing of the wound and also removed the lymphatic tube and bag as daily dicharge had come down below 30ml. This was a big mental boost for Mom as carrying these constantly kept her reminding of the disease.

The much awaited histopathology reports came on 10th Nov 11. The summary of the reports was:

1) Grade - II Infiltrating duct carcinoma (IDC) of left breast with tumour size 2.5 cm in diameter
2) Lymph nodes free from tumour
3) Estrogen Receptor (ER) - Poitive (Allred Score 5+2 = 7)
4) Progestrone Receptor (PgR) - Positive (Allred score 3+2 = 5)
5) Her-2/neu - Negative (10% tumour cells positive, intensity 1+)

The lymph nodes being free from cancer was a big relief to us.

We met the doctor afterwards on 12th Nov 11. He said the results are very positive and being ER/PgR positive is a good sign as the line of treatment becomes predictable(Hormone Therapy) and besides that Chemotherapy(CT) is not a must. Although the tumour size being more than 2cm keeps the possibility of Chemo open.

Radiation Therapy and 5yrs. of Hormone Therapy was a must though.

We were referred to one of the best medical oncologist in Bangalore Dr. Shekhar Patil for further consultation.

Meanwhile in the same visit ,surgery stitches were also removed.
Now things were much more clearer but still one intriguing bit was there, Chemotherapy required or not.

Surgery

After consulting my uncles, my sister (on the phone) and Mom I decided to go ahead with the surgery in Rangadore memorial hospital. I also dropped thoughts of another specialist opinion as I was convinced we were already dealing with the best.

The surgery date was fixed as Monday, 31st Oct 11.

Rangadore hospital is not your typical 5-star hospital of these days but it is well equipped, extremely clean and has a very friendly staff. We got Mom admitted on Sunday afternoon 30th Oct. We had taken a deluxe room which is for single patient, has AC and an additinal attendent bed. It was spacious too.

The duty doctor, nurses and support staff got into action. Mom's BP was continuously monitored and kept under check.

On Monday morning Mom was taken in the operation theatre at 9:00 A:M. At around 11 o' clock I was allowed to go in the post operation room and have a peep in. I waved at her and surprisingly she nodded. Either it was local anaesthesia or the impact of general didn't last much.

The operation was a success. All of us were hugely relieved. She was shifted back to the ward room at 12:30 P:M. It seemed the actual operation took only 1 hr. or so.

I had a full support team of my uncles, granny(Mom's mom), cousins and of course my wife. The importance of relatives is realized in such tough times. The next 3 days Mom recovered from the surgery in the hospital. Since my uncle's(Mama) house was very nearby, everything from tea/coffee to lunch/dinner came from his place. Although the cafeteria in the hospital also dished out decent stuff but no beating the home stuff.

One thing that bothered me was that all her axillary lymph nodes were removed. I was eagerly awaiting to talk to the doc about it. When I got to talk to him he explained that some of the nodes were swollen and he didn't want to take any chance although they seemed non-malignant. The subsequent biopsy would confirm whether they are malignant or not. Besides only level I and II were removed and level III were still intact.

On 3rd November Mom was discharged and brought home. Post operation one thing that she had to live with for a few days was a lymphatic fluid discharge tube and bag. It seems the liquid was coming because of lymph node removal. The discharge bag had to be emptied daily and amount of liquid measured. Once the discharge amount reached below 30ml the the tube could be removed. Mom got adjusted to this in a day or two.

As all this was happening we were also anxiously waiting for the biopsy reports. Two of them were there, one for the lymph nodes malignancy and other the nature of cancer whether hormone receptive or not. The later was expected from Bangalore institute of Oncology while the former was to come from the in-house lab in Rangadore.

Decision making

My search for the best surgical oncologists in Bangalore concluded with the following two names:
- Dr. B.S.Srinath
- Dr. K.S.Gopinath
I had searched on the net, checked with a known doctor and got information from my uncle who also stays in Bangalore.

Coincidentally another uncle of mine knew Dr.Srinath. So we decided to meet Dr. Srinath. We got an appointment on 28th Oct 11 at Rangadore Memorial Hospital.
This hospital is in Basavangudi on the Shankar Mutt road and is run by the Shankar Mutt trust.
Armed with all the test reports, accompanied with my two uncles we met Dr. Srinath on 28th. He saw the reports, examined Mom and then gave his opinion.

Cancer was in initial stages. But immediate surgery was required.

Couple of other things that came out did brought a lot of relief to me.

1) Based on his clinical examination the lump wasn't big enough. It was around 3x3 cm in dia.. The reason for the larger size in the FNAC could have been because of
swelling caused by pricking the lump.
One point to note that there was some bleeding in the lump that had happened due to the FNAC and the area around the lump had turned blue possibly because of clotting.
It seems this is also a good sign indicating the lesser aggressiveness of the cancer (This I got to know independently from other sources).

2) Axillary lymph nodes didn't seem impacted. Although a clearer picture would emerge during the surgery and the biopsy after that.

3) Removal of complete breast (Mastectomy) might not be required and just the removal of lump(lumpectomy) would be sufficient.

He asked us to decide on the surgery date and also referred Mom to the anaesthetist for his input on the surgery date.

The check-up by the anaesthetist revealed a high blood pressure (BP) for Mom, 190/100. This wasn't suitable for the surgery to happen and he prescribed medication to bring it down and also a one day advance admission before the surgery to keep it under control.

It was decision time now. We were convinced that surgery is a must but in the  back of my mind I was still evaluating whether to take another opinion and also whether to get the surgery done in Rangadore or somewhere else.