Second Opinion and Transferring Care

We have decided to get a second opinion.  I called the Revlon/UCLA Breast Center in UCLA Medical Center and they were very quick to accomodate me.  I was able to get an appointment for the next day and with no less than the center's director and world renowned surgeon, Dr. Helena Chang as my surgical oncologist. 

She reviewed my tests from the previous hospital and confirmed the diagnosis.  But she wanted more tests done to further evaluate the treatment plan they were going to give me. 

In a matter of days, I had another blood test, which this time included test for tumor markers, another chest xray, an EKG, breast MRI (which they did not have in the previous hospital), PET scan, CT scan and genetic testing.

She was concerned about the elevated liver enzymes which showed in my 1st blood test so she ordered the PET scan and CT scan.  She wanted to rule out metastasis (spreading) to the liver.  This was different from the previous doctor, who said its nothing to be worried about, without actually doing more tests to confirm it.  Im so glad we have gone for a second opinion.

Now we have decided that we will transfer care to UCLA, mostly because of the availability of facilities for more extensive tests and aggressive treatment.  And also, they are part of my insurance network, so its even better!

As of February 22, I am under the care of Dr. Chang and Revlon/UCLA.

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

On a lighter note...We will make music together!

Baby James and I decided we will ride through these all by making music together!  We both bought guitars!  How cool is that?  :)

We enrolled baby James in a music class a couple of months ago and he loves it!  He has been obsessed with their guitars so from now on, we will learn together!

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

Some Good News and Then Some...

Its been five days since I last posted a blog entry. I was in a bit of sadness for a few days. We went to see my case specialist at the hospital on Thursday to get an overview of the treatment plant and the results of recent tests done.

The good news: the bone scan, blood test for liver and chest X-ray all came out negative. Cancer has not spread to my bones, lungs and liver. These are the primary organs that breast cancer cells may spread into once it metastases (spreads). My heart scan also shows that I have 61% heart muscle function. My heart passed and can withstand chemotherapy because anything above 50%, they said, is acceptable for chemo.

Results for estrogen-receptor, progesterone-receptor and HER2 (protein) receptors also came back. My cancer is estrogen-receptor positive. It is 1-2% positive for progesterone-receptor and negative for HER2. It means that my cancer is sensitive to estrogen, which "feeds" it to grow. This is good because it means I can go on hormone therapy later on. I will be on Tamoxifen, which is a drug that blocks the action of estrogen for five years.

(It dawned to me that I was on an estrogen-based birth control pill for almost five years prior to having my baby. So I researched the pill, Necon 1/35. Their literature warns "avoid taking Necon 1/35 if you or someone in your family has ever had breast cancer or cancer of the reproductive system or liver problems". . I was not warned, informed or was aware of it. With two maternal aunts who succumbed to breast cancer, I should have taken other options.)

After the test results discussion, Melissa, my case specialist, talked to us about the next tests. I am being scheduled for genetic testing and genetic counseling. This test will show if I have BRCA gene mutation, which is crucial in my treatment. If shown positive, I would have to undergo double mastectomy and oophorectomy (ovarian removal) because the chances of getting cancer in the other breast and ovaries are much higher.

She also said that even when the test comes out negative, she recommends getting a double mastectomy because a Grade 2b has a 50% chance of recurrence in 5 years. With this decision, it will lessen the constant fear of "what if i have it in the other breast too?".

When I was pregnant, I was advised by a genetic counselor to have the breast cancer genetic testing. I didn't do it at that time, mostly because it was cost-prohibitive.  It was not covered by the insurance then yet.  If you have one of these "qualifications" in your health history, it would be good to get it done if you can.  
According to Mayo Clinic:
You might be at increased risk of having a BRCA gene mutation — and a candidate for BRCA gene testing — if you have:

• A personal history of breast cancer diagnosed at a young age (premenopausal), breast cancer affecting both breasts (bilateral breast cancer), or both breast and ovarian cancers
• A personal history of ovarian cancer and a close relative with ovarian cancer or premenopausal breast cancer or both
• A history of breast cancer at a young age in two or more close relatives, such as your parents, siblings and children
• A male relative with breast cancer
• A family member who has both breast and ovarian cancers
• A family member with bilateral breast cancer
• Two or more relatives with ovarian cancer
• A relative with a known BRCA1 or BRCA2 mutation
• Ashkenazi (Eastern European) Jewish ancestry, with a close relative who has breast or ovarian cancer
• Ashkenazi Jewish ancestry and a personal history of ovarian cancer

