36 hours

Update on the last 36 hours:

Texas Egg Hunt. I am Miss Pink Pants.
Andrea is Miss Lavender Pants. 

Yesterday Dr.Rosen eggstracted 22 eggs from my ovaries.  This is an eggcellent quantity by any of my doctors' standards.  They will be carefully frozen, then 'Egg Hoteled' at UCSF for the forseeable future.  The procedure went well with minimal pain afterwards.  It was only the anesthesia that made me eggstravagantly goofy and sleepy the rest of the day.



Today my Mom and I met with Dr. Melisko, my UCSF medical oncologist.  David was so irritated he could not miss work to be there. Dr. Melikso spent an extraordinary amount of time with us.  The UCSF Breast Tumor Board put in lots of thought and meticulous evaluation and re-evaluation of my clinical story and tumor biology.  They unequivically decided:

1. I am Her2 negative.  May tumor was tricky and if I had been Her2 positive I would be having a totally different treatment regimen so a lot hinged on this aspect of my tumor biology.  UCSF really went to town clarifying this.

2. I will have four cycles of chemotherapy (taxotere and cytoxan), each three weeks apart. Chemo will start sometime the week of Sept. 3rd. 

3. This next part we already new but to recap, after the chemo, they will give me monthly injections to turn off my ovaries, making me menopausal, and I will take 5 years of an Aromatase Inhibitor.  This drug blocks the enzyme aromatase, which turns the hormone androgen into small amounts of estrogen in the body. This means that less, if any, estrogen is available to stimulate the growth of estrogen receptor positive breast cancer cells that might be lurking somewhere after chemo or to help prevent my normal breast cells that for some genetic reason 'want' to turn cancerous, from doing so.


My eggs have been frozen once before.

4. I will likely get to take a break from the Aromatase Inhibitor two years after starting it, to unfreeze some of my eggs and have a baby with David. 

5. To be clear, I am not going to die from this cancer.  I just need a lot of treatment so that it never comes back.  Take that cancer!



Gross Anatomy

So it turns out when you have cancer for the second time, are recovering from a mastectomy, getting used to a partially filled expander wedged between layers of your pectoralis muscle, injecting yourself with three fertility medications a night, you are so bloated you can't button, let alone zip, your jeans or bend over comfortably without risk of ovarian torsion, and your estradiol level is 1,715 pg/mL, that from time to time, you may not feel like yourself, let's say you might even feel irritable. 

Yesterday when this wave of irritability engulfed me, David said I had every right to feel that way and then suggested that I break something. 

I replied, "I already broke our glass pitcher last night when I was trying to do the dishes!"

He responded, "I don't think breaking something by accident yesterday really counts."

Instead I did aggressive one-armed yard work that did not involve bending over.  I squatted to pick up stuffed innards of destroyed dog toys and plucked every dead leaf off every rose bush and vegetable plant in our yard. 

The wave of irritability washed away and I went back to just feeling bloated with a sore chest, meaning feeling quite excellent.  Over the past two weeks I decided to set a new baseline for my body.  Otherwise you just classify yourself as feeling not good everyday and that is depressing and also, quite dull.



This is a big week. 

David is going back to full time work after his summer break from Vocational Skills Tutoring at Santa Rosa Junior College for young adults with intellectual disabilities.  He has been teaching the summer cross country course for the past couple weeks but now he is going back to doing both jobs at the same time.   Our original plan for our mutual summer break was to rent a small RV and drive up to Canada with our dogs.  Obviously this didn't happen but we made the best of it and managed to have lots of laughs during this ordeal.  There is entertainment everywhere.  David has been skilled at always helping me see it, or in many cases, making the entertainment.  Thanks David.

