Twenty minutes after Professor Oncology nixes chemo therapy, five minutes after Dr. Alpha, the radiation oncologist, calls to tell me that I need a re-excision to get clear margins (you are supposed to have 2 mm) I am sitting in my friend’s garden sipping tea from her bone china cup. I am “in the moment” trying not to mull over all the “what ifs.”   The insufficient margin frustration is behind me. Well,  almost.  My new bosom buddy, the radiation oncologist, took charge of the incomprehensible pathology report. He even called a day earlier than promised to let me know that I , indeed, need a second surgery!

Suddenly, my cell phone buzzes. A Magnolia Cancer Center number.

The way Dr. Guru, my surgeon, puts it to me, one might think that he himself had called  my radiation oncologist, to tell him to hold off radiation,  not the other way around.

“I am still not convinced you really need this,” Dr. Guru says. “But maybe it is not such a bad idea, after all.” Then in what seems like a vague apology he adds:  “I know you are very busy and all and this will be a bit of an inconvenience for you, but we might as well go ahead and put it behind us. “

“Might as well. But when?”

“Next week.” Dr. Guru does not hesitate. “We will schedule this for next week. Joy will call you to arrange the details.”

I feel stupid for being so happy. How much happier could I not have been  had  I been wrong about the re-excision, and able to start radiation right away? Is it not childish to be happy about being vindicated? After all, I am the one who will be the most inconvenienced, just like Dr. Guru admitted. Also, I feel mildly irritated that Dr. Alpha has to tell me not to hurt Dr. Guru’s feelings by “not rubbing his nose in it.” What other profession is filled with egos so fragile that they need to be perpetually wrapped in velvet and praise? A master surgeon is never to be reminded of a mistake, however slight or insignificant.

“Sometimes when I consider the tremendous consequences that come from little things, I am tempted to think there are no little things.” – Bruce Barton

-When will you have your re-excision? my sister-in-law wants to know.

I tell her that I believe Dr. Guru when he says my margins are clear. He says that I don’t need a second surgery despite a pathology report  which seems to indicate a margin of less than 2 mm.

I tell my sister in law that my real worry is the prospects of chemo therapy. Of course, no oncology appointment has been scheduled yet. Somehow I am under the impression that Dr. Guru’s office will set it up.

-You need a second opinion,  my sister-in-law says firmly. I will call Doctor Weary to schedule an appointment. Now.

My sister-in-law’s friend died from breast cancer. Her margins were never clear despite several surgeries. But her situation was different from mine. She was much younger than me, by a decade or so. Her cancer was, sadly,  more aggressive. Her prognosis was more “unfavorable” from the outset.

I tell my sister-in-law that a new surgeon can not possibly figure out margins from an old surgery, now healed. But she will have none of it.  She calls me back with two appointments, less than a week out: one with Dr. A, her friend’s surgeon, one with Dr. Weary , a well known oncologist at the hospital that was feuding with my insurance company at the time of my diagnosis. But the feud is over. They will accept my insurance.

Although I cannot for the life of me understand how a second surgeon could possibly tell my margins, I feel relieved.  Someone, other than me, is doing the heavy lifting. A mill stone rolls off my shoulders.  Appointments have been set for me, whether they make sense or not. I realize how wonderful it feels to have been removed from the decision making process and able to just follow someone’s command

Energized, I decide to also ask the University Medical Center to send my pathology report along with a sample to Vanderbilt University for a second opinion.

Maybe it is not a bad idea to find out more about my cancer cells, given that both the Breast “Care” Center and the University Hospital says my cells are moderately to well differentiated and slow growing. Yet the OncoDX test indicates that they may not be quite as benevolent.

You, too, can send your pathology results to Vanderbilt for a second opinion. Check information below or go to www.breastconsults.com. In most cases, insurance will pay. If not, their fee is quite reasonable.

Q: How do I arrange for my slides to get to Vanderbilt (VUMC) for consultation?