With these, being in Tamoxifen for five years and the possibility of double mastectomy, brought me into a few days of sadness and confusion. Being in Tamoxifen for five years, prevents us from having any children until the treatment is over. I will be 40 years old by the time it is done. With my biological clock and what the chemicals might do to my body, I feared the odds of having more children will be against me. We were thinking/hoping for a daughter when baby James is 3 or 4 years old.

Having a double mastectomy, I won't be able to breastfeed my future child anymore. Breastfeeding was one of the things that made my motherhood fulfilling. No matter what others think, I would have loved breastfeeding James till he's ready to wean. It has always been a special moment for us, each and every time. I love how I can stare at him and share a part of me that no amount of money can buy. I love how I can tell him I love him by cradling him in my arms as he feeds and falls down asleep. Its a bonding moment that I cannot explain. Not being able to do this again to my future child/children made me feel a little lonely.

I am lucky to have Jim beside me, through it all. He assured me it will all be okay. We can explore the option of freezing my eggs or adopting. Although those are options I know are possible, it still feels different for me having to carry my child to term. Maybe I'll feel differently later on.

A good friend Tetet told me to watch Christina Applegate on Oprah who is a breast cancer survivor. She had double mastectomy and I found out that she just had a baby at 39. That gives me hope.

I know some sadness will come and go through all these treatments. There will be a lot of realities that I have to face as I go though it. There will be times that I will still question, "why me and why now?" "Why not later in life when I have all my kids and grown up?" "Why not later when I would not care much about having both breasts intact?" "Why not later when I have already spent as much time as I can with my growing family?".

But all these questions will not be answered just yet. Only time will tell. I believe there's a reason for everything.

P.S. I will be presented to the Tumor Board for discussion of my case and treatments on Tuesday, February 22. Also on that day, we will be getting a second opinion at the UCLA-Revlon breast cancer center in Westwood,CA.

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

Bone scan and Heart scan today- February 16, 2011

I just finished my heart scan or MUGA scan ( Multiple gated acquisition scan) it is one of two tests I am getting today in preparation for the chemotherapy treatment I am about to get in two weeks.

They said I need to get a heart scan to check my heart functions before chemo. One of the common drugs used for chemotherapy treatment of breast cancer is anthracycline. This drug have cardiotoxic properties which means it can cause heart failure even many years after chemo has been completed.

It just took about 10 minutes to complete. An intravenous (IV) line was inserted in my arm and an isotope radioactive dye was injected then a sudden surge of saline solution was pumped into the veins. I felt a little bit of tingling pain in the vein when it was pumped in but not too much to complain. I have a very low tolerance for pain so it's not too bad I think.

They took a high solution video of my heart pumping for about 5 minutes.

Now I'm just waiting for the dye to be absorbed by my whole body. It will take about four hours. They will then do a BONE SCAN. The dye will be taken up by the body's bone-making cells, found mostly in areas damaged by cancer, where these cells are busily trying to make new bones to patch the holes. The test will show if any cancer cells have spread to the bones.

I don't expect it to be painful, just lying on the scanner long. It will take about 45 minutes to an hour.

For now, I'm enjoying a warm cheese Danish and hot chocolate.

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

The Pathology Report

After a day of digesting the big news, I got myself to start understanding the important document in a cancer diagnosis, the pathology report. It is the result of the biopsy done from the breast mass taken four days ago.

I have never seen a cancer pathology report before so the terms were all new to me. For those who gets the diagnosis, I've learned this one of the important information to help you understand your condition. It's not yet complete since I'm still waiting for some more tests, but it says the big picture so far.

I searched a lot to find a source on how to understand it in layman's terms. I hope I can help someone by sharing these info in the simplest way I have understood it.