Today, the UCSF breast tumor board is meeting to discuss my case and come to a collective recommendation about the rest of my cancer treatment.  I thought about whether or not I should attend to listen in, a privilege often offered to doctor-patients, but I decided not to.  I want them to be frank with eachother.  For the non-medical foks reading this: see the picture to the right to see what a tumor board meeting looks like.  I recall as a medical student having no idea what the heck a tumor board was when I was told to show up at one and do a 20 minute patient presentation in front of 15 doctors who are national experts in their field during my first week of clinical rotations.  Although at the time I was less than pleased with the task I was assigned, tumor boards are actually a fantastic enterprise.  Cancer pathologists (doctors who looks at tissue samples and cells under the microscope and actually diagnose and describe the qualities of the cancer) and a whole team of medical, surgical, and radiation oncologists meet and review all imaging, tissue slides, and the medical history of a patient with a complex cancer situation.  They discuss various treatment options in detail and come to a consensus.  I am grateful they are providing me with this service and am curious what they will recommend.  One part of my treatment, shutting down my ovaries and taking anti-estrogen treatment for a total of five years, is a slam dunk.  However I anticipate that another aspect of my treatment, traditional chemotherapy or not, and if so, what agents and for how long, is going to be controversial and a heated discussion. 

Tuesday morning I get my eggs harvested at UCSF.  The other medical term for this procedure is "egg retrieval," which I dislike because it infers the eggs are not actually mine.  I am sticking with "egg harvest" for now but Lynne and I are brainstorming a better term.  Please email with suggestions. 

Wednesday morning I will meet with my UCSF medical oncologist to hear what transpired at Monday's tumor board meeting.

Per WI Katie's recommendation, after this double whammy, I will reward myself by seeing the new Will Ferrell movie, The Campaign.  I would rather go on a vacation to Bali, but the whole egg harvest thing was pricey, even with the UCSF cancer discount.  Will Ferrell is a close second.  He is reliably hilarious.  Bali will have to wait.

A final note:
I have the best friends, family, and colleagues in the world.  Thanks for your emails, cards, meals, thoughtful gifts and unending love and healing energy you have sent my way.  You continue to make a big difference in my well-being.  Thank you!

Drain

I really enjoy this cartoon schematic for the following:

a. the woman seems quite content with her mastectomy.
b. she is wearing make-up
c. she appears to be wearing her Jackson-Pratt drains as hip waste accessories.
I will no longer be accessorizing with my two JP drains because I got the last one pulled yesterday at UCSF! Every task seems so easy to complete now. I want to run around the block flapping my arms. 

Maybe next week.

Let The Fertility Preservation Games Begin!

Days before the world turned their attention to the Olympic games in London, I turned my attention to my upcoming fertility preservation.  When I was diagnosed with breast cancer again in June at age 33, every doctor and surgeon I saw named what was already on my mind upon diagnosis:  let's get your eggs harvested, pronto.

No, I do not have six-pack abs. I am not particularly good at any sport.  I can not be found on any Citibank commercial.  However I have a few things in common with this year's Olympic athletes.
 
1.  Training:  I completed training where I had to focus intensely on medicine preparation, storage and administration.  Just as McKayla Maroney on the vault, the consequence of error or miscalculation in my prescribed routine would be costly.  Not in medals or physical injuries, but rather an unsuccessful egg harvest (and incidentally $10,000). 

2.  Hydration: Once I start the medications, I have to drink lots of water to make sure my eggs are as healthy as possible at harvest time and to help prevent a complication called Ovarian Hyperstimulation Syndrome.  Although the Olympic Coca-cola commercials depict athletes consuming a cold Coke after practice, I am fairly certain that they too will be consuming large amounts of water just as I. 

3. Attention:  Thousands packed Old Trafford stadium to watch the US Women's soccer team play Korea DPR with particular interest in star Abby Wambach's moves.  Eight to nine people's attention are dead set on my ovaries.  Perhaps a slightly smaller number than for Abby, but these eight to nine people are really devoted, invested fans.  I do not recommend getting between potential future grandparents and my ovaries in question.

