Questions To Ask Prior To Surgery

Anonymous

Hi,

 My father who is 93 was just diagnosed with breast cancer and is scheduled for surgery next week.

We are meeting with the oncological surgeon this Thursday  - the 21st.

 What questions should I be asking especially in light of his age?

The surgery is scheduled at Cedar Sinai in Los Angeles and the surgeon is affiliated with that institution so I am fine with the facility.

My father has gone through the various tests but I haven't involved myself as I didn't want to waste the doctor's time until there was a firm diagnosis.

 THanks. 

SpecialK

Does the doc feel that surgery alone will solve this problem, or are they looking at any adjuvent therapy such as chemo or rads?  My Dad was diagnosed with stage IV lung CA at the age of 82, was not a surgical candidate but did do chemo and rads.

Anonymous

I only had a very brief conversation with the surgeon about 1 1/2 weeks ago prior to any tests being run but after he had examined the suspicious lump and thought it would prove to be cancerous.

 At that time, he spoke about a mastectomy followed by some form of chemo. It was a very brief conversation in which he didn't mention the word "chemo" but some form of medicine. Since I really didn't have information - nor did he - I didn't think that much would be gained by asking him questions in depth since he really didn't have much information - no bone scans, MRI etc. in terms of staging or possible metastasis.

 This will be the first conversation in depth with the surgeon. He has the results and I would like to have some intelligent questions to ask - or even if someone could point me to some good reading materials to research myself.  

SpecialK

There is a male breast cancer thread you can access from the drop down under the "connecting with others with a similar diagnosis" heading.  Am I correct in assuming that your Dad has had a biopsy and the surgeon has a pathology report, as well as scan results - is that what the surgeon will be sharing with you?  In terms of chemo, those decisions would be made by an oncologist, not the surgeon. 

Things you need to ask:  tumor type, size, location relative to other structures in the breast/chest, removal method options, involvement of lymph nodes and sentinal node biopsy at the time of surgery, whether distant metastasis and where are they, if mastectomy is elected does the surgeon think he can get clean margins (no chest wall involvement) and how they think your father will tolerate the procedure.  Because of his age they may elect to keep in the hospital for a longer period, I would also ask about anesthesia and pain control methods they will be using.  Will he have care at home?  He will have drains that will need to be emptied several times a day and will probably not be able to get in and out of bed by himself due to arm weakness, especially at his age.

That is all I can think of at the moment - I am sure others will chime in too.  Best of luck to you both.  I know how hard this is - been there and done it with my Dad and myself!

Anonymous

THanks - I will check out the other thread.

 Yes you are correct in terms of your assumptions - he's had the biopsy as well as the other tests - bone scan and MRI. Based on the tests, the diagnosis has been made but that appears to have been pro forma since both his primary care doctor and the surgeon seemed convinced it was malignant prior to the tests.

 At this stage, I really don't know anything but feel as though I should be as prepared as possible in terms of questions.

 As the surgery has been scheduled for the 29th, I assume that they feel that the surgical option - mastectomy - is indicated. In my brief initial phone conversation with the surgeon, he had indicated that would be what would be indicated.

 I had thought about the recovery process and was planning to bring it up with the surgeon since I don't think he is going to be safe on his own for a period of time. 

SpecialK

If your Dad is Medicare eligible, or has supplemental coverage, a visiting nurse may be arranged for the time period that he has drains, etc. to manage that, and monitor how he is doing.  Drains usually stay in for a week or two, and are used to manage the lymphatic fluid and keep if from accumulating and causing swelling and other issues. Does he live on his own now, or does he have some assistance?  My Dad actually did fairly well and had my Mom to help, but he was 10 years younger.

Anonymous

He has excellent insurance and I am aware of the home health nurse to do what is "medically necessary".

 He lives in an assisted living facility and I am more concerned with his having someone there to help him toilet/get in or out of bed. I had tried to broach the subject with him when we first learned that a mastectomy was probable - i.e. that he would be weak - have difficult getting out of bed since the muscles are impacted etc. but he didn't want to deal with it and I didn't want to hit him over the head with the severity of the "procedure" - as doctors call all operations.

 Until now he has been fully ambulatory and independent so it's more of a residential hotel than an assisted care facility per see although those services are available on an a la carte menu basis. 

 I would like him to stay in the hospital for as long as possible. In his current residence, there are people who do act as caretakers and I told him to contact some of them and see if they have friends or families who could be hired when necessary - there seems to be a good network of them already employed with people. He can also hire people through the place but I think it is obviously cheaper to hire people directly.  

