February 1-15
Decisions, decisions...weighing pros and cons (post infection conundrum)
While I continue musing over my lack of locks, I have had to concurrently decide what route to take to best manage the Cellulitis infection I have. Information is king, and I did not feel I had enough information to decide between two equally unsavory choices. The two main choices I had to weigh out were as follows:
Door #1: Keep the tissue expander (temporary implant that expands the chest muscles to prepare enough room for the final breast reconstruction and breast implant later this year after chemo and radiation are complete) :
Pros: this would save me two surgeries and additional infection risks from the surgeries - one surgery to remove the expander and one to insert it again should I go ahead with reconstruction later (as I would again have decide if vanity would be worth all this in the long term as additional surgeries as well as implants have ongoing risk of this and other types of infection. The risks are low, however, I have already lived a less than 2% risk with this episode thank you very much).
Cons:
A. The infection could progress where it "sticks" to the expander and I would have to take it out anyway. I would have to go through a surgery that I would need to recover from, hope no new infection crops up post surgery, continue on the heavy duty antibiotics that I am on and delay my chemo treatments.
B. I would need to remain on my heavy duty antibiotics for 6 weeks. If the antibiotics start working, this is the conservative and safe view that has been given by Dr. A., my new infectious disease doctor, (and one of the latest additions to my medical team), and would officially delay my next chemo treatment. This length of time on antibiotics is recommended due to the fact there is a foreign body that makes it harder and longer for antibiotics to do their thing. Unfortunately, there is no specific test that can conclusively indicate if the infection is completely eradicated or not. Doctors in this field can only tell by visual changes to the infection site, how the patient is feeling and studies/research that indicate the high probability that the infection is managed based on the type of antibiotics, its strength and length of time on the antibiotic.
C. I would worry about the recurrence of this type of infection throughout my chemo treatment and into the radiation reconstruction phase of this journey -- since I have only gone through one chemo treatment so far, I have 7 more treatments, radiation and the reconstruction phase to get through I have a long way to manage my fears. I don't know about you, but this is a lot of time to maintain a high level of anxiety.
Door #2: Remove the tissue expander
Pros:
A. The length of time that I would need to be on my heavy duty antibiotics would be lessened by a few weeks as the foreign body would have been removed
B. I could potentially get back onto chemo treatments sooner than if I left the expander in.
C. I would remove the concern that the tissue expander is contributing to or causing the infection in any way.
Cons:
A. I would need to have another surgery now to remove the tissue expander and another one later to reinsert it if I decided to continue with reconstruction later after chemo and radiation are complete.
B. The risk of post operative infection would be reintroduced during both surgeries.
C. I would need to make an immediate decision and ensure surgery can be booked immediately to gain the benefit of shortening the infection recovery timeline so that I achieve the main goal of minimizing the delay to chemo therapy.
With the information I had as of about February 1st (which would have been the date for my second chemo treatment), both these choices sucked no matter which way I looked at them. There were three other variables that I felt needed further clarity to help me tip the scale between choices.
1. How was my body reacting to the antibiotics and was the infection getting better with each day on the antibiotics?
2. What was the impact of delaying my chemo treatments by days and weeks?
3. Could some of these activities be performed in parallel?
Well the answer to #1 was something I could get immediate feedback on as I could see that the redness of the infection seemed to be getting a little more each day and I felt a little better each day. My plastic surgeon and the infectious disease doctors were both monitoring the progress with regular appointments and they also saw the progress. Getting an answer to #2 and #3 proved to be a little harder to nail down as my oncologist was hard get a hold of and there seemed be a stalemate on "who's on first" (chicken and the egg syndrome). The oncologist wanted to know how the infection was coming along and a go ahead for the plastic surgeon and the infectious disease doctor so that he could plan the next chemo treatment and these two doctors (and me) wanted to know what length of a delay would be the most detrimental to me and my treatment plan and curing the main issue - cancer.