A: Patients wishing to have their slides shipped to Vanderbilt should contact the originating pathology department and tell them you are requesting a second opinion from the Breast Consultation Service at Vanderbilt University (aka. David Page, MD and Associates). Request that they send the pathology slides and all reports corresponding to those slides. Also, ask them to include a face sheet of your demographics and billing information for billing purposes. The address to send the consults to is as follows:

David Page, MD
Vanderbilt University Medical Center
Department of Pathology
C3321 Medical Center North
1161 21st Ave. South
Nashville, TN 37232-2561
615-343-0072 (Phone)
615-343-5137 (Fax)

My husband and I are both stuck in the glue of our gloom, unable to reach out to each other.

I am restless, crabby, scarred, impatient, and distracted both at home and at work. I cannot concentrate on anything. All I do is obsess about a second surgery. It is not the surgery that scares me, but delaying the treatments has me excessively worried. And the type of treatment.

My husband is down for many reasons: his job, my situation, life in general. This time I do not have the emotional resources or stamina to try to help him break out of his zone. I am too preoccupied and self-obsessed. Also, I am, irritated with him.

He has not even glanced at any of the many brochures, articles, and books on breast cancer lying around the house. It would be good to have his perspective on matters. My husband has a scientific mind. He is the type who will read the instructions for a new Panini grill cover to cover. But the pamphlet “What to Expect from Chemotherapy” sits untouched on his bed stand while he gorges himself on a big fat business book. I am pretty sure he has not spent two minutes Googling breast cancer to learn more. It is as if he thinks: That is her problem. But if he had prostate cancer, I would be all over it. So to speak. I would want to try to figure out what he would be facing. What we would be facing.

Late one afternoon, I finally receive an email from Dr. Guru in response to my question about my lack of clear margin.

“I appreciate your concern. The primary excision was not oriented so I don’t know where they came up with lateral. The additional margins, inferior and medial, were removed after the primary excision was performed. They were the closest margins deemed from intra-operative inspection and no residual tumor was in those specimens. You do not need additional surgery. Sorry for the confusion.” Guru

I  read the mail several times without a clear understanding. Did he take out the tumor then went back in and scraped out some more? Is that what he means by “intra-operative perspective?” But what does “the primary incision not oriented” mean? He’d have to cut the first line somewhere.

I believe Dr. Guru when he says I do not need a second surgery (although I am still annoyed with him.) Had he only sat down with me to explain my pathology report, all this hysteria and worry and anxiety would not have come to pass. He would not have had to endure my blistering emails.

Yet, I am  relieved. Now I can move on to the next treatment. Will it be radiation or do I need chemo first? The mere thought of chemo therapy petrifies me.  Millions have endured it. So why am I such a complete whimp? And when will I find out if I need it? Where is my oncodx test result?

Dr. Guru meets with my family in the waiting room. Big grin, face mask dangling around his neck, arms raised, two fingers on each hand formed into the V for victory signs.  No cancer in frozen lymph node section. So far everyone agrees. Big wide margins. Some  heard only “wide” margins, but not “big wide” margins. One thought he said only “good margins.”  Another does not recall anything about margins.

Whatever he said, everyone is jubilant. The cancer “episode” is over.  The drive home takes 20 minutes. We stop to fill a prescription: a small brown plastic container filled with — Wow — FIFTY Percocet!   Good bye pain I don’t have. Hello euphoria.

In the living room, the mantel above the fire place is filled with flower arrangements. Calla lilies, Gerber daisies, roses of all kinds, delphiniums, chrysanthemums,  hydrangeas, and freesias fill the air with their perfume, lots of get well cards.

Our family lounges in the sofas and chairs around the large coffee table. Snacks and munchies are brought in .  After all, it is dinner time. Wine is poured for everyone but me. (I get water. One indication that all is not fully back to normal.)  A couple of neighbors stop buy. The phone rings. A friend brings over a water melon salad and a chicken salad. My sister in law brings a bag of fresh bagels from Goldberg’s  along with various spreads. The atmosphere is that of a festive wake.

