Treatment

Similar to a previous answer (http://talkabouthealth.com/for-what-types-of-non-hodgkin-lymphoma-is-rituxan-a-typical-treatment-option), the B cell non-Hodgkin’s lymphomas are usually treated with Rituxan. This is because all but a few of these lymphomas express CD20, the target antigen that Rituxan binds to. Rituxan has been shown the be beneficial a single agent therapy in indolent lymphomas, when combined with chemotherapy (R-CHOP or R-CVP are two examples) and for maintenance after initial treatment in the case of indolent lymphomas. Similar to a previous answer (http://talkabouthealth.com/for-what-types-of-non-hodgkin-lymphoma-is-rituxan-a-typical-treatment-option), the B cell non-Hodgkin’s lymphomas are usually treated with Rituxan. This is because all but a few of these lymphomas express CD20, the target antigen that Rituxan binds to. Rituxan has been shown the be beneficial a single agent therapy in indolent lymphomas, when combined with chemotherapy (R-CHOP or R-CVP are two examples) and for maintenance after initial treatment in the case of indolent lymphomas.

R-CHOP (cycophosphamide, adriamycin, vincristine and prednisone, with rituximab) is the standard front-line therapy for diffuse large cell lymphoma and older patients with mantle cell lymphoma. Hyper-CVAD ( a more intensive regimen of cyclophophamide, vincristine, and doxorubicin, alternating with cytosine arabinoside and methotrexate) is often used for younger patients who have mantle cell lymphoma or Burkitts lymphomas. Patients with follicular lyphomas may receive CVP (a gentler form of cyclophosphamide, vincristine and prednisone) with rituximab or receive single agent rituximab. R-CHOP (cycophosphamide, adriamycin, vincristine and prednisone, with rituximab) is the standard front-line therapy for diffuse large cell lymphoma and older patients with mantle cell lymphoma. Hyper-CVAD ( a more intensive regimen of cyclophophamide, vincristine, and doxorubicin, alternating with cytosine arabinoside and methotrexate) is often used for younger patients who have mantle cell lymphoma or Burkitts lymphomas. Patients with follicular lyphomas may receive CVP (a gentler form of cyclophosphamide, vincristine and prednisone) with rituximab or receive single agent rituximab.

Stem cell transplants can be performed as part of the initial therapy, at the time of first relapse and later in the course of the disease. Following initial induction therapy, autologous transplants are being used in first remission for patients with mantle cell lymphoma and T cell lymphomas; although there is not uniform agreement on this practice. Patients with diffuse large cell lymphoma are generally offered autologous transplant when relapse occurs following a first remission. Patients with follicular lymphoma are not offered transplant until the have relapsed 2 or more times or when their disease has transformed to a more aggressive subtype. Stem cell transplants can be performed as part of the initial therapy, at the time of first relapse and later in the course of the disease. Following initial induction therapy, autologous transplants are being used in first remission for patients with mantle cell lymphoma and T cell lymphomas; although there is not uniform agreement on this practice. Patients with diffuse large cell lymphoma are generally offered autologous transplant when relapse occurs following a first remission. Patients with follicular lymphoma are not offered transplant until the have relapsed 2 or more times or when their disease has transformed to a more aggressive subtype.

Rituxan is a useful drug for B-cell lymphomas. Most B-cell lymphomas express the B-cell marker protein CD20. Rituxan is a monoclonal antibody with specificity for B cell lymphomas expressing CD20. These include follicular, diffuse large cell, mantle cell and several other types. Rituxan is a useful drug for B-cell lymphomas. Most B-cell lymphomas express the B-cell marker protein CD20. Rituxan is a monoclonal antibody with specificity for B cell lymphomas expressing CD20. These include follicular, diffuse large cell, mantle cell and several other types.