My Pathology report :

Anatomic site/Laterality/Procedure: Right breast mass, 14 Gauge Core biopsy

Histologic Type / Grade: Infiltrating Ductal Carcinoma with focal necrosis, moderately-differentiated, Grade II

Modified Bloom-Richardson Scale: 7 out of 9 Points
Tubule Formation: 3 out of 3 points
Nuclear Pleomorphism: 2 out of 3 points
Mitotic Count per 10 high power fields: 9 out of 10; 2 out of 3 points

Invasive tumor size: Involves all four cores

The grading system used in the pathology report is the Bloom Richardson system. According to

The Bloom-Richardson grading system,or the modified Bloom-Richardson-Elston grading system,is a breast cancer staging system that examines the cells and tissue structure of the cancer to determine how aggressive and invasive the cancer is:

TUBULE FORMATION:
What percent of the tumor makes normal duct structures? In cancer, there is a breakdown of the mechanisms that cells use to attach to each other and communicate with each other, to form tissues such as ducts, so the tissue structures become less orderly. (MINE IS 3 OUT OF 3)

MITOTIC COUNT:
How many mitotic figures (dividing cells) can the pathologist see in a microscope field? One of the hallmarks of cancer is that cells divide uncontrollably. The more cells that are dividing, the worse the cancer. (MINE IS 9 OUT OF 10)

NUCLEAR PLEOMORPHISM:
Are the cell nuclei uniform like normal breast duct epithelial cells, or are they larger, irregular, and darker (pleomorphic)? In cancer, the mechanisms that control genes and chromosomes in the nucleus break down. Irregular nuclei are a sign that the mechanisms that control cell reproduction are breaking down. (MINE IS 2 OUT OF 3)

Each of these features is assigned a score ranging from 1 to 3. The scores are then added together for a grade that will range between 3 to 9. This value is then used to grade the tumor as follows :

3-5 Grade 1 tumor (well-differentiated). Best prognosis.
6-7 Grade 2 tumor (moderately-differentiated). Medium prognosis. (MY SCORE IS 7)
8-9 Grade 3 tumor (poorly-differentiated). Worst prognosis.

Lower grade tumors, with a good prognosis, can be treated with less aggressive surgery and medication, and have a better survival rate.

Higher grade tumors must be treated with more aggressive surgery, radiation, and drugs with worse adverse effects, and have a worse survival rate.

Looking at it as glass half-full, at least I'm at the "moderately differentiated" grade tumor. Score of 7, Grade 2.

It could have been worse so I am grateful and hopeful for a good survival rate and treatment.

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

The Biopsy Results

After what seemed like the longest four days of my life, I got the pathology result at the breast clinic.

From Friday to Tuesday, I armed myself with all the information I could gather about breast cancer. Even though at the back of my mind, i still cannot embrace it, I did not want to be caught off guard again and not be able to ask questions IF EVER the result came back positive of cancer.

I remember when I went in for the ultrasound, I was quite confident it would just be plugged milk ducts so I didn't prepare myself with questions to ask. This time around, I had questions written down like a news reporter.

As I was called by the nurse to take my vital signs, I wasn't aware that I was nervous until she told me that my heart rate was very fast, 119 per minute.

Jim was at home to take care of baby James so we agreed I will call him on speakerphone so he can hear everything the doctor has to say and ask questions too. I was very composed, I say. I psyched myself up that I cannot cry or breakdown because I need all the details I can get.

Melissa, the breast cancer nurse practitioner came in and started examining me again. She sat down and gave me the news: I have breast cancer, approximate stage 2B invasive ductal carcinoma with focal necrosis.

Okay. I was still calm. I started asking questions while jotting down the details.

1. How big is it: one was about 4cm in the 11 o'clock position. The other one was 1.5cm near the areola.

2. Is there lymph node involvement: yes. Based on the ultrasound and clinical exam, there is palpable gross lymph node involved. They will know more when they do lymph node dissection operation.

When lymph nodes are involved, it means cancer cells have spread outside of the breast and have possibly spread to other parts of the body.

3. What stage is it: stage 2B with the possibility to go higher depending on the results of the next series of tests.

Based on breastcancer.org, There are 5 stages of breast cancer:
Stage 0: used to describe non-invasive breast cancers such as ductal carcinoma in situ (in place) and Lobular Carcinoma in situ. In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or of getting through to or invading neighboring normal cells.