4. Sponsorship:  You might notice that Roger Federer is sponsored by Nike.  Instead of wearing his own country's jersey like his teammate Wawrinka in their doubles match against Japan, he wore Nike emblemed everything.  My ovarian stimulation is sponsored by the Livestrong Foundation.  They are paying for about $3,500 worth of the fertility drugs currently in my possession.  I am grateful.  I plan to purchase this Livestrong onesie for David and my baby down the road.  Incidentally, this baby will also be sponsored by Nike, just as Federer.  No pressure, future baby.

5. Coaching: Behind every Olympian is a hard working, meticulous, caring coach. Behind my fertility preservation are Audra Katz, RN and Mitch Rosen, MD.  They are the two-person UCSF Fertility Preservation Center serving young adults with cancer.  They do the same work as a reproductive endocrinology team but with the added twist of squeezing in appointments, ultrasounds, treatments, and egg harvesting between cancer diagnosis and the start of fertility-threatening cancer treatment.  They have a legacy of previous patient success stories, they contemplate their clinical recommendations with care and enthusiasm, they highlight the positive, they provide clear instruction so I can have my best chance at future pregnancy, they understand what is at stake, and they care about not just my ovaries, but the person who holds them, me.  Yep, I have all-star coaches.

Although our Olympians and I share a few struggles and support, our rewards differ.  My immediate reward is regaining a sense of control and hope in an otherwise out of control and depressing medical catastrophe.  But my gold medal will be holding our squealing baby, face and hands covered with mashed peas after David and my attempt to feed our little rascal, all before the Rio 2016 Olympic games.

Oasis

Albuquerque almost always suffers draught, and in the summer of 2008, strict water use rules were once again in place to help maintain the dwindling aquifer supporting the desert city.  The city's public education approach for diminishing personal water use was multi-pronged.  The most entertaining, and perhaps the most effective, occurred on the Albuquerque evening news.  Each day the public water utility would calculate which Albuquerque residence used the most water in the preceding 24 hours.  This information was then delivered to the local news station who dispatched a newscaster to the residence and reported live on how many gallons that greedy household consumed.  We called it the water report of shame.  Inevitably the reporter would be standing in front of a lavish mansion surrounded by a lush manicured lawn and sometimes even, gasp, a fountain or koi pond.  For a brief moment, Albuquerque's proletariat paused to chuckle at the follies of the rich, a very small population in an otherwise very poor, hard working state. 

The Albuquerque Water Report of Shame is what I contemplated on the afternoon of July 26, 2012 amidst the longest shower of my life.  Jenny had come to two days before to gently bathe me in the tub avoiding the drain tubes protruding from my right armpit, the large incision on my chest and a smaller incision in my armpit from the lymph node dissection.  The bath was a success and Jenny and I planned to tackle my hair the next day. But I got lazy and then the day after, bold.  I was going to shower myself, upright and one armed.  My Mom helped me roll up a wash cloth, wrap it around my neck, and safety pin a drain bulb to each end like a yoke. 

I examined the shower terrain.  The shampoo and soap were on a shoulder height platform on the left, this would work well because that side was my good arm. I double checked the drain bulb yoke and safety pinned the washcloth tails together to ensure the contraption wouldn't slide off my neck altogether dislodging the drains with the fall.  I stepped in the shower stall. 

The warmth ran over my tangles of dirty hair.  The wash cloth yoke absored water and became heavy around my neck, feeling more secure. It takes a long time to shower using only your non-dominant arm.  To not drop the soap because you don't have a way to pick it up.  To gently wash around the incisions and drain sites when you can't see them.  But for once in a long time, I was in no hurry. 

Why did I attempt my first post-op shower solo?  I was not embarrassed to ask for help or be helped naked.  Jenny would have gladly come to my assistance as she had the day before.  I showered by myself really just to see if I could do it.  And I did.  If I had been in Albuquerque, 413 Benton Street, surely would have been showcased on the evening's water report of shame.  But at least it would have been for an unconventional reason.  A sense of self-efficacy.