Patients with newly diagnosed non-Hodgkins lymphoma can have an excellent prognosis, but it depends on a number of factors. The most important piece of information is to obtain an adequate biopsy so that a correct diagnosis can be made. Small needle or fine needle aspiration biopsies are inadequate and it is strongly recommended than a excisional biopsy be obtained. Second, is to complete staging to determine the extent of disease. This includes CT scan of the chest, abdomen and pelvis and more frequently, a PET scan. Bone marrow aspiration, blood and urine tests are require to judge the extent of disease. Once these tests are obtained, it will be possible to develop a treatment plan based on lymphoma type, staging of disease, prognosis and the patients symptoms. The treatment could range from watchful waiting without immediate treatment to aggressive chemotherapy followed by autologous stem cell transplant. Patients with newly diagnosed non-Hodgkins lymphoma can have an excellent prognosis, but it depends on a number of factors. The most important piece of information is to obtain an adequate biopsy so that a correct diagnosis can be made. Small needle or fine needle aspiration biopsies are inadequate and it is strongly recommended than a excisional biopsy be obtained. Second, is to complete staging to determine the extent of disease. This includes CT scan of the chest, abdomen and pelvis and more frequently, a PET scan. Bone marrow aspiration, blood and urine tests are require to judge the extent of disease. Once these tests are obtained, it will be possible to develop a treatment plan based on lymphoma type, staging of disease, prognosis and the patients symptoms. The treatment could range from watchful waiting without immediate treatment to aggressive chemotherapy followed by autologous stem cell transplant.

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required. The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

Every patient must have a definitive determination of the tissue of origin. This is accomplished at the time of a careful review of the biopsy and provides a diagnosis. The second step is to determine where the disease has spread to at the time of diagnosis. This is done through x-rays, PET scans and MRIs, and is known as “staging”. At this point, most physicians begin treatment.
We add a third dimension to our workup. Knowing where it came from (diagnosis) and where it has gone to (stage), our laboratory then seeks to determine what to do about it (chemosensitivity). That is where our group is different from many. Every patient must have a definitive determination of the tissue of origin. This is accomplished at the time of a careful review of the biopsy and provides a diagnosis. The second step is to determine where the disease has spread to at the time of diagnosis. This is done through x-rays, PET scans and MRIs, and is known as “staging”. At this point, most physicians begin treatment.
We add a third dimension to our workup. Knowing where it came from (diagnosis) and where it has gone to (stage), our laboratory then seeks to determine what to do about it (chemosensitivity). That is where our group is different from many.

First of all, I would like to say that - of course - every patient has the right to choose her own treatment for breast cancer. And, furthermore, stopping in the middle of treatment is a personal decision. However, with that said, I fully understand why your radiation oncologist was frustrated by your choice.

Because you work in a cancer hospital, I assume that you are aware of the fact that if a woman chooses mastectomy, she does NOT require radiation after tumor removal. However, with lumpectomy, radiation is indeed the standard of care, and for good reason: no matter what the surgical margins are, no doctor can guarantee that microscopic cancer cells do NOT remain at the site. For this reason, without radiation therapy to kill any remaining cancer cells, local recurrence becomes a significantly higher risk.

As a survivor of invasive breast cancer-not DCIS-I chose to complete all recommended treatment to minimize my chances for local OR distant recurrences. And, knowing that I completed treatment has given me peace of mind as I have moved forward in my life after my diagnosis. Without that knowledge, I don't feel my emotional/psychological well-being could be where it is today.

Since you made a different choice, I would advise you to continue screening your breasts with regularity since local recurrence will always be a possibility. Also, please make sure your current gynecologist and internist are aware of your history so they can follow you closely to catch anything irregular before it is too late.
First of all, I would like to say that - of course - every patient has the right to choose her own treatment for breast cancer. And, furthermore, stopping in the middle of treatment is a personal decision. However, with that said, I fully understand why your radiation oncologist was frustrated by your choice.

Because you work in a cancer hospital, I assume that you are aware of the fact that if a woman chooses mastectomy, she does NOT require radiation after tumor removal. However, with lumpectomy, radiation is indeed the standard of care, and for good reason: no matter what the surgical margins are, no doctor can guarantee that microscopic cancer cells do NOT remain at the site. For this reason, without radiation therapy to kill any remaining cancer cells, local recurrence becomes a significantly higher risk.

As a survivor of invasive breast cancer-not DCIS-I chose to complete all recommended treatment to minimize my chances for local OR distant recurrences. And, knowing that I completed treatment has given me peace of mind as I have moved forward in my life after my diagnosis. Without that knowledge, I don't feel my emotional/psychological well-being could be where it is today.

Since you made a different choice, I would advise you to continue screening your breasts with regularity since local recurrence will always be a possibility. Also, please make sure your current gynecologist and internist are aware of your history so they can follow you closely to catch anything irregular before it is too late.

