Life is Just a Bottle of Wine

I am starting to sound morbid.

Really, I am not at death's door by any stretch of the imagination, but you might think that by reading my last few posts.  I am not so depressed that I am sitting in a lump in a closet waiting for the world to cave in.  Really.

And -  I am certainly not suicidal.  Quite the opposite!

When one is melancholic....one gets therapeutic and writes.  That's been my modus operandi throughout my life.

It's no different now that I have had another monkey wrench thrown into the works.  I write when I am feeling down or confused.  I actually advise my own patients to do this....because it does help.

 It also provides amusement when I am feeling better.  You see, you can look back and realize things weren't so bad after all.

My doc phoned me up on Monday last and we had a 30 minute conversation about everything that had gone on this summer.   Very good of him to do so.   He did it because he wanted to connect - because he felt that it was difficult for me not to have ongoing contact with the MD that did the surgery.

I thought that was very commendable of him. It momentarily made me feel better.

I sent him a recent photo of what the scar looked like and he in turn sent me a photo of the scar as he saw it at my first post op visit.   He reassured me about the pigmentation and thought it was a result of the surgery and also thought that some of it was already there.

I will still monitor it - and that is what he advises also.

He also advises monitoring my lymph for lumps, because that is the only way I am going to know if there is metastases.

Each year that passes, I will celebrate with a bottle of wine that I had made and specially labelled.

I believe I will get to polish off all of them!

Meanwhile, here are the photos my Doc and I exchanged:

What a difference 3 1/2 months make!

Victim of Summer

Remember my cousin I mentioned that was diagnosed with lung cancer mid August this year?  She passed away early morning November 1st.

That was quick.   She had been visiting with me at our house just a month before she passed while trying alternative medicine nearby.

She was able to meet her brand new grandson just 12 days before she passed if that's any comfort. She even looked pretty good on the photos they posted on Facebook of that special occasion.

So I started thinking again about the Sentinel Lymph Node biopsy (SNLB) that wasn't done, and the "whys" and "wherefores" of the whole summer Melanoma debacle.

I finally got the nerve up after my visit with my Dermatologist to email  #3 Plastic surgeon and ask what he would have done had he not been on vacation and had done my surgery.   The dermatologist had told me that had I gone to the #2 Plastic surgeon first, he would have done the SLNBx  prior to the excision.  #3 Plastic surgeon#3 emailed back immediately and told me the same thing.

Now, I have no other option.   The lymph flow has been interrupted with the wide excision and extensive reconstruction on the left side of my face.

I wondered - why the decision to go ahead and do the surgery then?  Perhaps an answer would help assuage my mental discomfiture.


I emailed the original Plastic surgeon #1 that did my excision and asked him.  Here is his reply:

Hi CC,

I just saw your message on facebook and got your email.

It’s great to hear from you, I had been meaning to give you a call and see how you are doing.  I’ll write some thoughts here in this email and maybe tomorrow you can give me a call here in Saskatoon, my number is XXX-XXX-XXXX.

The information you received from Dr. Plastics#2, Dr. Dermatologist and Dr. Plastics#3 is correct, for your depth of melanoma (2.3mm intermediate thickness) a SLNB is recommended.

I was aware of this recommendation as well and attempted to refer you to a surgeon either plastic or general to provide this service as I don’t do the procedure myself.  Referrals were sent to the Cancer care group in Abbotsford and we got a rather impolite response from them saying they would only see you after excision.  Referrals were then sent to Dr. Dermatologist, Dr. Plastics#2 and Dr. Plastics#4 and again we were getting no active response.  I spoke with Dr. Plastics#2’s office and they let me know he was away and had me direct the consult to Dr. Plastics#5 in the same office which I did.

Time was passing and your melanoma was not being treated, I had not received any definitive plan or response from my referrals and it became a situation for me to make a decision of whether we should continue to wait longer or go ahead and remove the tumor and leave the decision to carry out a SLNB after excision up to the surgeons I mentioned above.  The data that we have (and is again shown in the study you mentioned) shows there is no overall survival benefit to SLNB.  There is, however,  overall disease-free survival benefit to doing a SLNB vs not.  The overall disease free survival benefit at 10 years is 71% vs 65% to observation.

So my thought process at the time was weighing the risk of making you wait longer to remove your melanoma, this time frame I had no idea how long it would take probably in weeks to months given the availability of the surgeons in the region I was trying to refer you to, versus getting your melanoma out to put a stop to the risk of metastasis.  Was this the right decision? I believe it was.  It’s easy for the surgeons you have spoken with now to say “yes you should have had a sentinel node” and I completely agree with them, but would they say the same thing if the question was should you wait and extra 4/6/8 or more weeks with an aggressive melanoma growing on your face during that time to be able to have the sentinel node procedure.  I felt the risk of the melanoma spreading deeper or going to you lymph nodes during that extra amount of time was a major concern.  If I would have had an immediate response from my referrals I would have certainly sent you to have to node biopsy without question with reconstruction by their group or by myself.

During this time you and I were in contact frequently it was clear that the urgency of tumor removal was concerning you significantly and rightly so.  It is a very real possibility that should you have waited to get the node biopsy and then excision, your tumor thickness could have been much greater, mets could have went to your lymph nodes during that delayed time rather than having the lesion removed to stop this process completely.  I believed and still do believe that a 6% difference in overall disease free survival at 10 years wasn’t worth the risk of making you wait an undetermined amount of time to have your melanoma excised.

I hope this explains the situation from my perspective.  I was truly concerned about about the spread of the lesion and did my best to treat you.

You mentioned in your email that they told you they cannot do a neck dissection and I believe you are referring to if you had a positive sentinel node then they would have done a full node dissection. I just want to clarify that you certainly can and will have a full neck dissection should you have a recurrence ie. feel a lump in your neck.  You should have a physician examine your neck regularly and check for yourself.

I will speak to my colleagues here in Saskatoon regarding your situation and if they have any recommendations.  There are patients who have SLNB after wide local excision even though the drainage patterns may have been altered.  There is also evidence (have a look on pubmed) to support this and is why I still wanted you to get in to see someone who could offer you this.  The decision to perform a SLNB after excision is surgeon dependent and some may recommend just going ahead with a full node dissection which may be of interest to you.  This procedure does have risks and isn’t something to do without a lot of consideration especially since the decision would be to have it with no clinical recurrence noted.   If the fact of not currently knowing your node status is really bothering you and this is something you would like to explore I will do everything I can to help you make that decision and get you into see someone who will offer you this procedure.

Sorry for the long email and I hope this helps.  Please give me a call and we can discuss things personally and feel free to contact me anytime by phone or email.


Sincerely,

Plastics #1

So now the dilemma.

Not many therapeutic options exist for melanoma as no regimen prolongs survival. Surgery is the only proven treatment for melanoma.

I have to think on this awhile.  A decision to have a full node dissection is not one to be done frivolously.   That is, if I could even find an MD that would even attempt it.

Meanwhile, I am going to go to counseling to deal with this and I am avoiding my GP's suggestion to start on other medication for the anxiety I get from all this trauma and drama.  (She actually approves of me trying alternatives first. She isn't a pill pusher)

It's not good being an RN while dealing with this.  We know what the facts are, we know what we are supposed to do, who to contact, where to get support and we know our knowledge should assist us in coping.....after all, doesn't it help our own patients?

Or does it?

I am questioning the validity of my whole career at this point.