SpecialK

Sounds like a pretty good situation for him, especially if you can find someone to be with him for a dedicated period.  Interestingly, most people do not report a lot of pain from mastectomy.  I had discomfort after my double mastectomy, but really didn't require much in the way of pain meds.  There is numbness from the incision site spreading accross the chest because the nerves are cut when the tissue is removed.  My biggest concern would be the weakness previously discussed and I would encourage staying in the hospital as long as possible.  My mom eventually required 24 hour care (mentally alert and lucid, degenerative neuromuscular disease left her unable to walk or stand) and we coordinated with 3 ladies, day/night/weekend to care for her in her home.  I was very fortunate that they were great and worked with each other to cover appointments and illnesses, and even a maternity leave!  They stayed with her for several years until she passed away.  I was blessed to have them as she was in Los Angeles and I was in Washington, D.C.

Anonymous

End care for one's parents - especially at a distance - is incredibly stressful and you were lucky to have located caretakers who seemed to actually "care" about your mother.

 I understand about pain versus weakness. The worst scenario would be his falling and breaking a bone and starting down a degenerative tailspin. 

 I am concerned with quality of life issues - which I would also like to address with the surgeon or oncologist. 

SpecialK

This is just an off the cuff observation - you may get more compassion from an oncologist than your surgeon on the quality of life part.  Surgeons, many times, are busy and focused on what they do, the immediate aftercare, and then they are on to the next.  Oncologists are in it for the long haul and are more focused on treatments that span a longer period of time.  That being said, I had a great surgeon, who was busy lecturing around the world, but who was very dedicated to me during my time with him.  I was fortunate, as I hope your Dad will be.  If he requires no radiation or chemotherapy he may not need anything more than surgery and recuperation.

I was lucky on the caretaker front - I did travel to California half a dozen times a year to check on things and see my Mom.  I lived in D.C. because my husband was active-duty military (also stressful!) and was stationed at the Pentagon.  The ladies who cared for my Mom were wonderful - they were like family.  I am still in touch, just spoke to one about a week ago and my Mom passed in 2005, so absolutely I was lucky!

Leah_S

Blazedog, weakness will be more of a problem than pain. As SpecialK has indicated, because the nerves are cut the pain is lessened for most people.

If chemo or rads is suggested I would question it carefully. They are usually suggested in situations where long-term survival is a question. Unless the cancer is already metastasized past the lymph nodes it is unlikely that they would be useful, especially where quality of life is more of an issue than quantity. I am not saying that because of your father's age his life is not worth as much, I am saying the opposite. His life is valuable and its quality must be addressed.

So my suggestions are, first of all, make arrangements for as much help as possible post-op, and speak with an oncologist about any other treatment options. The "medicine" mentioned instead of chemo is probably an anti-hormonal to destroy any estrogen in his body that might be feeding the cancer. Yes, men do produce estrogen (just as women produce male hormones) just in significantly lower amounts than women. The SEs from those are usually not too bad and are tolerated well by most people.

Best of luck to you and your father. Let us know how he does.

Leah

Anonymous

Thank you Leah and SpecialK.

 Having friends who are surgeons, I do understand that their mindset is to cut and leave the rest to the doctors. About a decade ago, it was suggested that my father have open heart surgery but after conferring with other non-surgeons, we decided to treat medically - and it seemed to be the appropriate decision.

In terms of breast cancer, it does seem as though surgery is the most appropriate first step and then to take it from there in terms of doing a cost benefit analysis. THere is really no point in going through a grueling year of chemo in order to improve his five year survival rate.

 It does appear that my instincts were correct in terms of his needing some kind of person available 24/7 to help with weakness.

 The appointment is for Thursday with the surgeon - the options don't seem to start until after the surgery. 

SpecialK

Wishing you both the best.  It is a scary time at the beginning, but once you have a plan in place you will feel better.  As my parents aged they seemed less able to retain info from the docs, so it is good to be the eyes and ears.  I will never regret being there to do all I could for both my parents as they became too ill to make decisions, etc., I wish I could have done more, but I can sleep at night feeeling I was a good daughter.  Having just had my last chemo 2 weeks ago I have a new appreciation for my Dad who did 2 separate regimens, 6 months apart, at the age of 82.  He thought he was being proactive, but really it was for palliative reasons. I have nothing but admiration for his will to live and take care of my Mom.

ithaca

I'd be interested in asking the surgeon about the lymph nodes. Sometimes nodes are removed to see if chemotherapy is indicated. If chemo won't be pursued (which is entirely reasonable), is there a need to remove the nodes?

But there are times that lymph nodes are removed to help treat the breast cancer, especially if it's obvious that the breast cancer has spread there.

In any event, I think it's reasonable to ask about the nodes because what might be standard practice may not apply to your dad's situation.