I personally have specialty-level training in the field of Pain Medicine, having completed a fellowship in Pain and Palliative Care, so I have an understanding of the varied options and multifaceted approaches to pain management. With my background in psychiatry, I additionally have an understanding about the importance of the interdisciplinary approach, as its roots stem from psychiatric care is best applied to treating any psychiatric or medical condition, including quite substantially the treatment of pain, particularly when chronic, as well as in the cancer patient. For better or worse, the experience of pain is a complex and multidimensional phenomenon, so its management also requires utilizing an array of techniques. In addition to the continuing advances in interventional pain medicine, which include nerve blocks and injections and infusions or continuous delivery of medications including anesthetic agents and opioid pain medications as well as corticosteroids which have potent anti-inflammatory properties, as well as electrical stimulation, delivered to or around the central nervous system; and the use of medications in a variety of classes – opioid pain medications which can be administered in pill form and via host of other routes, corticosteroids, NSAIDs (non-steroidal anti-inflammatory drugs) many of which are available over the counter but present a host of potential medical risks, what are called muscle relaxants, anesthetic agents, and other classes called “adjuvants” which include some antidepressants, anti-seizure medications also used in psychiatry, and other channel blockers; there are other somatic treatments that involve electrical stimulation as well as the delivery of other types of energy – thermal, mechanical, or chemical – across the surface of the body, such as Transcutaneous Electric Nerve Stimulation or Cranial Electric Stimulation – and physical therapy – key to most types of persistent pain to improve functional status, as well as psychotherapeutic techniques, ranging from supportive psychotherapy and cognitive behavioral therapy, to incorporating mindfulness-based, relaxation, and hypnosis/ hypnotherapy techniques, to biofeedback, and support groups, along with non-medical treatments such as massage, acupuncture, and other mind-body approaches.

I am not an interventionalist, so I basically do nothing with a needle. That rules out a fair amount of the mainstream approach to pain management as it exists in practice today. Psychiatry happens to be one of four medical fields in which there is formal sub-specialization in Pain Medicine, the others being Neurology, Physical Medicine and Rehabilitation (PM&R or Physiatry), and Anesthesiology which is the most common. Since training generally entails the same program regardless of specialty, anyone completing a fellowship program in the field can pursue expertise in the main existing approaches. The involvement of psychiatry comes from an understanding, which certainly needs much further characterization, that psychiatric factors are indelibly and complicatedly interwoven with the experience of pain, both driving and exacerbating or, for that matter, ameliorating, pain and resulting from it. While people, particularly those who suffer from the very real experience of pain, are troubled when they perceive others think that “it is all in their head”, and, conversely, family, friends, lay people, or even clinicians, can become distraught when dealing with someone who is debilitated from that which does not present with a clear physical manifestation or appearance, there is no truth more useful to recognize in dealing with the mysteries of pain than the fact that “pain is in the brain”. While it is a controversial and weighted statement, there can be nothing closer to the truth. In dealing with psychiatric problems, psychiatrists and their patients, alike, are used to confronting stigma, and dealing with uncertainty, complexity, and compound logic which may involve, and typically expects, more than one explanation for things, so that dealing with the, at times elusive, problem of pain is something which we may be particularly adept and uniquely skilled to pursue, though one might argue that the trouble with pain is even greater due to the expectation of a physical explanation that often escapes the understanding of what is typically framed as a physical problem. However, a distinction must be made from the term “nociception” which is specifically defined as the ‘neural processing of noxious stimuli’ and is that which is specifically at play when we think about the sensation from the physically harmful effects of tissue injury. "Pain", on the other hand, the end product of nociception, if you will, is a perceptual phenomenon and, as such, is nothing other than a brain phenomenon. With this in mind (no pun intended) how could one’s emotions and thoughts, also perceived and processed, respectively, in the brain, not affect and interact with the experience of pain? This is such a simple concept that is unfortunately lost on so many, because it is, at the same time, somewhat difficult to grasp with respect to our expectations.

