Sunday, October 20, 2013

Surgery Pending, So is More Chemo...

It was exactly one week before my scheduled bilateral mastectomy.  I had been waiting for nearly an hour with more than a dozen other patients at the Winthrop P. Rockefeller Cancer Institute to see Dr. Makhoul, my oncologist, for the results of the recent breast MRI. The good doctor had recently been appointed the new director of oncology at the University of Arkansas for Medical Sciences and was busier than ever. Since being diagnosed with cancer six months earlier, I had learned the virtue of patience and it was a good thing.

Don had a conflict and couldn't accompany me to my appointment with Dr. Makhoul, but I was okay with going solo because I felt good about the pending results.  After being called to the exam room, I waited anxiously for Dr. Makhoul to enter.  A few minutes passed and the door opened, but it wasn’t Dr. Mak.  Instead, a new doctor entered the room.  He introduced himself as an oncology “fellow,” training with Dr. Makhoul. The young Syrian doctor was polite and engaging. I was impressed that he had read my medical history and was prepared to discuss the topic du jour – my breast MRI results. He informed me that the once large tumor now measured 1.6 centimeters by .6 centimeters and the second tumor, which had always been much smaller than the primary mass, appeared to be completely eradicated. I really wasn't sure how to interpret what I had just heard.  I missed Don.  The new doctor told me he was going to find Dr. Makhoul and let him answer any questions I might have.



It had been nearly a month since my last visit with Dr. Makhoul and I was actually excited to see him when he breezed into the exam room with his new protégé.  His jovial, yet soothing tone always worked wonders on those who might be wrestling with fear and uncertainty, like me. He wanted to know how I fared after my last chemo treatment and I told him that I did okay; however, I was thrilled to have the Taxol treatments behind me, because the drug was taking its toll on my weary body. He nodded his head in agreement.

Dr. Makhoul reviewed my medical file and reiterated the dimensions of the existing tumor. He said it was now a manageable size and my surgeon, Dr. Suzanne Klimberg, shouldn't have any problems excising the breast tissue.

And then he dropped a small bombshell.

“Depending on what the pathology report shows after your surgery next week, he said, "I may recommend another round of chemo."  He further explained that my triple negative diagnosis had everything to do with his recommendation.  Needless to say, I was having trouble processing what I had just heard but knew it was exactly what needed to happen.  “We won’t make a definite decision until I review the post-surgery pathology reports,” he reminded me.  Dr. Makhoul wished me good luck with my upcoming mastectomy and said he would see me on November 5 to discuss a future treatment plan...if necessary.

As I departed the cancer institute, my mind was a whirl with thoughts of surgery and the possibility of more chemotherapy.  That aside, I was prepared to do whatever my medical team suggested to rid my body of cancer, because I had literally placed my life in their healing hands

One Day Before Surgery: The Game Plan Changes

Less than a week after my appointment with Dr. Makhoul, Don and I reported to Dr. Klimberg’s office to fill out paperwork and consult with my surgeon the day before the scheduled procedure.  Upon arrival at the women’s oncology clinic, Don and I had to search for two chairs together in the overflowing waiting room.  As I scanned the crowd, I noticed that only a few patients were older than me and was stunned at how many were in their 30s and early 40s.  I was curious if the recent Angelina Jolie breast surgery phenomena had reached central Arkansas and was a reason for seeing so many young women in the clinic. Hopefully, they were there for preventative purposes, as Jolie demonstrated with her decision to have a bilateral mastectomy before she actually had cancer, and not because they had already been diagnosed with breast or gynecological cancer.

My appointment with Dr. Klimberg was scheduled for 11:00 a.m. and we expected a long wait; however, my name was called about 30 minutes later.  We were escorted to a small conference room, where an RN specializing in tissue research counseled me on the benefits of donating my breast tissue post-surgery to UAMS for scientific research.  I wholeheartedly agreed.  The fact that the type of cancer I had – triple negative – was found in only 15% of women offered a solid reason for me to participate in current and future research projects. My triple negative diagnosis was starting to weigh heavily on my mind after doing a little online research of my own.  If my tissue could help provide answers or even a vaccine, I was more than happy to help.