Stage 1: describes invasive breast cancer with tumor measuring up to 2cm AND no lymph nodes involved.

Stage 2:
2A: no tumor in breast but cancer cells are in axillary lymph nodes OR tumor up to 2cm and has spread to lymph nodes OR tumor 2 to 5 cm and has not spread to lymph nodes.

2B: tumor is larger than 2cm up to 5 cm and has spread to lymph nodes OR
tumor is larger than 5cm but has not spread to lymph nodes

Stage 3:
3A: no tumor is found in the breast but cancer is found in axillary lymph nodes clumped together or sticking to other structures, or spread to lymph nodes near breastbone OR

Tumor is 5cm or smaller, spread to lymph nodes clumped together or sticking to other structures OR

tumor is larger than 5cm , spread to lymph nodes clumped together or sticking to other structures.

3B: tumor may be any size , spread to the chest wall and/or skin of the breast AND
may have spread to axillary lymph nodes clumped together or sticking to other structures. Cancer may have spread to lymph nodes near breastbone.

Inflammatory breast cancer is stage 3B

3C : No sign of cancer in breast or if there is a tumor of any size, it may have spread to the chest wall and/or skin of the breast AND
cancer has spread above or below the collarbone AND
cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.

Stage 4:
Invasive breast cancer that has spread to other organs usually lungs, liver, bone or brain.

4. What do we do next: I need to get blood tests to check for tumor markers which will detect cancer activity in the body. Circulating tumor cells are cells that break off from the cancer and move into the blood stream.

Chest X-ray to check cancer in lungs.

Bone scan to check cancer invasion in bones.

MUGA (Multi gated acquisition scan) scan to test the condition of the heart, to withstand chemotherapy. One of the drugs used in chemotherapy, Adriamycin , can be toxic to the heart and can lead to heart failure.

Other tests to follow are estrogen-receptor, progesterone-receptor and HER2 tests to define the breast cancer further. These tests are crucial in treatment because being positive to these receptor means the cancer can be treated by not "feeding" it with these hormones.

I am also a candidate for the expensive genetic testing to find out if I have the BRCA 1 or 2 gene mutation (Breast Cancer Susceptibility gene) known as tumor suppressors.
Deleterious or harmful mutation of these genes greatly increases a woman's lifetime risk of developing breast and/or ovarian cancer.
This discovery, in case, will affect my treatment and will enable other family members to get tested too.

5. What do you do next for treatment:
I would need to be in neoadjuvant chemotherapy as soon as possible. We are looking at within 2-3 weeks.

Mastectomy. The whole breast needs to be taken out because the size of the lumps and the locations do not make me qualified for a lumpectomy anymore. Removal of both masses leaves the breast basically gone.

Radiation therapy. After mastectomy, I will be treated with radiation on the site of surgery. This will destroy cancer cells in te breast that may stick around after surgery. It decreases the risk of recurrence.

Hormone therapy. If the cancer cells is shown to be positive to estrogen, progesterone or HER2, I will be given hormones for at least 5 years.

She said they are pulling the big guns on my treatments because I'm young. I thought being young with breast cancer has an advantage. But it was otherwise. According to youngsurvival.org, compared to older women, young women generally face more aggressive cancers and lower survival rates. More and more evidence shows that breast cancer before age 40 differs biologically from the cancer faced by older women. A lot of startling facts can be found in this site that helped me learn more.

Despite the prevailing belief that young women cannot have breast cancer, we can and I did. I am even breastfeeding at the time of diagnosis. Even though breastfeeding has been known to decrease breast cancer occurrence.

Ok. These were a lot of information to digest. I was still composed and hoping Jim was still listening over the phone. We can hear James playing in the background so it was a good breather for me.

Finally she told me I can get dressed and wait for her to schedule these tests asap.

As I was getting dressed, it started dawning on me, I'm in for a big fight. A very big and long one.

It was comforting to know that I have a life long partner to go through this challenge with. I also have a son to push me to fight for my life. They are my source of strength.

