Part 5: The Sentinel Lymph Node…
“You are going to feel two sticks – one deep, with slight pain, the other superficial, with more pain.” These are the words the nuclear medicine doctor told me as he was about to inject a radioactive colloid solution, specifically Technetium radioactive isotope, into my breast. My poor left breast – all of this prodding and probing made it start to feel like a pin cushion. I took a deep breath and felt the needle go in. “Okay, not too bad.” I thought of the first injection. But then came the second – flashbacks of my stereotactic biopsy raced in my head. That same hot probing sensation flooded through my breast. Luckily, this stabbing pain only lasted about 5-7 seconds! Whew! I asked the physician, “How long does this isotope stay in my breast?” He responded, “About 24-48 hours. The ½ life to the isotope is about 6.5 hours – so after 4 half-lives, it should be out of your system.” The thought of my breast harboring a radioactive isotope and lighting up didn’t necessarily thrill me but I know it needed to be done.
I was then instructed to return to the hospital the next day for my procedure, initially scheduled as a sentinel lymph node biopsy (SLNB), partial lumpectomy and intra-operative radiation therapy (IORT). Before I get too in depth about this procedure, let me first explain what IORT is. IORT is a procedure done at the time of surgery that delivers a concentrated dose of radiation to the site of the tumor. This technology can help to kill microscopic disease and reduce radiation treatment times.
Unfortunately, the IORT was NOT approved by my insurance. Wow, imagine that? I’m not trying to be the ultimate skeptic regarding insurance companies, but when a panel of designated “experts” do not thoroughly examine the 5- plus years of data showing benefit, claiming that it’s still in the “investigational phase”, it’s a hard pill to swallow. Dr. Toosie told me that in certain countries, such as Italy, this is the standard of care in patients, who meet certain criteria: tumor size less than 3 cm, negative margins and low-grade tumor. Exactly the characteristics of my tumor. After researching the data myself, I found that the risk of recurrence with IORT is approximately equal to 4 – 8 weeks of external whole breast radiation – approximately 1% per year to the ipsilateral (meaning same side) over 5 years. Therefore, approximately 5% recurrence risk over 5 years for both interventions.
I also found it quite interesting that if I had had a different type of insurance, it may have been covered. I have a PPO and won’t name the carrier. Certain insurances will approve it without a problem, others flatly deny it, while others have a “in review” status. My insurance fell under the “in review” category, so by the time of the surgery, it was not approved. Interestingly, if I had been over 65 years old and had Medicare insurance, it would have been covered. I truly believe that there is no real rhyme or reason for why insurance companies cover some things and not others. Again, I could go on ad nauseum about this, but I will hold my tongue and bring you back to the hospital.
Thus, rather than undergoing a lumpectomy, with sentinel lymph node dissection and IORT, I was just having a sentinel lymph node biopsy. The reason for the lumpectomy before the IORT is to provide a fresh bed of tissue for the IORT balloon to lay in to help irradiate the surrounding cells. Because my tumor margins were negative, and since the IORT was denied, I did not need another excision of tissue – just the sentinel lymph node biopsy. “It is what it is” rang through my head.
Let’s now delve into the sentinel lymph node biopsy. The sentinel node, also known as the “guard node”, is the first line of lymph nodes that a tumor can spread to. To help review, our lymphatic system helps to fight infection and drain fluid out of our bodies. This system consists of lymph nodes, lymphatic vessels and lymphatic fluid. If the sentinel lymph node(s) are found to be negative then the cancer has not spread beyond the primary tumor into the lymphatic system. If it is positive, then further dissection of this area is performed. Of course, I was praying (as well as many others!) that this would be negative. Yet, given all of the procedures done thus far and the unforeseen results received to this point, I couldn’t be sure what was in store for me. Thus, I was a bit nervous the next morning entering the hospital entrance and heading to registration.
My favorite escort was not there but another friendly elderly chap guided me to the radiation department. Now, images of my breast were needed to help identify the sentinel lymph node. I asked the amiable technician whether these were x-rays and she explained to me that they were like “reverse x-rays”. Rather than directing x-rays to my breast, my breast was emitting radiation to the machine through the radioactive isotope. After 10 minutes, she showed me two big splotches on the screen – one where the dye had been injected the day before and one further to the side where the lymph nodes were located. She marked my left underarm with a Sharpie and I was off to pre-op.
I quickly recognized the pre-op area having just been there one month before. It was still bustling with nurses inserting iv’s and taking vital signs, patients waiting in their beds for surgery, and various monitors emitting random beeps. I was instructed to change into my beloved hospital gown and scrub my body with the cleansing solution. I was becoming a pro at this now!
The iv line was placed by the friendly nurse, who recognized my name from my previous practice. We caught up a bit and it was nice to see a familiar face. Later, Dr. Toosie arrived, grumbling about how disappointed she was about the insurance not authorizing the IORT. This was her baby, IORT, and she brought it to the hospital. I said it was okay – I can do the 4 weeks of radiation, no problem. I, too, was disappointed, but reminded myself of my ongoing slogan, “It is what it is”. We need to let go of things that are beyond our control and accept what is.
I signed the consent, stated my name, birthdate and procedure for the 5th time – Correct patient, correct side of surgery (left) and correct body part (breast). It’s crazy (and scary!) to think how often these might be confused, but it happens. Even when they do a “time-out” in the OR to repeat this process, mistakes can happen.
Lastly, Dr. Toosie informed me that I would have blue urine for a few days. What? Blue urine?! A blue dye would be injected in the operating room around the tumor site to help further identify the sentinel lymph node. Apparently, this is now the standard of care, to both inject with radioactive isotope and methylene blue dye. The combination has yielded a 97% accuracy rate in detecting the sentinel lymph node.
My anesthesiologist was a serene middle-aged Indian physician, who put me at ease and soon the LMA was in place. I woke up in the recovery room and all I could think about was, “Was it negative? Was the sentinel lymph node negative?” “Yes”, said my nurse. I smiled and fell back asleep. In another 10 minutes, I awoke and asked the same question with the same response. Really? OMG – this is fantastic news!!
I’m healing well. And yes, my urine was an aquamarine blue color for 2 days. Glad she told me about this beforehand!! My post-op appointment with Dr. Toosie is in 10 days. After that, we will schedule the radiation therapy which will be approximately 15 min sessions, done Monday – Friday, for 4 weeks.
Reflecting back at this entire experience and the past 4 months, I can see it more clearly. A patient today said to me, “It’s like seeing the forest from the trees.” I had been on auto-pilot trying to take care of my patients and scrambling to care for my mother with her worsening dementia. I never slowed down – I just worked. Pretty much, 24/7 of work and caring for others. Now I can clearly see the huge impact that my actions, or lack thereof, had taken on my health and well-being.
I feel so fortunate that my cancer was found at such an early stage and that I followed my physicians’ orders and recommendations. Remember, I’m not the best patient and it took a little time for me to realize that I was no longer the physician in control but now was the vulnerable one sitting on the exam table. Wow, what an awakening that was!
Some questions still puzzle me. What if I hadn’t gotten the 3-D Tomosynthesis of my breasts when I got the mammogram? What if the radiologist hadn’t picked it up? What if I lived in a place that didn’t have this 3-D technology?
In the end, I believe that things happen for a reason and that there are no accidents. My Stage 1 breast cancer was a stentorian wake-up call. A warning that if I didn’t start taking care of myself, things would get worse. As a physician, I believed that I was indestructible and above disease – but this has proven me wrong in so many ways. I am human, susceptible to the exact conditions that affect my patients. As a woman and like my patients, we believe that we can take care of everything and everybody to the detriment of our own health and well-being.
Remember, we are not super-hero’s, Wonder Women or Mother Theresas. We need to take care of ourselves first and foremost, before we can take care of others. Our health reigns supreme- without it we are nothing. No money, material belongings or elaborate possessions can every match up to the importance of our health.
From this experience, I realize that I need to an advocate for women, a voice for women to take care of themselves. To not put yourself last on the list but to put yourself first! Yes, first! This is truly the only way that you can take care of others. Please know that this is not selfish, but selfless!
Here are some suggestions to putting yourself first.
- Say “No” to obligations that are not important or that you are doing “out of guilt”.
- Delegate responsibilities to others that make your life easier – they can do their share.
- Mark a time in the calendar for a facial/massage and DO NOT cancel it- no matter what!
- Schedule a date night with your partner, or girl’s night out with your friends once a month, or more!
- Take time to breathe – even if just for 60 seconds of mindful inhalation/exhalation a few times a day – at a stoplight, waiting in line at bank/grocery store, or walking to your car.
Please share your own tips for putting yourself first and we will compile a long list. The time is NOW!
In health and happiness,