After I signed the release forms for the tissue donation, I was moved to an exam room, where I waited for my consultation with Dr. Klimberg.  Her nurse, Maureen, arrived first and handed me several forms to review about the surgery.  Then Dr. Tummel, a very young associate of Dr. Klimberg, entered the room and conducted a brief breast exam in advance of my surgeon’s arrival.  In typical Klimberg fashion, the dry-witted doctor made an entrance into the exam room wearing blue scrubs and accompanied by a timid, female intern.  “Let’s get this show on the road,” she directed her entourage.  One of her first duties was to explain to me all the things that could go wrong during surgery…including death…and handed me a pen to sign the consent form, which I did.  I was given additional forms to complete that would allow Dr. Klimberg and UAMS to use me in a lymphedema research project she is conducting.  Lymphedema is defined as arm swelling common in mastectomy patients.  I was familiar with the problem after observing a former colleague deal with a re-occurrence last year, which was a determining factor in me signing up for the experiment (Thank you, Renee).

After all the paperwork was in order, Dr. Klimberg pulled a permanent marker from her scrubs and began drawing possible incision lines on each breast as Dr. Tummel and the intern observed over her shoulder.  The first mark of significance was where she planned to move my nipples, followed by the “flaps” she would create for the plastic surgeon to insert the implants a few months later.  “Are you still going to do the procedure you created just for me?” I asked.  With her chin nestled between the thumb and forefinger of her right hand, she stared at my breasts and responded with a comment I wasn’t expecting.  

“I think your breasts are just too small for me to do the ‘Breast Over Pants’ as planned.”  

I started laughing and told madam surgeon that she is the first woman to ever tell me that I had small breasts.  “I meant it in a good way,” she said, trying to recover from her comment.  “Have you lost weight since I first suggested the new procedure?” she inquired. In fact, I had, but I didn't think it was a game changer.  She continued to discuss possible alternatives with Dr. Tummel for nearly 45 minutes.  Finally, they had a plan.  When I looked down at my apparently small breasts, all I could see were multiple black lines that resembled a web - and small, black dots where each nipple would be re-positioned.

Before leaving to see another patient, Dr. Klimberg told her nurse to call the surgery scheduler and make sure I was the first patient the following morning.  In a few minutes, Maureen returned and said Dr. Yuen, my plastic surgeon, already had the time slot reserved for one of his patients.  It was immediately apparent that Dr. Klimberg didn't like Maureen’s answer.  

“I’ll be right back,” she told me.  

Within a minute, Dr. Klimberg returned with a frustrated expression on her face and informed me that I would be second on the surgery schedule, which would be approximately 11:00 a.m.  “How long will the surgery take?” I asked.  “About four hours,” she told me as she hugged me before leaving the exam room.  

“I’ll see you before we put you to sleep,” she added.  “Don’t mess with my artwork,” she told me, pointing to my marked up breasts. After she left the room, I looked at my watch.  In less than 24 hours, I would be in surgery, receiving a life changing procedure.  It’s merely the next step in my treatment plan, I reminded myself, as I put on my favorite bra for the last time. 

Tuesday, October 8, 2013

Dr. Suzanne Klimberg: The Surgeon Schedules the Surgery

The aches and pains from my final chemo treatment were causing some discomfort when I reported for my appointment a few days later with nationally known breast surgeon, Dr. Suzanne Klimberg. I nicknamed the good doctor “Picasso” because of her penchant for drawing imaginary incision lines on my breasts as a way to explain the upcoming mastectomy surgery.
marla crider, UAMS, breast cancer, mastectomy, Dr. Suzanne Klimberg
Breast surgeon, Dr. Suzanne Klimberg.

It isn't unusual for Dr. Klimberg to have several medical students shadowing her every move and hanging on her every word.  These fresh-faced wannabes are eager to learn from the best in hopes of one day using their knowledge to create new, streamlined surgical techniques or, perhaps, to develop a vaccine that could eradicate cancer all together.  There’s no better reason to be a patient at the University of Arkansas for Medical Sciences – the state’s only teaching hospital – because you see the future of medicine in every young face wearing a lab coat and can’t help but think about the possibilities.

