DCIS, BMX/MX, and radiation ladies

Julianna, thank you for your post.  I have not decided for or against rads yet...but ALL input and experiences, especially from the very few of us facing this, is invaluable.  I've looked at all the studies - and unfortunately - they are not all that clear cut to me due to the small number of studies and small number of patients in those studies.  I am WAY too analytical for my own good, LOL.  I need to learn how to go from my gut. It doesn't help that I've had conflicting opinions from two different teams about radiation. 

Distancerunner, I have plans to discuss tamox with my team.  I'm not sure which risks are worse, tamox or radiation.   I guess no matter what, we are all paving the path for those behind us who face this difficult decision.   I wish we had more research to base our decisions on.  Obviously, I don't do well with shades of grey, but this cancer crap is teaching me a good lesson along those lines.  

Hi all - had surgery this morning - all is well.  Minimal pain thus far, just sleepy!  

This has been my dilema for weeks. I have finally decided and am getting a bilateral mastectomy on Dec. 8. It has been a rough decision. I went the phases of grief and continue to grieve. It helped that I bloged about it and many of the other fears and emotions I haveing with my IDC and DCIS. I don't know about chemo until the node and oncyotype. Good luck and prayers and huggs to all.

three17 - hello - I know as well how difficult that decision is.  It is an ongoing process of grief with so many emotions abound.  Best wishes for your treatment! 

Hi All,

I just posted some info on the confidence intervals of the Rashtian and Carlson studies on another thread. You can find them here:

http://community.breastcancer.org/forum/68/topic/778944?page=1#idx_8 

Hope this helps,

Lisa 

Hi Julianna,

So glad to hear you are doing so well!  So why are you seeing a DIEP surgeon if your implants are doing well?  

I have until mid January to make my rads decision.  I had my 3rd RO opinion this past Thursday, and I also saw an MO.  The 3rd RO said no rads needed for L side, yes to R rads R side (no L b/c I had fascia removed and margin was posterior, yes R b/c it is an anterior close margin with no barrier between breast tissue and skin).  The MO said no rads needed either side, and no Tamoxifen needed (2nd opinion RO felt I should consider Tamox in addition to her bilat rads recommendation).

MO is taking my case to their tumor board for further review and says I can wait until mid January and possibly even longer before deciding.

I've been posting a lot over on the thread Zteam started:  http://community.breastcancer.org/forum/68/topic/778944?page=1#idx_8  

I'm going ahead with my 2nd reconstruction surgery this Friday, as suggested by my plastic surgeon.  He says I will need fewer surgeries in the long run if I can get at least another fat grafting in before rads, if I have it.  

Julianna that makes so much sense to look into the DIEP given the increased risk of complications with implants and rads.  I've heard there are less complications with DIEP post rads.  Please do update us after your appt this week!  

80 to 85%??? Holy cr*p!!!  I would definitely be looking at the flap as a better alternative, too, in your situation.  

I feel fortunate that according to my PS, complications with rads after fat grafting is minimal (he says it is like radiating a post-lumpectomy breast).  I hope that is the case, should I decide to proceed.   I have one more appt with my 3rd opinion facility set up for Jan 9th, then I believe they take my case to the tumor board.  So assuming the tumor board happens quickly, I should be making a decision within the next 2 weeks. 

I just posted this in Z-team's thread, but wanted to share it here as well for those who may not be on that thread:

Hey all - haven't had my appt yet with the Emory surgeon (that's Monday), but I just was able to get my hands on the FULL copy of an article he published, along with commentary and questions from other docs at the end. We've discussed this article here or on the other thread, but I only had the abstract to look at. The commentary was very helpful...I'm pretty sure they will end up recommending rads for my R side (ant margin), but not my L (post margin)...we'll see! And I will be very comfortable proceeding with that if that is the recommendation. Something new I noticed on my path review from Emory for the R side - it was a small amount of DCIS and LCIS < 1 mm from the superficial margin, BUT, the LCIS was pleomorphic. Everything I've read said that is a different beast and should be treated like DCIS.
I will include the link to the abstract and will type out some of Dr. Carlson's most important comments in his response to other doctor's questions. If anyone wants the entire article and commentary, PM me.

Local Recurrence of DCIS after Skin-Sparing MX

"There were several questions pertaining to imaging of the reconstructed breast. Generally, it has not been standard practice for several reasons. Local recurrence after total MX for invasive cancer is almost always associated with systemic relapse. Imaging these patients to detect earlier local recurrences would have no survival impact. Detecting local recurrence after SSM for noninvasive cancer has the potential to improve survival. As Dr. McMasters said, 'this is a potentially curable problem.' In the breast conservation literature, half of the local recurrences of DCIS treated by excision and radiation therapy are noninvasive. Imaging after SSM and immediate reconstruction has the potential to detect early, noninvasive recurrences."

..... (later)... (basically he goes on to say that mammo's are tough with TRAM's, due to fat necrosis, and the mammographer has to be skilled to avoid confusion with post-op changes. However, he doesn't recommend it with implants, b/c most recurrences would be pushed superficially and would be palpable; rather he thinks MRI is more useful in this group)

"I agree with Dr. McMasters that radiation therapy has a deleterious effect on all forms of breast reconstruction. That being said, it is hard to ignore that 11% or 2 of the 19 patients with close margins developed local recurrence." ...(later)... "A close superficial margin is different from a deep margin. The fascia of the pectoralis major muscle is routinely removed during the mastectomy and serves as a fascial barrier, especially in noninvasive disease. Based upon our experience, I feel that adjuvent radiation therapy is indicated for close superficial margins. Followup breast imaging is indicated in this setting."

...(later)...

"In closing, I believe that we have leaned to radiation therapy in cases of close superficial margins. We now routinely excise the core needle tracts at the time of SSM. We are studying the use of imaging in patients with diffuse microcalcifications who undergo SSM and TRAM flap reconstruction as well as patients who have close surgical margins."

Julianna - are they doing followup mammo's with you (assuming you had SSM?)?  Mammos every 6 months and MRI yearly are being recommended for me. 

I bet no mammo's since you have the TE's; sounds like the MRI is consistent with what the Carlson study advocated for postMX with implants and close margins.  Will be interesting to see what they recommend after your DIEP.  And yeah, 5 minute cursory check sounds lame to me, too, especially since you had close margins.  Good idea to follow up with the MO.