As I was the "piggy in the middle", I was finally able to get coordinating nurse on my side after actually reaching and talking to the radiation oncologist that I will also be dealing with later in the process (I wanted to talk to her as I needed to find out what her view was if I went into radiation, I did not have an expander, but still wanted reconstruction -- I won't belabor this discussions other than to say that there were options, but again, not great. I will expand on them if there is a need to revisit removing the expander). What this coordinating nurse accomplished that I and my oncologist's assistant (the jury is out on her effectiveness to date--I will need to meet her sometime to confirm my opinion of here capabilities) were not able to do was to get an answer to question #2 and question #3.
Answer to #2: It seems that the impact to a delay in chemo of three to six weeks would not be substantial as I have received one treatment and I had the bulk of the treatments yet to complete. I am sure there is some impact, but there is no significant proof/ statistics to the contrary.
Answer to #3: If the infection improved enough (based on the plastic surgeon's and infectious disease doctor's evaluation) in the next two to three weeks, chemo could be resumed concurrently with continued antibiotic treatments. In addition there is a handy dandy drug that could be prescribed that is proven to boost the immune system (specifically the white blood cell count) and does not contravene chemo treatments. This medication could be used in parallel with the chemo and antibiotic treatments. The drug is really expensive (about $200 per injection with 7 injections between every -- and yes it would be another injection, but this time it is a self injection in any major muscle tissue -- not sure how I will manage this since Todd is terrified of needles and I am not sure if I can self inject yet – don’t know how druggies find the nerve to do this. I will cross that bridge once I get to it. I think a strong immune system outweighs this little requirement).
Now I finally fell that I had the pieces of the puzzle together to make a more, but still painful decision. The winner is...
Door #2: The tissue expander stays!
One would think that I would be completely ecstatic about the decision and actually making one, but like everything in this journey, there are risks with every decision. As I preach to any of my project stakeholders that will listen, if there is a known risk at any point in a project and you accept the risk, you will always live the risk at some point in the project or will need to mitigate it in one way or another--- and there is always a cost of some kind. So these are the risks that I am accepting:
1. Three week delay to my chemo treatment – better than anticipated due to the confirmation that we can continue with chemo concurrently with the antibiotics (since the infection seems to be under control, but we want the extra 2 weeks insurance) and the immune boosting meds (Neupogen).
2. Infection may not be completely eradicated – both the Plastic surgeon and the infectious disease doctors are happy with how the infection is clearing up and I feel much better. The “insurance” 2 weeks of antibiotics also makes everyone happy (also based on the fact that I am tolerating the heavy duty antibiotics fairly well so far). The risk is back to original risk of less than 2%. Recurrence is scary since Cellulitis can become much worse than what I experienced – can lead to other parts of your body, can become a continual problem ongoing, can lead to more extensive tissue damage, etc, etc… So I DO NOT WANT A RECURRANCE!!!
3. Surgery to remove expander is still present if the infection comes back – if the infection comes back, I will definitely have the tissue expander removed and will have to live through the other risks I am avoiding through this around.
4. Emotional state – although this is probably a reasonable decision, I will have a medium-high grade of anxiety until I am through with all my treatments. I am mentally trying to manage this fear on a daily basis and most days I win. I will be trying different angels to belay my anxiety so that I don’t get completely paranoid and so that I don’t carry paranoia past the overall journey. I was level headed before and I want to be that and more after this is all over.
Onwards and upwards as they say…. The decision is made and my next chemo appointment has been scheduled for February 23rd at 3:30pm at Surrey Memorial hospital, my antibiotics are still in action with the IV pump that I wear 24/7 (for two more weeks) and the immune boosting meds are on their way (including all the financial coverage that goes with it – I am so fortunately to work for a great company like TELUS that offers a great benefits plan and that we live in a solid socialist society in Canada and BC – I believe we would be re-morgaging our house by now to cover the multitude of costs already incurred and the ones yet to come – I will muse more on this topic on future posts as this is really important for all of us to understand and appreciate as Canadian citizens).
Onto Round #2… finally
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