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.

Diagnosis

It took some time for the news to settle in as we sat in the lobby of Apollo hospital. It was a double blow for me as my sis is already battling the same disease since early 2010.

The lump was 5.0x4.0 in diameter. It was big in size.

We met the surgical oncologist again and he suggested an immediate surgery for breast removal (Mastectomy) followed by chemotherapy and other treatment later based on biopsy of the lump. He also suggested the following test to check if the cancer has spread to any other part of the body:
-  PET - II - This checks vital organs like liver, lungs, kidney etc.
- Bone scan
- Echocardiography

As we finished all the tests in the next couple of days it became clear that the cancer hadn't spread to other parts of the body. This was a big relief.
But I was a still scared with the lump size, mastectomy and chemo bit and was keen on getting a second opinion.

I started searching for the best surgical oncologist in Bangalore.

The beginning

I live in Bangalore, India. My Mom got diagnosed of Breast Cancer recently, 25th Oct. 2011 to be precise.
Since then it's been quite a trial for her and all of us in the family. I would like to share the details of the treatment that she has been undergoing and other experiences in general.

I hope this would be useful to many others battling the disease and looking for some info on treatment in Bangalore.

Besides I would be delighted and greatful if I get some suggestions that would help in Mom's recovery.

Mom started feeling some pain and heaviness in her left breast in late June, 4 months before the formal diagnoses. But she thought of it as muscle pain and applied some pain relieving gel/balm. The pain would subside briefly but came back and stayed. She felt giddiness also sometimes.
In late September she started to feel some hardness and lump formation which kept growing . In October when she came to bangalore (she keeps shuttling between Jodhpur and Bangalore) we went for a checkup to Apollo hospital on Bannerghatta road near IIM Bangalore.
The oncologist we showed was a medical oncologist who after checkup adviced us of a Mammogram and a FNAC to be done as she thoght the lump didn't look like something that can be ignored. She also referred us to a Surgical oncologist . The surgical oncologist also suggested us to get the tests done immediately to confirm whether it was malignant or not. Although I have a feeling he knew after clinical examination that the lump was malignant. Don't understand how.

The mammo and the FNAC cofirmed the malignancy.