But then I still cried. I cried hard than I can ever imagine. I cried to Jim over the phone for a good ten minutes or so. I was crying because I was sad he has to go through this too. I know it will be tough for the caregiver as much as the patient. Emotionally, physically psychologically. I was sad for baby James, although he still doesn't understand it, he may see me sad or weak at times. I'm his primary playmate and I love that. I'm sad that I might not be anymore at times.

But I had to console myself, bring my self together to drive home. The journey will start.

If you can , please help in raising funds for Krissy's Breast Cancer treatment:

The Ultrasound and Biopsy day

February 4, 2011, Friday

The day has come!! At long last. I've been waiting happily for this day because I can finally clear up my mind of this lump. I can't wait till they tell me they can get the milk out of the cyst sac.

I went to the basement of Harbor-UCLA to get to the breast clinic ultrasound. I was told to register then wait in this tiny waiting area where there were 10 seats for about 15 people waiting. So I squatted along the hallway. It was 8am. I played with my phone, editing all my 215 contacts in my address book because there was no cellphone service/signal in their basement. Arrgh.

Two hours later, I was still waiting. I've already finished eating a hearty breakfast at the cafeteria, walked around, texted and made some calls in the lobby. Still waiting.

I finally went in the waiting room and shared stories with other women waiting for their ultrasound. One young lady, just started losing 25lbs in one month after feeling a lump. One Asian lady was there for a follow up. She had a tumor, it was biopsied and after the needle biopsy, the lump was gone. (I'm sure it was just a cyst). Another younger girl has been there 3 times already. Her cysts keep coming back so she just gets them removed every time. All were benign. A lot of different stories, but none scared me a bit. I was confident mine was just plugged milk like everyone has been telling me. Because I'm breastfeeding. Every where I read, websites say breastfeeding lowers your risk of breast cancer.

There were informational posters about breast cancer, stages, symptoms and treatments, in the waiting room. I read it out of boredom. The terminologies got stuck in my head because I'm naturally drawn to medical lingo. I wanted to be a doctor. I finished Pre-med in college and had one year of med school.

Finally after 4 hours of waiting, my name was called. I changed into a hospital gown and was instructed to lie down. The nurse was very motherly and thoughtful. Checking on me if I was cold or comfortable.

She finally placed the ultrasound probe on my breast where the lump is. She paused and did it again. She then told me to wait and when she came back, there was a doctor. She is a surgeon. The nurse had that worried look on her face as she showed the ultrasound image to the doctor.

The doctor, Dr. Dauphine, told me that the lump looks suspicious. She said she thinks its CANCER. She did another clinical breast exam and she said she can feel some abnormal lymph nodes too, aside from the two masses on my breast. She told me she has to do a biopsy.

The ultrasound of the lump in the 11o'clock position looks like a Mickey mouse image. It has ridged edges and not round at all. Same with the lump in the middle of the breast behind the arreola. She also made me feel the abnormal lymph node. It was hard and a little painful, which I've never noticed before until she showed me.

Uh oh. Then I got scared. I wasn't scared that it might be cancerous. I was scared of the huge needle to be stuck in my breast. And then she explained that one of the risks of the biopsy is having a MILK FISTULA. The needle may hit a sinus that can create a canal on the side of my breast. Milk can start oozing from that canal.

I hesitated if I want to get that biopsy done. I wanted to get dressed, go up the lobby and call Jim to ask his opinion. Or maybe I'll just go home.

But Dr.Dauphine did not even give me a choice to bail out. She said, the risk of milk fistula is lesser than the possibility that it IS cancerous. My mind kept blurring out the word "cancerous". It was like I'm not hearing it. All I was scared of was, the needle, the milk fistula and the possibility that I have to stop breastfeeding my baby abruptly.

It took them only 5 minutes to set up the biopsy equipment, the consent form and arranging for a stat result with the pathology department. The doctor said she is making a special appointment for me the following Tuesday, so the results will be ready by then and discussed with me.

I didn't have anyone with me so the motherly nurse offered to hold my hand while the doctor injects the anesthesia. That was an OUCH! It was an ultrasound-guided biopsy so I can watch whats happening with the needle inside my breast. She was poking the anesthesia needle inside the lump and she said it is definitely solid and not milk or fluid filled.

