When one of the medical technicians at the UCSF Breast Care Center says I need to make a “rad-onc” appointment, I don’t understand her at first. “Rad-onc” sounds like a noise you would make when you have a cold, or something a rapper would improvise to fill space between verses.
“I’m sorry,” I say. ” I don’t understand.”
“Rad-onc!” she says. “Radiation-oncology.”
With chemo and the second surgery behind me, I show up for my first radiation oncology appointment on the Monday 10 days ago. (I have gotten woefully behind on blog posts.) This department fills the basement of UCSF Mt. Zion. It feels a bit like I’d imagine the dark arts domain of the Harry Potter universe, a place where wizards turn the sinister magic that destroyed Hiroshima and Nagasaki into something that, controlled and laser-targeted, cures cancer.
Like everything else in the rad-onc domain, the waiting room is completely below grade. As I flip through an old issue of “Real Simple,” I give thanks for the natural light pulled 20 feet down from sidewalk level, through a light well designed by a local glass artist. Before I get to all the article jumps at the back of the magazine, an assistant calls my name and leads to an exam room.
Soon, my new medical wizard, Dr. Barbara Fowble, comes in with one of her residents. She is warm, but formal. Like everyone else at UCSF, she is insanely qualified: Phi Beta Kappa, magna cum laude, someone who pioneered the idea that breast conservation therapy might be as effective as mastectomy and radiation, editor of a major textbook on breast cancer care, founder of a complementary medicine program at Fox Chase Cancer Center in Philadelphia, named one of the top doctors in the country by several magazines.
Though she has treated more than 2,000 patients with radiation, Dr. Fowble treats my case as if it’s the most fascinating and new medical puzzle that she’s ever encountered. She takes an incredibly detailed history: how my cancer was first identified, the gauntlet of biopsies and scans in New York, surgery in San Francisco, surgical recovery, chemotherapy, chemo side effects, three echocardiograms to rule out heart damage from the Herceptin, second surgery.
“I’m impressed that the radiologist in New York even noticed the micro-calcifications on your mammograms last May and June,” she says. “That was a really good catch.”
I’m impressed that she has even looked at my original mammograms. I tell Dr. Fowble that I’ve already written two thank-you notes to that first radiologist.
Then Dr. Fowble goes into the shpiel that I imagine she gives to all new patients. She speaks slowly and clearly but with a manner that says, “Hang on to your questions until after I’ve finished.”
Unlike my early appointments, when I brought an entourage to take notes and provide emotional support, I’m alone this time. I decide to just listen, and not to take notes.
Dr. Fowble mentions the various options given my type of case. She discusses what’s known about the possible outcomes, what studies in Milan and elsewhere bode for my future. I’m embarrassed that I don’t remember the details. I should have brought a tape recorder. I’ve written magazine articles advising people to tape appointments like this one.
But I haven’t been organized enough to think of bringing a tape recorder, so I hang on to this basic message: With my kind of case: early detection, mostly local “ductal carcinoma in situ” and a small but aggressive tumor that is Her2 positive and receptive to estrogen, I have a 70 percent chance of a recurrence without radiation. With radiation—which has its own mode of action but also seems to enhance the effects of chemo—I can bring down the risk of recurrence to about 10 percent.
So. Sign me up. Is there really a choice?
Dr. Fowble takes some detailed measurements of my arms, does a breast exam, pulls up my digital medical records, “Oh, your pathology report is back from surgery,” she says, looking at the computer screen. “Seems that they got clear margins this time, a little bit of ‘atypical ductal hyperplasia.” That’s kind of a pre-cancer. But nothing to worry about.”
She then explains that I’ll come back in about a month, when I’m fully healed from surgery. The first appointment will take a couple hours. They won’t actually zap me this first time, but make everything just right so that the radiation zap goes where it needs to go. They’ll place me in the radiation machine, take lots of detailed measurements. Then I’ll come back, every day Monday through Friday, for six weeks. No antioxidant supplements during this time. I’m not to use any commercial moisturizers or creams on my left breast. They’ll give me all the creams that I’ll need. It occurs to me that she’s really glossing over the sunburn and peeling and soreness I’ve heard attends radiation, but I guess we’ll deal with that when it comes.
She asks if I have any questions. I ask her exactly how the radiation kills cancer cells.
“Well,” she says, “The radiation damages the cells that it touches. It sets off a cascade of ‘free radicals’ that damage cells. Healthy cells can repair this damage. Cancer cells, which have damage DNA and no purpose other than dividing, can’t repair the damage from the free radicals and so they die.”
“So that’s why you’re not supposed to go crazy with antioxidants during treatment, because they’re meant to combat the free radicals?” I ask.
We talk for a while longer, then the appointment’s over.
“See you in April,” Dr. Fowble says.