Under the Influence

At the end of medical school I still viewed benzodiazepines and opiates as miracle medications that we are lucky to have access to. Midazolam allows people to relax before and during a procedure with no memory of the events.  Morphine and its family members take acute pain away after surgery or while healing from a fracture.  And both benzodiazepines and opiates have had tremendous impact in improving comfort in end of life care.

Three short years of residency training later when I read Vicodin, or Ativan, or Percocet, or worse yet MSContin, on a patient's medication list, I shudder.  I scan the patient's problem list, hoping to see  'fracture,' 'metastatic cancer,' or 'recent surgery' but that only happens 1 out of 100 patients that I see.  Instead, like so many other patients, this next patient has 'chronic pain syndrome.'  The commonly used western medicine diagnosis that explains the use of opiate medication for the long term.

I brace myself before I enter the examining room reviewing the scenarios:  is the woman actually taking the medications or selling them? I have been fooled several times.  If she is taking the medication, is she fully informed about the risks (messes up hormone levels, causes depression, can't drive safely, efficacy wanes overtime as our body gains tolerance)?  Has she tried other things to live with her pain with fewer side effects (acupuncture, meditation, writing, gentle yoga, swimming)?  Where is her pain?  Often time the answer is 'all over.' I remind myself that Dr. Flinders wisely responds "unfortunately these medicines don't help with psychic pain" in such a situation.  I consider the threats I may confront before I enter the exam room with a patient.  "Well, doc, if you don't give me more (fill in the blank benzo or opiate) I will just have to go back to drinking alcohol. I don't want to go back to the booze but I will if I have too."  This happened to me more times than I can count during my residency training.

Now I look at the orange plastic pill bottles with childproof white lids lined up on my dresser. Ibuprofen, Bactrim, Ondasetron.  These words do not bring back distressful patient stories.  The remaining two, oxycodone/acetaminophen (Percocet) or lorazepam (Ativan), brought back the proceeding paragraphs.  Now after having those bottles in my possession for 2 days, those two bottles stare back at me almost as a friendly joke.  My full name in bold printed on each. Several pills already missing from the total count.  I think how much I enjoyed each pill, what comfort it afforded me.  Two more hours of sleep with tolerable pain, a slow walk around the block with David with both dogs to get some fresh air.  Less muscle spasm so I could dress myself more easily.  All the misuse associated with those medications, the deep sorrow my patients carried, my involvement in propagating their use with grave misgivings.  All that darkness slid away.  And again I was thankful.

Nitty Gritty:

1. I am home from the hospital and doing well.

2. I took two short walks today.  Slow walks while David wrangled Luna and Olive himself.

3. I am very sore but it is manageable.

4. I am not nauseous!

5. I have two drains coming out of my arm pit. They will be in for awhile.

6. My surgeon removed two sentinel lymph nodes.  Neither showed cancer during the quick testing they can do during the surgery.  Final results will be ready in about two weeks along with the rest of the tumor results that will help determine what further treatment I need.

7. Friends are taking turns making delicious dinners for my parents, David and I. 

8.  A hummingbird flew into the dining room during dinner tonight.  It left some tiny,tiny feathers then flew back out the door.

Surgery Update

Jessica is out of surgery!  She has been moved to the recovery room and is doing great!  The surgeons said that both the mastectomy and the expander placement went very smooth, no complications, completely straight forward.  Now we wait for Jess to recover.  More updates to come!

*** UPDATE ***
Jessica is out of the recovery room, has zero nausea (is actually drinking a lot, and eating crackers and jello), and is doing great.  she is even feeling up to updating her own blog.  The following is Jessica (slightly drugged) updating her blog (David acting as stenographer):

Hi everybody! that was the best saltine cracker I have ever eaten in my entire life!  We have a view of the city, and I hope to get the oxygen nose prongs out soon.  I'm doing well, and I have been getting wonderful care.  David is staying over night with me in the hospital, and my parents are staying in Oakland with Marc and Lynne(one block from Obama).  Thanks for all the LOVE, good energy, and support. I felt totally surrounded by goodness and healing.