This all goes to explain the underpinnings of the multidimensional approach to pain, and the richness and importance of the psychiatric understanding, support, and treatment for someone with pain, and the value added by the involvement of a psychiatrist, with expertise in medical pain management, in the approach to the patient with pain. What is called ‘needle-jockeying’ involves highly technical procedures which would not be conducive to a psychotherapeutic encounter. Assessment of non-interventional pharmacologic approaches to pain is within my practice, as my input with potentially overlapping psychiatric medication can be helpful, but, without being able to give details depending on the case and the setting, I generally do so in the context of multidisciplinary pain management. In addition to medication evaluation for juxtaposed pain and psychiatric issues, psychotherapy is a main focus of all of my practice, on some level. In addition to psychopharmacology, I have expertise in psychotherapy which incorporates basic training in hypnosis, an evidence-based intervention for pain. The meaning of pain to a given individual, and the dramatic effects it has in changing one’s life when it enters, calls for such work. I personally have specialty-level training in the field of Pain Medicine, having completed a fellowship in Pain and Palliative Care, so I have an understanding of the varied options and multifaceted approaches to pain management. With my background in psychiatry, I additionally have an understanding about the importance of the interdisciplinary approach, as its roots stem from psychiatric care is best applied to treating any psychiatric or medical condition, including quite substantially the treatment of pain, particularly when chronic, as well as in the cancer patient. For better or worse, the experience of pain is a complex and multidimensional phenomenon, so its management also requires utilizing an array of techniques. In addition to the continuing advances in interventional pain medicine, which include nerve blocks and injections and infusions or continuous delivery of medications including anesthetic agents and opioid pain medications as well as corticosteroids which have potent anti-inflammatory properties, as well as electrical stimulation, delivered to or around the central nervous system; and the use of medications in a variety of classes – opioid pain medications which can be administered in pill form and via host of other routes, corticosteroids, NSAIDs (non-steroidal anti-inflammatory drugs) many of which are available over the counter but present a host of potential medical risks, what are called muscle relaxants, anesthetic agents, and other classes called “adjuvants” which include some antidepressants, anti-seizure medications also used in psychiatry, and other channel blockers; there are other somatic treatments that involve electrical stimulation as well as the delivery of other types of energy – thermal, mechanical, or chemical – across the surface of the body, such as Transcutaneous Electric Nerve Stimulation or Cranial Electric Stimulation – and physical therapy – key to most types of persistent pain to improve functional status, as well as psychotherapeutic techniques, ranging from supportive psychotherapy and cognitive behavioral therapy, to incorporating mindfulness-based, relaxation, and hypnosis/ hypnotherapy techniques, to biofeedback, and support groups, along with non-medical treatments such as massage, acupuncture, and other mind-body approaches.

I am not an interventionalist, so I basically do nothing with a needle. That rules out a fair amount of the mainstream approach to pain management as it exists in practice today. Psychiatry happens to be one of four medical fields in which there is formal sub-specialization in Pain Medicine, the others being Neurology, Physical Medicine and Rehabilitation (PM&R or Physiatry), and Anesthesiology which is the most common. Since training generally entails the same program regardless of specialty, anyone completing a fellowship program in the field can pursue expertise in the main existing approaches. The involvement of psychiatry comes from an understanding, which certainly needs much further characterization, that psychiatric factors are indelibly and complicatedly interwoven with the experience of pain, both driving and exacerbating or, for that matter, ameliorating, pain and resulting from it. While people, particularly those who suffer from the very real experience of pain, are troubled when they perceive others think that “it is all in their head”, and, conversely, family, friends, lay people, or even clinicians, can become distraught when dealing with someone who is debilitated from that which does not present with a clear physical manifestation or appearance, there is no truth more useful to recognize in dealing with the mysteries of pain than the fact that “pain is in the brain”. While it is a controversial and weighted statement, there can be nothing closer to the truth. In dealing with psychiatric problems, psychiatrists and their patients, alike, are used to confronting stigma, and dealing with uncertainty, complexity, and compound logic which may involve, and typically expects, more than one explanation for things, so that dealing with the, at times elusive, problem of pain is something which we may be particularly adept and uniquely skilled to pursue, though one might argue that the trouble with pain is even greater due to the expectation of a physical explanation that often escapes the understanding of what is typically framed as a physical problem. However, a distinction must be made from the term “nociception” which is specifically defined as the ‘neural processing of noxious stimuli’ and is that which is specifically at play when we think about the sensation from the physically harmful effects of tissue injury. "Pain", on the other hand, the end product of nociception, if you will, is a perceptual phenomenon and, as such, is nothing other than a brain phenomenon. With this in mind (no pun intended) how could one’s emotions and thoughts, also perceived and processed, respectively, in the brain, not affect and interact with the experience of pain? This is such a simple concept that is unfortunately lost on so many, because it is, at the same time, somewhat difficult to grasp with respect to our expectations.