Normally, during casual family gatherings or Sunday dinners, people arrive late or leave early. Some excuse themselves to check emails, or make cell phone calls, turn on the TV  to catch the last few minutes of some game, or sneak away to play billiards downstairs. All signs of a certain restlessness, an eagerness to escape the tight family noose. Not today.

Like on  Christmas Eve, everyone remains seated: content and mellow, we bask in the glow of  togetherness.  I feel their warmth and concern, happiness about the outcome.  We even play a few hands of my favorite card game in a concession to my status as Queen for a Day. (Although they don’t let me win.)

At 11 PM, I go upstairs to prepare for bed. I am not particularly tired and I feel no discomfort. Dutifully I swallow a Percocet because my husband reminds me of the nurse’s wisdom: “Take them before you start to hurt. It is easier to prevent pain than to chase it away. ” Plus who wants to hear “I told you so” should I wake up wreathing in pain.

When I roll over on my side, I feel a tighness, tenderness, in my swollen, bruised  breast. A pleasant reminder that I still have that breast,  and that it is now tumor free. Post operative treatment options are completely off my radar screen as I drift off to a night of uninterupted, dreamless sleep.

My surgery is expected to take two and half to three hours. Dr. Guru promises that he himself will do the whole procedure. “Won’t even let a second year student help,” he says. He will make a slit in the twelve o’clock position on my right breast,  a slit under my right arm, and a slit on the left side of my left breast (where the titanium chip is implanted.)

Everything, Dr. Guru scoops out will be sent to  pathology although both my breasts have been biopsied already.  This time the pathologist will have bigger samples to work with and it will be easier to make sure that earlier biopsy results are correct.

The windowless operating room is surprisingly small, and seems crowded and noisy. Several people in scrubs sit by a table at the far end of the room facing  monitors lined up  in front of them. I am surprised at how many persons seem to be here. What are they all going to do? Then a voice announces that a lumpectomy is about to take place on a post-menopausal female. That has to be me! (Although I never think of myself in those terms.) All of a sudden, I realize how young everyone looks behind their masks down there by the monitors.  Medical students!

Dr. Guru II, my anesthesiologist, guides me up on the table which is shaped like a cross. Electrodes are placed on my back and my chest.  A pair of foam boots without feet are put on my legs. (They will massage my calves so I don’t get blood clots.) I lie on my back, arms stretched out.  My head is covered with a shower cap, the rest of my body, except for my breasts, is covered up with sheets.

All around me: a steady hum of activity:  instruments rattle, machinery blinks, people talk. Despite the busy  atmosphere, everything  seems under control, relaxed and congenial.

“Here is your glass of vine for today,”  says Dr. Guru II, a syringe in one hand, as she grabs the tube I am attached to with the other.

“Oh, you really read that crap people put in your pre-op questionnaires?” I remember thinking, but I suspect I am out before I give her my flippant response.

When I wake up I am back in a chair in the same area of pre-op area where my gurney used to be.  I have no idea how I got here. Did they really lift me off the table and put me in this chair?

I don’t feel the slightest pain, nor drowsiness or grogginess. Last time I had anesthesia I was told over and over again that I had a boy and a girl. Still I kept asking: What did I have?  I remember not being able to lift my limbs. Even my eye lids were too heavy to open as if they had been glued shut.  Back then my whole body felt as if it had been filled with lead. Not this time.

“We have different drugs now,” the nurse tells me. “They are much better than before.”

I feel completely free from nausea and clear headed. Actually, I feel light as a feather, perhaps my imagined weightlessness is from the idea that my tumor is now out. I am cancer free.

Then I remember the blue ink that was supposed to stain my lymph nodes (sentinel node biopsy.)  Did Dr. Guru find cancer cells in any of them or what?

Suddenly, a flurry of activity, like when trees and leaves are set in motion by an approaching storm. The curtains, surrounding my gurney, open and flap, close and flap, as doctors, nurses, and technicians come and go. Doctor Guru’s wife, my anesthesiologist, arrives along with her second in command (or perhaps a resident in training)  a  young female doctor of Asian ancestry.

Dr. Guru II looks to be in her early 40s, blond, energetic,confident. I startle as I notice a thick gold chain, just above the neckline of her scrub top. The other anesthesiologist  has a pair of stunning, artsy ear rings dangling from her lobes while most of the rest of her is covered by a shower cap,face mask and scrubs. A quick introduction, a couple of questions about the state of my health this morning. My health, of course, is excellent, except for that pesky cancerous tumor. The curtains quickly close behind the two anesthesiologists.

I realize the memo about “absolutely no  jewelry of any kind,”  refers to me, not my doctors. They may wear any “bling” they want as long, I suppose,  as the “bling” does not interfere with their job.

A nurse checks my vitals again, checks the needle in my hand and adjust the bag on the pole. She gently shakes the the tube a bit before she, too, sails away.

Finally Dr Guru breezes onto the scene, just out from an earlier surgery procedure. His  ill fitting scrubs, the kerchief tied around his head does not in the least detract from his a super star quality.  Dr. Guru does not give off  airs or act like a prima donna. For that, he is way too busy and focused.  But it is the staff’s response to him that lends Dr. Guru his super star image. People grow quieter and recede into the background as Dr. Guru’s presence fills the small space.

He sinks down at the edge of my gurney and I move over to make room for him.

“Now, this is what we’re are going to do.”  Dr. Guru sounds upbeat, looks cheerful. Pen in in hand, he sketches on a piece of paper while explaining the steps ahead.

“I will take out a slice of a lympnode, wait for pathology to freeze it and disect it. This usually takes 45 minutes. While I wait , I will work on other things. But keep in mind, although the frozen section may not contain cancer cells, we may still find cancer when the entire node is examined by the pathologist later. If I find one single, little cell in the lymph node, it means chemo,” says Dr. Guru and looks me straight in the eye.

Ever since my surgeon and his assistant started to babble about a “procedure with a wire” I assumed my tumor would be removed with a wire, as opposed to carved out by a razor blade or an exacto knife.  As silly as it sounds, I have been mentally stuck on the image  of a wire lasso slung around my lump.

Children often get stuck on words that will, in their immature minds, take on strange and  incomprehensible meanings. Yet children usually do not ask for clarification, they  just conjure up these bizarre images in their heads. And apparently, so do 60-year olds.

The scene playing out in my head has been this: the surgeon makes a slit in my breast, of the kind I do when I want to stuff a prune into a pork roast.

He then proceeds to take a thin wire and shapes it into a lasso around my lump before he pulls the tumor out,  roots and all, like a radish pulled up from its garden bed.

The mysterious wire procedure (needle localization) turns out to be a procedure where a wire is inserted in each breast before surgery to later guide the surgeon to the right place during the operation. It is important to have the “wire guide” where tissue is to be removed from lesions that cannot be felt, or perhaps not even seen seen by the naked eye. The exact spot where the wire needs to be is identified on a computer monitor, hooked up to either a mammogram or an ultrasound machine, and the wire insertion is preceded by the insertion of a hollow needle.

Before the needle is plunged into my breast,the skin is cleaned and numbed. The doctor and the technician checks a computer screen to make sure the needle is in the right place before a thin wire is pushed down to replace the needle.

Doctor Competent and her nurse, two middle aged women, are both jovial and seem to enjoy working as a team. They banter and tease as would two sisters on good terms, or two old childhood friends. Like a well choreographed dance troupe, they anticipate each others every move. They  respond to each other before a word is ever spoken. And they giggle and laugh a lot while still  maintaining their professional aura.

Despite their pleasantries, the procedure hurts, especially when they try to stick the wire right down in the tumor site.“But of course,” says Dr. Competent, smiling. “It is only natural that it will hurt you more in that area.” It also tickles when the nurse puts her hands on me and tries to adjust my position in the machine. I squirm and the nurse shouts: “You moved!”

“She moved again?” asks Dr. Competent.

They both laugh although they have to start the whole thing over.

Finally, I end up with a bopping extra-terrestrial antenna sticking out of each breast. The nurse bends them down and tapes them to my breast before I shuffle back to my gurney to wait for the “real” procedure.

In the waiting area, before receiving my mysterious “wire,”  I immediately set eyes on a young woman, at the most 25 years old, too young to be wearing a hideous hospital gown and a plastic ID bracelet at the Magnolia Cancer Center. The middle-aged woman next to her is fully dressed. I feel emotional as a look at them.

The mother, I assume, notices. She, too, have tears well up in her eyes before we both look away, neither of us, obviously, want the girl to see our reaction.

I hope she will escape chemo. But because of her young age, the odds are not in her favor. And what about five years on the estrogen interfering pill Tamoxifen, while her biological clock is ticking? And what about her very survival? The young woman just sits there, quiet and calm,  seemingly unaware of the high stakes.

Three other women, all older, are also in the waiting area.  The women talked freely but quietly among each other.

One is a nurse in the child oncology department of the Magnolia Cancer Center. She quietly says: “Breast cancer may be one in four now. But it is not official yet.”. She is here for her first annual check up after lumpectomy, radiation and chemotherapy. All her hair is back on her head: Thick and dark, streaked with gray, curly. “It used to be straight and thin,” she says,visibly shaken by what she has been through during the past year.

Another woman in the waiting room is a slim, light skinned black woman with a pleasant smile and a dignified demeanor. She sits with her back straight, one leg gracefully crossed over the other, hands in her lap.  She looks serene, only the nervously tapping foot betrays her tension.

Her great-grandmother, her grandmother, her mother and sister all died from breast cancer, she tells us. Ten years ago she herself had a lumpectomy and radiation. Then it was ductal carcinoma in situ. Now, in a routine check up, she is discovered to have lobular carcinoma. She needs a full mastectomy. Her voice is calm, she looks brave, but then again: there is the jiggling leg. I don’t know if she is aware of these scandalous statistics. The numbers below are truly something to scream about at town hall meetings instead of ranting about imaginary “death panels.” How about a certain death trap (unless you have deep pockets): breast cancer without health insurance.

According to the American Cancer Society the gap in death rates from breast cancer between African American and white women has increased substantially. In 1991, death rates among African American women were 18 percent higher compared to white women; by 2004, they were 36 percent higher.

It is amazing how four women in a waiting room can bond so quickly. It reminds me of female bonding during pregnancy. Although back then I sensed more of a competitiveness among expectant mothers in the obstetrician’s waiting room. Who had kept her weight down better? Who was thinking she would handle labor pains better? Whose baby would be the best baby ever? (Mine, of course.) Now we, the breast cancer patients, seem genuinely interest in each others’ stories, seem to care about everyone’s fate. We do not compare.

I am called away before I hear the result of the  oncology nurse’s check up.  But a few minutes later, in the adjacent room, I hear laughter and applause from the waiting area. After one year, the nurse is still cancer free. The room cheers for her as she walks away. (The two first years after surgery are the most likely for recurrence.)

I have no idea what happened to the young woman who waited for surgery with her mother. I still think of her.

The day I have worried about, fought for, and pushed for, is finally here. Last time I had surgery, 26 years ago,  two healthy full-term babies, a boy and a girl, were removed from my body. This time the surgeon will remove a specimen of malignant neoplastic tissue, surrounded, I suppose, by normal grizzle and fat. (My niece, a medical student, says the inside of a woman’s breast looks like it is filled with spaghetti-Os.)

My cancer cells have been hiding inside me for years, secretly dividing themselves, feeding and growing through angiogenesis until they reached a palpable lump, the size and shape of a hazelnut. Nobody can tell me how this excessive cell division got started. Too much consumption of hormone treated meat and dairy? DDT? Chest X-Rays? Just a DNA roulette?

Nothing to eat or drink after midnight, I am told.  No latte. No orange juice. Not even water. Also, no make up is allowed. They want to see the normal pallor of your skin and be able to tell if your lips turn blue. Normal morning routine takes an hour, including ten minutes for the New York Times. Now  I am showered, dressed, and ready to go in less than 20 minutes.

Summer traffic is sparse and traffic lights line up green, practically all the way. Accompanied by my husband, I arrive way ahead of schedule. We valet park and before I know it, I am back in the outpatient surgery waiting room where I waited an hour only two days earlier. Now, at 7 A.M., the place is filled with couples, one patient and one a “responsible party”  and designated driver. This time I don’t wait.

I am ushered into the inner sanctum almost immediately and shown to a gurney behind some drapes in one of the pre-op units. Over a loud speaker I hear a female voice: Dr. Guru, Dr. Guru, OR 4. OR 4. Holy smoke, my doctor is doing another surgical procedure before mine. How many after me? How does he manage it? How many coffee breaks does he get? None?

It feels strange to arrive  feeling perfectly healthy and normal.   I am weighed in like a prize cow, stripped of my clothes and donned the hideous gown that is supposed to be “one size fits all” but appears to fit no one. My vitals are checked and approved. Within minutes, I have a plastic ID band around my wrist, an IV in my arm, and a  warm blanket around my legs.

I feel like the perfect nursing home specimen as I take a couple of shuffling steps. I  try to  keep my gown closed in the back and the blanket from falling off.  The IV pole rattles and the tube tangles. My whole sorry appearance highlighted by unforgiving sharp ceiling lights. I sink back on my gurney.

On the other side of the curtain, a wife (I assume) and a nurse, both try to talk sense into some confused male. It is hard to tell if he was waking up from anesthesia, or if he is this confused already before his procedure. They shout at him, explain to him, cajole him. But he remains recalcitrant. “No why? No, I don’t want to,” he keeps saying. It is unclear what he doesn’t want to do.

Suddenly my husband is allowed into pre-op and shortly after that comes Dan, my friend Elise’s husband, the anesthesiologist, on his day off! He is dressed in scrubs although his colleague is the one who will put me under. He showed up just for me although he does not really know me. I am Elise’s friend. Why am I not surprised that my dear Elise has such a wonderful husband?

But I cannot socialize for long.  A nurse leads me away. I shuffle behind her, my IV pole swaying, to another waiting room. I am about to recieve the mysterious wires. Before I can ask the nurse exactly what “the wire” means, she is gone. I am alone in a tiny waiting room with three other women, and a young girl.

In the morning, as soon as Dr. Guru’s office opens,  I call to nail down my surgery date.

“We can not plan anything until we have your MRI results,” his assistant sounds tired. “We don’t know what we’re dealing with yet. Yes, you can have a lumpectomy next Tuesday.  Anything more involved, requiring more time, will have to wait until the week after that, possibly until  the end of the month.”

End of the month? I don’t understand why she cannot “book” a couple of dates and then cancel one or the other. That is how you book hotel rooms and air line tickets when you are unsure of date and time, certain of the destination.

“What about all the doctors that need that slot? And what about all the doctors and staff members who need to co-ordinate everything?”

I did not think of those minor details. My line of thinking is more along the lines of me, me, me and now, now, now.

Joy tells me the result of the MRI and the left breast biopsy will be available  within a few days.

“So that is when we can set a firm date?” I ask, full of hope.

“No that is when he needs to meet with you to discuss your options.”

Options?

Since my diagnosis, I have come full circle. I have infiltrating ductal carcinoma in my right breast, and who knows what else might lurk in my left breast.

A month ago, I was declared  a “good candidate” for a lumpectomy. Now, 30 days later, I am being told by Dr. Guru’s office that we’re still considering “options.” I may have lymph node involvement. The MRI may reveal cancer not found on the mammogram or the ultra-sound. I may not just breeze through a lumpectomy, after all. I may face a full mastectomy.

It slowly sinks in: a candidate is not the same as a graduate. A candidate is not the equivalent of a hire or employee, a candidate is the equivalent of an interviewee. It is someone who has high hopes, wishing for the best.