Monday, December 10, 2007

Q&A


My unanswered questions were answered this morning by a very patient Professor Mokbel.

With Anne, the breast care nurse in attendance, he first attended to the physical side of things. My portocath removal scar had healed nicely. He'd nipped in the skin around the original insertion scar to neaten it up a bit, and he seemed pretty pleased with the results. Slice, slice on the stitches with a fresh scalpel blade and he was done.

Then I quizzed him.

Firstly about the fact that he has always spoken to me about my chances of recurrence within the context of a ten year period. I had guessed that it was probably because the data does not exist for predicting longer range recurrence statistics but could he give me a feel for what happens after ten years?

The absence of data is the thing that stops them giving an accurate prediction. If you think about it, such advances are made in medical treatment, plus the nature of cancer and individual tumours is changing all the time, that it is impossible to give an accurate forecast over too long a time period.

However, he was happy to discuss the possibilities and essentially it's all good. The biggest threat of recurrence comes within the first two years after diagnosis. These are all aggressive tumours like mine, grade 3. Although not all grade 3s recur. If you have an aggressive cancer recur within two years chances are it's really, really bad news. The type of bad news that killed Dina, for example.

Between two years and ten years the chances of recurrence are at a flat rate for each year. There is no more or less chance of you recurring earlier or later within that timeframe - if it's going to happen, it has equal chance of happening in year 3 or year 6 or year 10.

If you make it to Year 10 with no recurrence, you can give yourself a pat on the back. For although the chance of recurrence doesn't ever go away, there is very little incidence of aggressive cancers coming back after so long.

The few cases that do see recurrence of a cancer after 10 years are, in Professor Mokbel's view, patients whose bodies have learnt, somehow, to live in harmony with cancer. This sounded like a very romantic view, until I realised he was using it purely as a medical term. What he meant was that for some reason, the birth rate of cancer cells remained constant with their death rate, until, one day, because of a compromised immunity or other such problem, something prompts the cancer cells' birth rate to overtake their death rate and the cancer presents itself again.

I asked about lymph nodes, and whether there was any evidence to suggest that patients whose nodes were clear may yet have cancer cells marauding around their bodies. I got a look straight in the eye for this one. Yes, there is evidence, he said.

Essentially, about 20% of women with my sort of tumour with clear nodes, still have cancer cells apparent in the bloodstream after the tumour has been removed. This is why they recommend chemotherapy, to mop up those cells. The chemo will, alomg with radio, greatly improve their chances of avoiding recurrence. Mine stand at 96.2% for no recurrence within ten years.

So, if there was still a chance that I had some random cancer cells floating around, looking for a place to wreak havoc, would it be sensible to do a CT scan, MRI, blood test, whatever it takes to see if they are there.

No, said the Professor, for several reasons.

He explained that if some cancer cells had made it to the liver, lets say, and they had not been eradicated by the chemo, well, then there would be no more point in scanning now or in a year's time. If they have made it to an organ in this way, it would be stage 4 and therefore incurable. There would be no point in rushing headlong to meet it. At some point, the cancer would physically present itself and you would find out then.

Also, these types of treatment are generally damaging in their own right and are only recommended when the benefits for the patient far outweigh the risks. He cites reports and speculates that most people have no idea how harmful a CT scan is. Apparently they are equivalent to the same dose as 500 X-Rays. My right boob perks up at this comment. It has been inside the CT scanner. Not to mention under the radiation beam for radiotherapy for weeks on end. Poor boob.

The only non-damaging technique they use to establish if there might be cancer recurrence elsewhere within the body is the blood test. Which I will receive in March when it's time for my annual mammogram.

All this we talk about and more. He is a most patient man with me. At one point I apologise for trying to force him to explain the world of oncology to me in the space of five minutes, but somehow, he manages it, in terms I understand.

I leave feeling reassured that there are no other options at this stage, and more optimistic. If not about the odds per se, at least about the way I view them. I have wrestled with all the different scenarios, eliminated any remaining doubt, and the truth is simply this.

The doctors have done their best. Now it's up to me. And cancer. And a little bit of luck along the way.

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