This all goes to explain the underpinnings of the multidimensional approach to pain, and the richness and importance of the psychiatric understanding, support, and treatment for someone with pain, and the value added by the involvement of a psychiatrist, with expertise in medical pain management, in the approach to the patient with pain. What is called ‘needle-jockeying’ involves highly technical procedures which would not be conducive to a psychotherapeutic encounter. Assessment of non-interventional pharmacologic approaches to pain is within my practice, as my input with potentially overlapping psychiatric medication can be helpful, but, without being able to give details depending on the case and the setting, I generally do so in the context of multidisciplinary pain management. In addition to medication evaluation for juxtaposed pain and psychiatric issues, psychotherapy is a main focus of all of my practice, on some level. In addition to psychopharmacology, I have expertise in psychotherapy which incorporates basic training in hypnosis, an evidence-based intervention for pain. The meaning of pain to a given individual, and the dramatic effects it has in changing one’s life when it enters, calls for such work.

The study presented by Dr. Grace Smith at the San Antonio Breast Cancer Symposium entitled Partial Breast Brachytherapy is Associated with Inferior Effectiveness and Increased Toxicity Compared with Whole Breast Irradiation in Older Patients has garnered a tremendous amount of print and internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in the breast surgery and radiation oncology fields, it has become necessary to try to clarify the data on APBI, discuss the 'information' in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, Acellerated Partial Breast Irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer. Numerous retrospective studies and 2 prospective randomized (the gold standard) studies have shown no difference in survival, local-regional recurrence rates or complications between APBI and Whole Breast Irradiation (WBI). The American Society of Breast Surgeons Mammosite Registry has published more than 16 papes showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The abstract and presentation is drawn from the Medicare claims-SEER database which is a large database with cancer patient data linked to Medicare claims data. The database is managed by the NCI and sold to institutions to do research. The linked database has information about cancer type and treatments but no specific data on margin status, prognostic factors such as ER/PR and Her2Neu, or even local, regional or distant recurrence. The study stated that 'subsequent mastectomy' is a 'validated surrogate for local failure' although I am unaware of any literature that states this. The 'two-fold increased risk for subsequent mastectomy' is misleading (and inaccurate - it's 4.0% for APBI vs. 2.2% for Whole Breast Irradiation in their study). Both of these rates are quite small and questionable whether there is any clinical significance between the two. Not emphasized but equally (?more) important is the overall survival rates which were equivalent. The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast) but there is no statement regarding severity (were the APBI patients just placed on prophylactic antiobiotics and that is how an infection was defined?). Fat necrosis and breast pain were also significantly higher in the APBI group although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity or the fat necrosis or breast pain. Lastly, they state there was a 9.6% hospitalization rate for APBI patients vs 5.7% for WBI patients. This is quizzical since no diagnosis was given for hospitalization nor the time period over which they were hospitalized (was it APBI related[doubtful] or related to first chemotherapy cycle [perhaps] or other unrelated health issues [APBI often used in older, sicker patients who may not be candidates for 6-7 weeks of WBI]). In summary, this retrospective study of an inherently inacurate (no data on tumor characteristics and margin status - both known to be significant determiners of local recurrence) database with questionable outcomes (admission rate) and non-validated 'surrogate endpoints' (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and 2 prospective randomized trial to the contrary.
Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options.

You have enough time to prepare without too much time to worry excessively. How are you feeling about the appointment? The fact that you've already found this web site tells us a lot. You're obviously doing research and looking for answers.

There are a million things I could tell you: but the most important thing is to know yourself. How much information do you want? Do you know the medical system, how it all works? Are you comfortable advocating for yourself? Is your general health good? Do you have all your current medications (if any) and the name of your PCP written down as well as your health history? You will write out this information (plus your insurance policy numbers) a million times so you might want to consolidate it all into a word document to make it easy to copy. Take it with you to your appointment.

Here are a few things I've learned and recommend for others:

1) Realize that YOU are in charge. Take strength from that. This is your health, your cancer. No one else can or should make decisions for you. An excellent doctor will listen to your concerns and preferences then make recommendations based on evidence and best practices. If you don't click with the first doctor find another. It's worth the time and anxiety. You need to be able to communicate comfortably with this person; and he/she should listen honestly and sincerely to you.

