I finally bit the bullet and made a date for surgery: on August 23rd, I will undergo a salpingo-oophorectomy and total hysterectomy. That means that I will have my fallopian tubes (salpingo-) and ovaries (oophorectomy) removed, and undergo a total hysterectomy (removal of the entire uterus and cervix, with vaginal reconstruction). Just typing this makes me feel a bit anxious, as it’s a big surgery, and it also seems like a lot of information for those who are not perched on the edge of their seats waiting for updates on the status of my lady-parts.
I chose to go forward with the surgery at this time for a few reasons. First, my last two scans have been stable, so I’m currently not shifting any medications or treatment regimens. I will stop Ibrance and letrozole a week prior to my surgery at the direction of my Oncologist, to allow my immune system to build up ahead of surgery. This means that cycle 8 will only be a 2 week cycle, not the usual 3 week cycle. If all goes well, I will stay off of the medications for two weeks, and restart at the normal time for cycle 9. Second, we have already hit our insurance out-of-pocket max for the calendar year, and so I have full insurance coverage for the surgery without any coinsurance or deductibles to be met. Our insurance out-of-pocket max has risen steadily and significantly over the last few years, and after all of the medical bills and expenses we have had in the last year, it made sense, timing-wise, to schedule the surgery now, rather than wait. I have also had a very significant increase in my menopause side effects, which have been incredibly unpleasant and difficult to manage. It is everyone’s hope that, in no longer having to receive a monthly lupron injection, my body can better adjust to menopause, instead of continuously fighting it. The timing also worked out for our family: my parents would be able to come out and help with childcare, my husband would not be traveling during the surgery and first few weeks following my recovery, and I would hopefully be fully recovered by the flurry of fall and holiday activities, not to mention be up and about once the weather cools off a bit.
The oophorectomy is a standard treatment option for many women with breast cancer, both metastatic and otherwise. My cancer is estrogen-receptor positive, which means that my tumors are fed by estrogen, which, in turn, is produced by my ovaries. In removing my ovaries, the main source of estrogen in my body is removed. While this is also accomplished by a monthly lupron injection, they are both expensive and I would have to receive them every four weeks for the rest of my life. My age played a big factor in this decision as well: since I am only 33 years old, I would rather not be tethered to a medication my body likes to fight for the rest of my life. In addition, many of the lines of treatment for metastatic breast cancer can cause damage to existing eggs, making it important for my body to remain in menopause so as to avoid any possible future pregnancies, apart from the estrogen concerns for a potential pregnancy.
After consultation with my oncologist, gynecologist, and gynecological surgeon, I also elected to have my fallopian tubes and uterus removed. Although I did not test positive for any known genetic variants that increase my risk for breast or gynecological cancers, I do have a family history of breast cancer. Because most ovarian cancers, particularly those with genetic linkages, actually start in the fallopian tubes, Dr. Z, the gynecological surgeon, recommended that I have my fallopian tubes removed as well. After several discussions about this, I agreed. My choice to undergo a total hysterectomy, which removes the uterus and cervix, but leaves the vagina intact, as opposed to a partial hysterectomy, which leaves the cervix, or radical hysterectomy, which also removes a portion of the vagina, was driven primarily as a preventative measure as well. For the past four years, I have had abnormal pap smear results. For a few years, these results were unconcerning, but my gynecologist and I discussed and monitored them, and I diligently returned to see her each year to keep tabs on those results. Unfortunately, this year, the abnormal results shifted from low-grade abnormal, which requires a minimally invasive biopsy-like procedure called a culposcopy, to high-grade abnormal, which required a much more invasive procedure called a LEEP (loop electrosurgical excision procedure). Without going into too much more detail, I did not tolerate this procedure well. Because my immune system is already fairly suppressed from my current line of treatment, it made sense to remove the uterine tissue completely rather than continue to undergo the biopsies and procedures year after year (which are medical procedures that carry their own set of risks), or run the risk of developing a gynecological cancer.
The procedure will be at the Cancer Center, performed by one of the gynecologist surgeons recommended by my oncologist. My surgery will be done laparoscopically, with four small incisions into my lower abdomen. It’s considered outpatient surgery, and although I will actually be spending the night at the hospital, I will not be there for over 24 hours. Should any sort of complications arise, I will be transferred to the inpatient hospital center, and treated there. In the meantime, I’m preparing as best I can, and coming to terms with the true end of my fertility, which has been a hard pill to swallow (and I swallow quite a few pills each day). However, I am hopeful that this procedure will be a big step in helping my body channel as much of its energy and resources toward continuing to minimize its tumor burden as much as possible.