2nd Oncologist Advice

Went to Prince Court Medical Centre to meet Dr Azrif today.

Unexpectectly, he is a nice guy, and give me confidence to undergo my treatments with him.
He anwered all my doubts, like, some ppl says radiation will cause recurrent of cancer in another breast etc.
He also explained to me, about the radiation methods that I have learned online, 3D CRT, IMRT and IGRT.
IMRT - Low dose wave shoot into our body from every angle (front, side and back), and only high dose focus on the breast. Therefore, lung will also receive a lot low dose wave.
3D CRT - Low and high dose shoot front ftont and focus on the breast. Therefore, only the top layer of lung will receive the low dose and high dose wave.
IGRT - is type of technolgy that is also used in the above 2 methods.

According to him:
- Breast cancer can mainly categorized into 3 groups, i.e. ductal, lobular and misc. About 75% of breast cancer is ductal cancer, and 20% for lobular, and 5% for misc. Tubula, Mucinous, Papillar, Medullary are some of the rare type of breast cancer under misc category.
- My cancer type is rare type, and is not as dangerous as the ductal cancer, therefore he suggests me to undergo radiotherapy and hormone therapy only.
- Radiotherapy will last 4 weeks, 3 weeks for entire breast shooting and last week is boost shooting which focus on the lump area only.
- About 20% of young breast cancer patients that undergo radiotherapy will still have recurrent of cancer on the same breast, but it reduce to 10% only after boost shooting.
- He suggested 3D CRT for me, which he think this is best for me as it minimize the low dose wave to other organs in the body, especially the lung. Which indirectly to minimize the damage to the lung.
- Sample of side effects: Redness, peeling expecially underarm and breast, skin darker (temporary) and breast becomes firmer (permanent).
- Tamoxifen will cause irregular of menses cycles, or in worst case, will cause menopause.

1st Oncologist Advice

Today, I met Dr Christina Ng at Sunway Medical Centre, to discuss about the treatments that she will suggest to me if I decided to undergo the treatments under her supervision.

She made a call to Prince Court Medical Centre. After getting the detailed lab result of the tumor, that was not printed in the pathology report, she suggested the 3 most popular and common therapies to me, as expected. They are chemotherapy, radiation, and hormone therapy. Therapy will be carry one one after another. Chemotherapy will start first. Chemotherapy is suggested due to I am fall into young age category.

The discussion, somehow is a bit disappointed me, although this is the expected result. Some online articles and information gave me hopes that I might not need chemo and radiation base on my pathology report. But the result of discussion is in opposition.

Chemotherapy
6 cycles, 3 weeks once.
Will finish in about 4 months time.
The quality of drug that they are using will not cause much nausea, but hair lost is confirm.
Will cause < 1% heart damage.
In most cases, other organs will recover after chemotherapy.
Should start on 16 or 17 Feb 2011.
Total cost is about RM20K.

Radiation
25 sessions, finish in about 5 weeks, from Monday to Friday.
Using external beam.
The good radiation machine / chemical material will not cause damage to lung and other organs.
Focus on the whole breast.
Total cost is about RM12K.

Hormone Therapy
Tamoxifen will be used, which to stop the body from making estrogen.
Menses will be stopped.
Side effect similar to menopause.

Shortlisted oncologist

With frens' help and online information, I had shortlisted 3 oncologists and I am going to meet them to get consulation about the treatments. They are Dr Christina Ng from Sunway Medical Centre, Dr Ho Gwo Fuang from UMSC, and Dr Azrif from Prince Court.

Tomorrow is the first meet up with Dr Christina, and then Dr Azrif on Saturday, lastly Dr Ho on 7th February.

My surgical pathology final report (partially)

Clinical Information
Mucinous carcinoma right breast.

Source of Specimen
A. Right breast tumour with additional superior margin.
B. Right axillary fat and node.

Microscopic Description
A. Sections show the mass is a mucinous carcinoma, 2.3cm in largest diameter, composed of small groups of malignant cells with mild nuclear pleomorphism within pools of mucin. Lumina formation is seen in some cellular groups. A few foci of cystic ducts are seen in the breast lobules of thew surrounding breast tissue. All margins are free of malignancy. The other piece of breast tissue also shows a few cystic ducts and is free of malignancy.

B. Sections show fibroadipose tissue with a few nerve bundles. Lymph nodes are not present.

Diagnosis
A. Right breast tumour with additional superior margin: Musinous carcinoma with clear surgical margins.
B. Right axillary fat and node: No lymph nodes present.

Addendum Report
Immunohistochemistry Report
Estrogen Receptor : Strongly Positive
Progesterone Receptor : Strongly Positive

Anti Her2/neu (clone 4B5) for CerbB2 oncoprotein: Negative (score 1+).

My 1st analysis on the pathology report

The lump is confirm a mucinous cancer, namely Mucinous carcinoma.

There are few therapies which oncologist will normally recommend:
Radiation therapy, chemotherapy, hormone therapy and targeted drugs.
http://www.mayoclinic.com/health/breast-cancer/DS00328/DSECTION=treatments-and-drugs

Radiation therapy - Looks like this is a must for lumpectomy surgery, which only remove the breast cancer, but not the entire breast (mastectomy).

Chemotherapy - HIghly recommended  in order to control the spread.

Hormone therapy - Use hormone blocking pill to reduce the hormone production or to block hormone to attach to cancer cells. Because of I am strongly positive in both Estrogen Receptor (ER) and Progesterone Receptor (PR) positive, therefore I am suitable for hormone therapy. For those patients with ER/PR negative, they may only rely on chemotherapy and radiation therapy to kill those cancer cells. In other words, I have averagely  30% success rate after for each therapy but those iwth ER/PR negative, is 50% on chemo and radiation. I personally think, if i skip chemotherapy, I still can rely / put hope on hormone therapy + radiation.

Targeted drugs - I am not suitable for this therapy, as mine cancer cells is Her2/neu negative. Lucky me, I heard this treatment costs about RM100K.

*Not very sure about all the information in the report.*


Some additional information about Mucinous Breat cancer, which is quite match to my report.
Information from:
http://www.breastcancer.org/symptoms/types/rare_idc/mucinous/symptoms_diagnosis.jsp

There are some other key features of pure mucinous carcinoma:

• Hormone-receptor-positive: Studies show that pure mucinous carcinoma tests positive for estrogen receptors 90-100% of the time and for progesterone receptors in 50-68% of cases.
• HER2-negative: Mucinous carcinoma usually tests negative for receptors for the protein HER2/neu.
• Negative lymph nodes: Pure mucinous carcinoma rarely spreads to the lymph nodes, especially if the tumor is 1-2 cm or smaller. Larger tumors may involve spread to the lymph nodes. Sometimes, cancer in the lymph nodes indicates that the tumor is actually a mixed mucinous carcinoma, with invasive ductal carcinoma cells present.

About recurrent of cancer

Early conclusion
Lesser chance of recurrent.

Supported statements from report
"All margins are free of malignancy", and "Musinous carcinoma with clear surgical margins"

References
http://www.mayoclinic.com/health/recurrent-breast-cancer/DS01078/DSECTION=risk-factors
Which describes a few factors that will increases the risk of recurrent, either local recurrent (same place) or at other areas (spread)
Lymph node involvement - Mine does not
Larger tumor size, more than 5 centimeters, or about 2 inches - Mine is 2.3cm
Positive or close tumor margins - Mine is margin clear
Lack of radiation treatment following lumpectomy - Still under consideration to go or not to go, lets say i go
Younger age. Women under age 60, particularly those under age 35. - Considers a

Some statistics (source from Dr Harjit)

Dr Harjit showed me some statistics on the day I met her for the pathology report.

A. Alive rate in 10 years, with or w/o therapy
B. Alive and w/o cancer rate in 10 years, with or w/o therapy

Alive rate
Decision: No additional therapy
88 / 100 women are alive in 10 years.
4 / 100 woman die because of cancer.
8 / 100 women die of other causes.

Decision: Hormone therapy
1 / 100 women are alive because of therapy.

Decision: Chemotherapy
Less than 1 / 100 women are alive because of therapy.

Decision: Combined therapy
1 / 100 women are alive because of therapy.


Recurrent rate
Decision: No additional therapy
74 / 100 women are alive and without cancer in 10 years.
18 / 100 woman relapse.
8 / 100 women die of other causes.

Decision: Hormone therapy
4 / 100 women are alive and without cancer because of therapy.