2) Get a copy of Susan Love's Breast Book, the most recent edition. This is excellent background information about breast health, breast cancer, and an overview of treatments. That's a good place to start.

3) Don't believe everything you read or hear about so & so's aunt or what's her' name's sister. There are many different forms of breast cancer and and an even greater number and combinations of treatments. Not every case is the same. Take information, stories and unwanted advice only as you can accommodate it. It's easy to be overwhelmed.

4) You can get a terrific treatment guide from Livestrong.org here: http://www.store-laf.org/gbj001.html or DM me on Twitter and I'll mail one to you. I found it helpful to have one notebook where I recorded all my information.

5) I also felt empowered by the Livestrong Manifesto, which begins: "We believe in life. Your life....We believe in information. Not pity. And straight, open talk about cancer." http://www.store-laf.org/gbj001.

6) If you are in your child-bearing years and still want to have children talk to your oncologist about protecting your fertility.

7) Was your tissue analyzed by mammaprint or OncotypeDx? These tests can provide some guidance whether or not chemo is necessary.

8) If your oncologist recommends chemo - and you say you don't want it - make sure he/she specifically states why it is considered ESSENTIAL for you. Is your cancer hormone receptor positive? It's important for you to know this, as you know your stage, grade and HER2-new status.

9) I trust that someone is going with you to this appointment? This is very important. Another set of ears is essential. And remember you have TIME to come to a decision you are comfortable with. It took me three weeks to review information, and see four different doctors. The search was worth it. I was diagnosed with a locally advanced breast cancer, had surgery, chemotherapy, radiation and three years of Tamoxifen. This was thirteen years ago. My health is excellent and I've had no recurrence. Wishing the same for you,
Jody



My heart goes out to you during this difficult time. I remember being where you are now, although I didn’t have to do chemo. The thing I didn’t want to do was go to the hospital, lie down and submit to a mastectomy. I was terrified.

I had about two months to think about it and each day added to my anxiety. Unfortunately, at that time I had no support other than from family and friends. They did their best, but they were scared themselves and couldn’t really know what I was going through. Finally, I realized I needed to do something. I bought a guided imagery CD and listened to it several times a day. It really helped me be in a better frame of mind.

Since your appointment is in just a few days, I would suggest you go on the Internet and search for “guided imagery relaxation exercises” and “relaxation breath exercises.” You should find a wealth of sources, so I will leave the choice of which is best for you to you.

What I suggest you not do on the Internet is go to chat rooms or the like. Everyone’s experience is different and you don’t want to unnecessarily scare yourself. As hard as it is, try to take each moment as it comes, without letting your thoughts jump to the “what ifs.” But, when the “what ifs” hit, the breathing exercises can really help to bring you back to the present and decrease your anxiety.

I would also make plans to bring a supportive friend, spouse or significant other with me to the appointment. I really believe in the necessity of support in whatever form or forms work for you at all stages of the cancer journey. It’s the only way I got through it and I hope I’ve helped support you today. Good luck and all the best to you.

Chemotherapy was definitely the most challenging for me. I had a 16-week course with treatments every two weeks. Although the physical challenges of chemo are intense, I found the emotional and mental aspects of it to be also very hard. Many people refer to chemo as "poison" and I found that to be not a good way for me to think about it. I needed to think about chemo as a healing agent that was promoting my health rather than "killing" bad cells. I had a meditation practice during my chemo in which I visualized the chemo liquid as rapid and purifying waves of ocean water coursing through my blood. It helped to transform the experience into a healing one. I still had many physical challenges, including fatigue, loss of sleep, skin and mouth issues, etc. but I think my meditation practice helped to mitigate them and keep me on track with the treatment. Chemotherapy was definitely the most challenging for me. I had a 16-week course with treatments every two weeks. Although the physical challenges of chemo are intense, I found the emotional and mental aspects of it to be also very hard. Many people refer to chemo as "poison" and I found that to be not a good way for me to think about it. I needed to think about chemo as a healing agent that was promoting my health rather than "killing" bad cells. I had a meditation practice during my chemo in which I visualized the chemo liquid as rapid and purifying waves of ocean water coursing through my blood. It helped to transform the experience into a healing one. I still had many physical challenges, including fatigue, loss of sleep, skin and mouth issues, etc. but I think my meditation practice helped to mitigate them and keep me on track with the treatment.