Emaline

If your father is in AL versus independant living, there should be someone there via call light for help. However you may want to check and see if there will be more cost incurred.  This may qualify as a higher step in the level of care that they provide, so there may be additional cost. Depending on the level of care your father is at right now, this could take him out of the level of care that they provide. All facilities are different.

You may also want to check with his doctor and see if they want him to go back to an AL place right off the back.  They may want him to go to a skilled nursing facility for short term rehab, to help strengthen him up prior to going back to AL.  If the doctor does recommend a short term rehab, then as long as he has a three day qualifying stay, his Medicare or whatever his primary insurance is, should cover the first 20 days of his rehab at 100%.

I'm 41 and had few issues with my mastectomy, however at 91 we are talking a different kettle of fish, usually.  So long story short (too late, I know), I would ask if the doctor would recommend short term rehab in order to strengthen him up to return to assisted living.

I wish your father and your family the best.

Larry44

Blaze,

I was 59 when I was diagnosed with breast cancer.  My oncologist recommended chemo for me as adjuvant therapy, which I had done, but he also told me that had I been over 70 he would not have recommended chemo for me.   Chemo is very tough on the body.   Your dad's case is undoubtedly different than mine was, but I sure would be very reluctant to have a 93 yr old go though chemo.  In terms of the surgery, I'd be focusing on finding out what care your dad will need after surgery.  I've found that surgeons usually won't volunteer that information.   I think they are afraid that patients won't have life saving surgery done if they know what the recovery will be like.

Anonymous

THanks for the responses. I had thought we would be meeting with the surgeon this afternoon but there was some kind of emergency so it was rescheduled for tomorrow afternoon - but I had printed out the questions/issues raised.

 Larry - Surgeons god bless 'em - every surgery is a procedure and any pain is "discomfort". My father certainly seems to have gotten a very bizarre view of the operation as he told me that the surgeon told him that it could be performed on an outpatient basis and people go home the very next day. I'm not taking that seriously - my sense is that he was seeking to alleviate to the extent possible - fear of the operation. I do think that the relationship between doctors and people of my father's age seems to be different. I have to believe that the doctor isn't a complete whack who seriously thinks a 93 year old would be discharged home the day after mastectomy.

On the other hand, my father who is not senile seems to have forgotten that he had two bouts of prostate cancer - as my friend said, we should all be lucky enough to live long enough to FORGET we survived cancer. I wonder if that could be related at all although it seems unlikely since his last bout was in 1987.

I don't want to the the voice of gloom and doom so to speak by trying to let him know that he is going to be weak after the operation and will have drains and certainly is not going to be able to fend for himself. I spoke to the nurse at his residence who obviously agreed and thought the most appropriate solution would be a nursing/rehab center after discharge from the hospital - at least until he doesn't need care with the drains and such. After that play it by ear in terms of what level of care is necessary during the recovery process. Emaline - The place he lives at is more of an independent living facility with the ability to get more services as needed. They aren't licenses to provide medical care or skilled nursing care but obviously having him with a base level of support system simplifies things. I am pretty sure there would be no problem getting him medically approved for rehab/skilled nursing as his Medicare/supplemental is pretty good. Not that it is necessary (or probably even desirable) but he also qualifies for VA medical services as a vet.

As I haven't seen the doctor yet, I really don't have any answers to the issues which you are all raising and which are mine as well. I would assume chemo for a 93 year old makes no medical or psychological sense. I am assuming that mastectomy would be appropriate but I don't know anything yet about staging or metastasis until I see the doctor tomorrow so I have no idea what the prognosis is after surgery. As I posted originally the surgeon had mentioned medicine after surgery but not chemo in my very brief initial (and only) telephone conversation - he seemed like a hail fellow well met type of jovial guy so I don't know whether it's in line with procedures and discomfort.

Larry44

Blaze,

The mastectomy is not that extensive an operation, especially on a man.   In the USA, the only reason that a mastectomy patient would not be discharged from the hospital the day after surgery is in case of a complication. I doubt that Medicare would pay for additional days unless in the rare possibilty your father has complications.

I chose a lumpectomy which was done as an outpatient.  I entered the hospital at 6:30 AM and left by 3:00 PM.   I live alone and was able to take care of myself after discharge.   Handiling drains is not a biggie, the collection bag needs to be emptied periodically and the amount of drainage measured and recorded.  You haven't told us anything much about your father's health other than he is 93.   So, if he in good mental health, this won't be as large a problem as I think you are expecting.

I also had my prostate removed using the DaVinci robotic surgery.   The recovery from that operation was much tougher than from my lumpectomy.   There really is not that much difference in the amount of flesh removed for a man between a lumpectomy and a mastecomy for most men.