Decision: Chemotherapy
2 / 100 women are alive and without cancer because of therapy.

Decision: Combined therapy
6 / 100 women are alive and without cancer because of therapy.

Gather opinion abt the therapies

Frens, I need your opinion now...

Perhaps you guys can spend some time help me read the information posted below.

My father ask me not to do any therapies, but put hopes on chinese medications.
Of course I won't reject chinese medication. Furthermore, it is in my initial plan of treatments too.
Looking at the risk, if I don't go for radiation, it increase my risk on recurrent of cancer.

My initial plan is, I will go for radiation, considering on hormone (pro and side effects), then NO for chemo, together with chinese medication.

Now, I need your opinions to help me decide.

Side info: I met a patient who is also diagnosed with breast cancer stage 2 yesterday in hospital. She told me that, after her first chemotherapy in Glenneagle, her hair was dropped (now she shaved all her hair), and nausea for 4-5 days.

Got my surgical pathology final report

Frens, knowing everyone is worrying about me and care about how my report is. Just want to let you all know, report shows positive result. I will post the report here later. But, still not clear about what type of treatments will be undergo. Am going to meet oncologist this coming Saturday to discuss and get information about radiation, hormone and chemotherapy. Basically I guess these should be the 3 treatments that he will suggest to me on this coming Saturday.

RIP 谭家荣

Heard from old friend that Tham Ka Weng 谭家荣， my primary schoolmate has passed away during his sleep on Saturday. Age only 36, same as me. Still so young. Heard from fren he even got stroke before this. Health already start alerting at such a young time.

Appreciate every moment of living! Just like what my blog's title means.

Swelling breast

Operated breast become bigger than normal. I think it is swelling, the breast! Not sure why. Did some studies online. Some articles say it is common after operation especially if I had axillary dissection. But I did not. Some even says this situation may continue for months. Underarm also still feeling numb. Hope it will get back to normal very soon.

Wound Bleed

May be move too much, causing the wound bleeding and pain. Have to take pain killer to stop it.

Now like "orang cacat", avoiding using right hand, and need to use the other hand to hold the breast while walking or moving, to avoid stretching the wound.

home

finally, home with little pain on right hand.
will be on mc for 1 month temporary.

frens, sorry cant type too much and reply some sms and calls. i hope i am left-handed.

"Coma" for the day

Frens, I will be undergo a surgery at 8.30am today. I forgot to ask doctor how long it takes. I guess it could take about 2 - 3 hours. I will not able to update anything here, as I guess I will be keep sleeping and sleeping for the whole day.

Good night.

Btw, Dr Harjit says, radiation and chemotherapy will only be started about 3-4 weeks after the operation. So, I still have time to make some studies on it.

Operate liao...

Nurse pushed me into operation room at 8.05 this morning. I stilll actively looking around. He told me his name is "Koh Wah", and he is the one in charge of anaesthesia jab. He told me i will going into sleeping mode in 1/2 minutes. I remembered my last sentence is, "I am getting blur." Then I really sleep for 3 hours.

By time, I start having little feeling and awake is at 11.30AM. I can see the clock on the wall.

Go back to wad and sleeps till 12.30PM, woke up by fren. Till now, I am totally awake liao.
My friend keep telling me most people will be sleeping and blur for the entire day. But I feel OK wor... nothing. May be 箭猪粉 really helps?

OK, about operation, 2 leading lymph nodes were took out and tested, no infection. So Dr Harjit only removed the tumor from my right breast, no further lymph nodes were being removed. They are safe!

When I just go back to my wad, the wound is pretty pain. So nurse gave me pain killer. After then I am ok, dun feel anymore pain (may be due to pain killer is taken). The wound still got little pain now. Cannot type keyboard too much, cannot stretch my right hand also.

Full report will be out on Thursday or Friday. I will be seeing dr on Monday for the report. Probably will discharge from hospital tomorrow, and continue rest at home.

Another Shock - Cyst / Lump in Right Ovary

In hospital today. Done the CT Scan in the morning, about noon time.

After the scan, I did not wait for the result, but I went out to take lunch with fren. After 1-2 hours, hospital called me, and ask me back to meet a gynae doctor. I was shocked. I asked whats the matter over the phone, but the nurse was not sure about it.

I met Dr Tan, the gynae that Dr Harjit refers me to. Dr Tan told me, they found a cyst in my ovary during the CT Scan. Argghhhh!!!!! Another breaking news. He did a scan for me again, but cant see the cyst clearly as compare to CT Scan. End up he did a scope for me. Saw the cyst!

Dr Tan says that is hard, not soft as a cyst, not suspicious on cancer, because my CA125 test result is good, not so high (high means cancerious). But all are based on "guess". Will need to cut the cyst out and send to lab for test to get the actual result. If it is only a cyst, then should be fine. Cut out and thats all about it. But if it is something not good, and  may need to remove one side ovary. And worst case is remove the entire uterus.


Sigh...

Dr Tan says he can do the cut in the same operation. But I told him I want to think about it first.

Found Prince Court with SNB

While waiting for my surgery day to come, I spent some time on breast cancer studies online.

I still have some doubt and can't believe that I really have breast cancer. So, I was still thinking if I sould go down Singapore to do second biopsy test. I emailed Prof Dr Yip about some questions, like the accuracy of the biopsy test and a new technology called Sentinel Node Biopsy (SNB). Dr Yip is really a good and responsive doctor. I never seen a doctor that can share her personal info, like HP number with patients. She told me from the ultrasound is very suspicious of cancer, and the fine needle biopsy test is very accurate. She told me that, UMSC does not has the facility to do SNB, and the only one has it in Malaysia is Prince Court Medical Centre. And she also wrote that, "Perhaps you can meet Dr Harjit Kaur if you go there."

So, I end up appearing in Prince Court today. And Dr Harjit also a very kind doctor. She explained things to me clearly, about SNB, did ultrasound again for me on the day. Her schedule is actually full with appointments, but she still meeting me as I told her nurse about the urgency of my case.

I then decided to take the surgery in Prince Court under Dr Harjit. The surgery is to remove the tumor, and together Dr Harjit will do SNB for me, which will then further decide whether to remove the other lymph nodes or not.

The surgery is scheduled on next Tuesday, 18-Jan-2011. But have to admit to hospital on Monday, to do a thorough CT Scan.

Detected Lump -> Mucinous Breast Cancer

I detected a lump in my right breast few months back. I did some researches online, and some recommended to wait for at least 2 months after menses. To see if the lump is actually caused by the menses cycle.

I waited for months, and it does not get smaller. So I decided to go for a scan. I went to Sime Darby Megah Centre located at Taman Megah there.

I met Dr Evelyn Ho, recommended by Yvonne Loh. Yvonne has few frens working in medic line who can really recommend good doctor. Dr Evelyn Ho is a radiology specialist. She has lot experiences in detecting breast lumps. She did ultrasound and mammogram for me. Result is, both my breast are full of water cysts, but not harmful. Except, one, on my right, which is the hard one. I remembered she said, “Something not very good.”

She recommended and referred me to Prof Dr Yip Cheng Har from UMSC. Dr Evelyn also said that, I should meet a specialist in breast cancer rather than gynae. She made call to Prof Yip immediately and squeeze me in to meet Prof Yip the next day.

When I meet Prof Yip the next day, she did a biopsy test for me. Which the result will only be out after one week. May be my case is quite serious, so Prof Yip ask me to call her for the result after 2 days. When I call her on Monday, she already told me is confirm a cancer. It is Mucinous Breast Cancer. When I met her yesterday, the full biopsy report is not out yet. She actually call to the lab and get the result. She keep ask me to seek second opinion if I doubt and encouraged me to discuss with frens.

You can get information about these 2 doctors from these links:
http://www.breastcancer.org.my/cms/index.asp?menuid=18
I got this link when I try to google some of the doctors’ info.

Ok. I booked the operation to be done next Monday. It is going to be a “minor” operation (according to doctor ). But to me, it is a major one. It is going to remove the lump and some normal tissue from my right breast, together with the full lymph nodes. Radiation therapy is a must after operation, which will be 30 days continuously and about 5min daily. Chemotherapy is required if determined is stage 2. To determine the stage, they will send the tumor and lymph nodes to lab after removed. Breast after operated will have scar, and in smaller size than normal.

The Journey Start

There are many things happened recently. And since I have to update frens who are very care about my condition, therefore I decided to update my condition here. So everyone can read the updates from here.