Don, an accomplished surgeon himself, accompanied me to my appointment to ask questions about the surgery and interpret the answers.  We had only been in the exam room a few minutes when Dr. Klimberg’s nurse came in to inquire about my chemo regimen and to confirm the date of my last treatment.  She surprised me when she requested to examine my breasts.  The nurse took a black pen out of her pocket and drew a circle very near the right nipple where she felt evidence of the remaining cancer (Hmmmm.  Apparently, everyone in the Klimberg clinic is an artist and my breast seems to be their favorite canvas). She explained that she was marking the area for Dr. Klimberg to evaluate. 

A few minutes later Dr. K entered the room with a med student at her side.  The doctor introduced her protégé to Don and me as one of her brightest scholars. The fresh-faced young woman blushed at the compliment. There were now a total of five people in the small cubicle, yet no one seemed to notice (or care) that I was lying bare-breasted on the exam table. It was all in a day’s work for them. I learned quickly after my first visit to the UAMS Cancer Institute six months ago that my breasts were no longer just mine.  I had to relinquish custody of “the girls” to my medical team in an effort to rid the right one of cancer.  Dr. K moved to the right side of the exam table and the med student was on the left. The RN was in the background making notes.

Dr. Klimberg immediately zeroed in on the black circle made by the nurse.  She palpitated my right breast, then the left, and moved back to the right breast where she found what was left of the once very large mass. She instructed the med student to feel the small tumor, as well.  I was beginning to get a little nervous listening to the two of them bantering back and forth until Dr. Klimberg explained that her concern was not the small remnant of the tumor but rather the close proximity to the nipple. She was uneasy about saving it. “Do you like your nipples?” she inquired.  “Heck, yea,” I replied rather shocked at her question.  “Why wouldn’t I like them?  We’ve been close pals for 60 years,” I stated rather matter-of-factly. “Well, in case you didn’t or should I not be able to save the blood supply to the right nipple, I want to assure you that Dr. Yuen (my plastic surgeon) makes a very nice nipple.”  (It’s comforting to know that my reconstruction surgeon is known for his nipple-making.) No doubt, that was the strangest conversation I have ever had with anyone.    

I asked Dr. K if she was still planning to do the new surgical technique created just for me in an effort to salvage more tissue and skin for the breast reconstruction that had been delayed for six months due to my diabetes. “Absolutely,” she remarked. Dr. K, or should I call her Dr. Picasso, took the black pen out of her lab coat and started drawing imaginary incision lines (Here we go again, I thought. It's “show and tell” time).  The med student listened intently as Dr. Klimberg explained the procedure to her, as well as Don.   The two surgeons in the room – Dr. K and my significant other – began to throw technical terms around until I reminded them that the bare-breasted patient didn’t understand a thing they were saying.  I interrupted their physician bonding moment and inquired if Dr. K had decided on a name for the new procedure. “Breast over pants,” my surgeon said with a straight face. Interestingly, Don knew exactly why she chose it.  He enlightened me that there is a hernia repair called “vest over pants” and it all had to do with making a flap that restores blood flow to the impacted area. 

Dr. Klimberg shared with me that several of her students were vying to assist her in surgery to observe this new technique. I asked how she would determine which young surgeon-to-be would be in the operating room.  “It all comes down to which one has the best bribe,” quipped my brilliant body artist.

Dr. Klimberg’s nurse jumped in and asked if she was really supposed to put the name “breast over pants” on the surgery orders because the medical staff would question it, having never heard of such a procedure.  “Even more reason to do it,” Dr. K responded with a twinkle in her eye.  After sitting up on the exam table and covering my bareness with an unfashionable gown, the nurse informed me that I was on the surgery schedule for Friday, October 11.  “Do you know if it will be morning or afternoon?” I asked.  Dr. K jumped in and said the team usually reserves the early morning surgeries for old people and diabetics and I qualified for both.  I couldn’t help but laugh out loud at her comment as did the others in the room.  The nurse handed me several pages of instructions and told me to return for a pre-surgery consult with Dr. Klimberg on October 10, followed by a meeting with the assigned anesthesiologist. 

“It’s really going to happen,” I remarked to Don as we exited the cancer institute.  “I just hope I’m emotionally prepared when the date rolls around.” 

“I have no doubt that you will handle the surgery with the same determination that you did the chemotherapy,” he said.  From his lips to God’s ears…