Emaline

In order to get Medicare to cover a skilled nursing center or rehab, he needs to have a 3 day qualifying stay at the hospital.  Most doctors know how to work the system in order to get that 3 day..however not sure they could do it with a mastectomy.  Which is generally a one night stay.  However...you just don't know.  With your father's age, they might be looking at more time.

He can always get covered under his part B benefits for therapy, however room and board can get very pricey.  Many places run between $100 to well over $200 a day.  You can look up places on the Medicare website to see how they are rated.  I would also suggest touring some facilities.

Anonymous

Had the consult with the surgeon yesterday. Since my father's primary physician is on vacation and can't do the pre-surgical physical, the surgery was pushed back until his return after July 4th. If the surgeon had felt that getting immediate surgery was critical, I would have pushed for a physical with another doctor immediately but I assume the surgeon is not going to delay surgery if it is medically inappropriate.

 Because of the delay, the surgeon scheduled a more detailed biopsy of the underarm lymph nodes. He doesn't think there is lymph node involvement but since the surgery is delayed anyway the additional test will enable him to plan ahead more appropriately and possibly shorten the length of the actual surgery as well as enabling more extensive tests than are possible during surgery - if necessary.

 I'm not sure I really know more at this point. The tumor are hormone receptive (do I have the phraseology correct?) and so the post operative medical treatment would consist of daily hormone pills. Chief side effect being menopausal symptoms - my mother's revenge LOL.

He seemed optimistic - I have no idea whether they are always optimistic until they open you up or whether all of the pre-operative tests actually give them precise diagnostic tools.

Regarding after-care, I don't think the doctor had really considered the effects of a 2 hour surgery on a 93 year old. I realize that it's not as invasive a surgery as many in terms of possible complications and side effects but I think it would leave him in a potentially vulnerable position in terms of balance and falls. If my father is feeling fit as a fiddle one day after surgery, that's fine but the surgeon immediately saw the benefit of being discharged to a rehab/skilled nursing facility as being appropriate - given his age and medical condition.

Emaline

I, huh, okay this is showing my own newbiesm.  From many of the women and people that I have talked to, the underarm lymph node dissection, or the SNB is where they feel the most pain (Unless they are doing immediate reconstruction, which is probably not the case with your father).  I think it is kind of odd that they are doing them at different times. 

Here is my understanding and I hope others with more knowledge will come along here:  Prior to the mastectomy either a few hours or a day prior to the surgey they inject a nuclear material into the breast.  They wait for this to travel into the system. When you go under for surgery they use the tracers to find your sentinel nodes and they do a quick pathology to see if anything cancerous is found in the nodes. If the nodes are clear, you are "good", if they find cancer, they may take the rest of the nodes.  However it is a quick pathology of the nodes. A more extensive one is done after the surgery and if anything else is found, they may recommend a second surgery to remove more nodes.  

If I am reading what you wrote correctly, they are doing the node surgery first?  

I am glad your surgeon saw that the benefit of skilled rehab and will do what is necessary for that.  I was fit as fiddle ahead of time, and was sore as you know what afterwards.  I had issues. I can't imagine discharging a 93 y/o man to home, on his own, with no care.  That would concern me.  

If it isn't obvious, I work with the elderly in a nursing home/AL/skilled rehab. I know what is very easy for me to take on the chin..even with a fit elderly person can knock them for a loop. Your father is very lucky to have you in his corner

Anonymous

Emaline - He isn't having the actual node surgery first. Because of the delay, he is having the nodes biopsied prior to the actual surgery. 

 As described by the surgeon, the sentinal node biopsy would normally be done during surgery and there would be whatever delay there was while they waited for results. There would also be the possibility of further surgery if the results were inconclusive when the more extensive tests were done after surgery.

The advantage to having the node biopsy done prior to surgery is that they can do the more extensive testing prior to surgery. Therefore the surgery could be theoretically slightly shorter and I guess there wouldn't be a need for a second procedure. He also indicated that he could plan exactly what he would do if there was node involvement.

So it's not node surgery - just the node biopsy since the actual date of the surgery was being pushed back.

The surgeon "got" it almost immediately. I was "conflicted" about how much in his face I should be about the "realities" of the operation in terms of the aftermath since his takeaway from the surgeon had been that it was a very minor procedure. Not that he wasn't anxious about hearing the diagnosis and having an operation but he didn't quite realize that the surgery would be about 1 1/2 hours - there would be drains which would preclude normal showing activities etc. 

The rehab facility he would be going to is one that is affiliated with his current residency so I'm familiar with it. There have been a number of my acquaintances who have spent some time there so it's not a nest of horrors as I've been inside to visit. 

 As I recall there is a geriatrics empathy seminar in which they have medical personnel put stones in their shoes; vaseline on glasses and wear heavy gloves in an attempt to simulate the physical environment of even a relatively fit senior.