After I was numbed, there was pressure of something being inserted on the side of my breast and then a click. She did it four times. These were the core biopsy needles. They had to collect four containers to make sure there were enough cells and not have to do it again.

Finally it was over. I was cleaned up of the blood, bandaged and asked to put pressure on the area. I should not use much of this right side arm, where the biopsy was done, like lifting and even opening doors. The motherly nurse hugged me. She said it will be ok. She said she is also a cancer survivor for 10 years now. She said with loving eyes, I'm sorry.

Another nurse, a Filipina, gave me my discharge instructions and led me to the door. She also said "I'm sorry" and opened the door for me and trying to help me carry my stuff. I went on my way to the car starting to digest what had happened.

I went in my car and called Jim. I told him with a straight voice at first that they think it's cancer. I was trying to explain to him the procedures done calmly but then it started sinking in to me. I have cancer. I then started crying.

Flashback, 4 months ago...

October 2010

I am 34 years old, generally healthy, breastfeeding mother of a two year old boy.

I felt a bit of a lump on my right breast. It's a little prominent because I can feel it by just accidentally swiping my hand on the side of my breast.

I have felt some lumps in my breasts before. Ever since I started breastfeeding, my breasts have sometimes felt lumpy because of milk engorgement. Usually, when I get plugged milk ducts, I would just apply alternating hot and cold compresses, use the breast pump or let my baby breastfeed more on that side of the breast. This kind of lump, when it is plugged, is usually painful. It also feels warm to touch. You can also see tiny white spots on your nipple.

This time around, the lump I felt was hard and it doesn't seem to be moving inside. I didn't think of it any more than breastfeeding related but I still called my doctor and scheduled an appointment.

They were quick to accommodate me. I was seen within two days. During the clinical breast exam, the doctor felt that the lump was about 2cm. She asked about my family history and I told her that I have two maternal aunts who succumbed to breast cancer.

I've had a mammogram the year before, in 2009 but because my breasts were very dense, they did not find any abnormalities thus it was negative. The doctor was actually surprised that I have had a baseline mammogram at my age. I said, my OB-Gyn told me to get one after 6 months post-partum because I have a strong family history of breast cancer.

I cannot get a mammogram again this time because I was still breastfeeding. So the doctor suggested that I get an ultrasound because it can pick up images even with dense breasts. But she also said that she would recommend waiting about 2-3 months before getting the ultrasound, hoping that if it's milk related, the lump will just clear itself. From what she said, getting the ultrasound was more to ease my mind that it's nothing more that just milk.

So I waited for an ultrasound referral.

December 2010

I didn't want to wait for another month anymore. I had to go to the doctors clinic to proactively ask for a referral. I told them even if I don't have an insurance, I'll find a way to be able to pay for the ultrasound. I felt that the lump was getting bigger.

After getting the referral, I got an ultrasound appointment with Westchester Imaging Clinic which we will pay $220 from our own pocket. However, a couple of days after, the breast cancer clinic at Harbor-UCLA finally called me for an appointment on December 21, 2010. Finally! It was a low-cost clinic, so I can probably afford this one better.

Surprisingly, in the same week, I was approved for a self-pay private insurance I have applied for a few months ago. I didn't even think I would need it this quick. Maybe it was meant to happen.

December 21,2010

This is my first visit to the breast cancer clinic. After hours of waiting, I will finally get my mind at ease and have that ultrasound done.

But no. The doctor came in, gave me a clinical breast exam and told me to just massage the area and do hot compresses. He also said he found another lump in the middle of the same breast, near the arreola or nipple.

He said he will go ahead and schedule the ultrasound for NEXT MONTH, February 4. And if the lumps don't subside, they might do a biopsy. He said he thinks it is GALACTOCELE (According to Breast Diagnostic Center, www.breastdiagnostic.com: it is a milk cyst, clogged milk duct, usually associated with childbirth, in both breast feeding and non-breast feeding mothers). And that the other lump is just a cyst.

I was a bit upset because I have to wait for another month and a week to clear my mind what this lump is all about. But he looked like he knew what it was.

So we will wait. Thank God, Christmas, my favorite holiday, was coming up, and my sister was to visit. I was pleasantly distracted.

If you can , please help in raising funds for Krissy's Breast Cancer treatment: