First face/face onc is 1/13/03.
Axillary Node Surgery scheduled for 1/27/03. 

DX:  IDC, left breast.  Lumpectomy done.  Tumor 1.7cm, clear margins.  Tumor classed as Grade 1
SN(1) had micromets, evidence extracapsulary spread.

HMO is Kaiser.  The Gold Standard:  Axillary Node dissection/chemo/rads/Tamox or Arimidex

Dilema:  I'm balking at doing more nodes and just going right to chemo because SN was micro and surgeon and onc stated was "fairly recent mets".  Am considering not doing more nodes because of the "given" ie numbness from armpit to elbow; and, potential problems ie lymphodema, inhibited range of motion, etc.  I would be really upset if I do the nodes and they're all negative and then I'm stuck with any or all of the ensuing issues/problems.  I realize if I do the nodes and all are neg, I should be happy.  If I do the nodes and all are neg, I would be inclined to not do chemo and just do rads and Tamox/Arim.  However, if I decide to NOT do nodes, I accept I should probably do chemo.

It's an ugly quandry.  And then you throw into this mix, the new staging guidelines effective January 2003.  I'm now Stage IIA.

I can't help but feel strongly that the Gold Standard is overkill in my situation.

Any recommendation/suggestions OUTSIDE of the Standard would be appreciated.

12/21/02 - First thing this morning, a response from Dr. Love.  As I'd hoped, she gave me more information to seek out (the "missing pieces").  I'll be taking this with me when I see Dr. Brett on Monday for my "second opinion" consult.

"Dear Teddy

"You do pose an interesting dilemma, and one that we hear about often. 

"You might want to clarify how the sentinel node was evaluated as there is some suspect that IHC (ImmunoHistoChemistry) can over read sentinel node biopsy.  Although having said that, the "evidence of extracapsulary spread" does make one suspect that this would be true  node spread. It is important to get a second opinion from a pathologist who only does breast pathology, and who is very experienced with sentinel node cases.  We are beginning to suspect that many of these cases represent mechanical displacement of the cells during the massage done after the contrast is injected, and not a true metastasis. If it is determined that the sentinel node truly is positive then you would be faced with your dilemma.  If it is determined that the nodes were negative then it will change your staging as well. 

"One can look at this several ways.  You are right if the nodes are negative then you would certainly be 
"bummed out" that the nodes were done. On the other hand an axillary node recurrence is nasty to treat and one advantage to doing the axillary surgery is to help decrease the risk of this occurring, especially if there is  extracapsulary spread. All in all you are in a gray area because at this point for tumors that are between  1-2.0cm  the recommendation to have chemotherapy is not quite clear, especially if you are post-menopausal and the tumor is ER positive.   I would assume that you are post-menopausal since Arimidex was recommended and this drug is ONLY for post menopausal women - we have no data to support its use in pre-menopausal women. 

"You other option would be talk with a radiation oncologist about irradiating the axillary nodes in the 
treatment field.  The lower nodes are already included in the standard two field treatment, but irradiating the nodes would include adding the third field. There has been research to indicate that this is just as an 
effective way of reducing the risk of axially recurrence as removing the nodes.  You will still need to discuss chemotherapy as the local treatment options do not negate the recommendations for systemic 
treatment. 

"Additional info that would be needed to move forward on recommendations for systemic treatment would include: whether there was lymphatic vessel invasion LVI - within the tumor,  what the grade I,II, 
III of the tumor was,  and what the her2neu status was.  If you choose not to do your nodes you will not be eligible for research studies but that would be your choice anyway.

"We cannot tell you what you must do only lay out the information as it exists. The standard has been developed as a guide but you are questioning something that is being questioned by many women as well as oncology specialists.   Just to clarify - all of the axillary nodes are not removed,  just a fat pad that contains nodes from level I and level II.  Tthe larger extended dissections (like the old days) are no longer 
done.

"I am not sure if this information is helpful in  moving you toward a decision - but having everything reviewed by a breast pathologist would be your next step as that review could change everything."

Dr. Love's team will never know how much their response helped me to move forward, with greater clarity, towards a decision about my treatment.  I am forever grateful.

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