Meeting with the Pulmonologist

Meeting Thursday, March 26, 2015, with Dr. Jaffer, Pulmonologist

In response to "how have you been," Yvonne stated she is having some difficulty breathing deeply / on deep breaths since the biopsy. Dr. J said she had had a pneumothorax, a little bit of air in the lung (or lung lining?) but that was on the left side. He briefly discussed doing another chest x-ray today to see if that had cleared up, then looked at the scan again and said it was really small and wouldn't show up on an x-ray. He didn't really address the pain in her RIGHT side.

Dr said that Yvonne has squamous cell carcinoma, a kind of non-small-cell lung cancer. It doesn't look as though it's spread to other areas of the body, and none of the lymph nodes are showing up ("lighting up," as he said) on the PET scan. He explained that there's a possibility that they're cancerous anyway, but that it's hard to tell, and if he does another biopsy it probably wouldn't change the course of treatment.

There was something "lighting up" near Yvonne's chin on the PET scan. He said this was probably her dental implant or bridge. He briefly examined her mouth and chin and didn't see anything.

Dr. described the results of Yvonne's pulmonary test (breathing test)? from earlier today and said she breathed out 1.29 liters in the first second, which is only 49% of baseline; she has a "significant airway obstruction." He said she must be very tough, and showed us on the scan that she already has some emphysema which is causing this decreased lung function.

Because of this borderline lung function, a "resection" of the lungs would be difficult and he doesn't recommend surgery. "This is pretty complicated."

Dr. describes that pathologically, the masses look like the same thing: they are the same kind of cancer. Whether they are two independent tumors or whether one started first, then became metastatic and moved to create the other one is the big question. He said it makes sense that it is metastatic, but because there's no cancer anywhere else, he's not sure.

Dr. recommends brain MRI to ensure that no cancer has spread to the brain (it wouldn't show up on PET scan). If there are tumors there, that means the cancer has metastasized and Yvonne is in Stage 3a (he earlier said Stage 4 but switched when Nurse Kathy came into the room). If not, there's still no determination of whether the cancer is metastatic, but he wants to proceed as if it is not: aggressively and tackling the tumors in a targeted way. If there are brain tumors, he said, radiation would be "palliative, not curative." If there are no brain tumors, we would wait until another CAT scan was done (probably after chemo, in a few months from now) to see whether the tumors are spreading.

We asked about the side effects of radiation and how long the course might last. Dr. said he's not the expert but maybe 1x / week for 6 weeks? and that main side effects to worry about (given the placement of the tumors) are scarring and fibrosis. With chemo, it's nausea, vomiting, immunosuppression. She would probably be doing a cisplatinum type of chemo. (My medical dictionary says this is "used to treat cancers, especially solid tumor such as testicular and ovarian carcinoma" and also lists renal failure as a possible side effect.)

So: brain MRI, then meeting with radiation oncologist, and meeting with medical oncologist (chemotherapy doctor). Dr. J will discuss this course of action (and the question of not biopsy-ing the lymph nodes) with the "chest conference" team of doctors on Monday morning. Kathy added later that this team includes a pathologist, a radiologist, etc.

We then met Nurse Kathy Millson, the "nurse navigator" for lung cancer at the PeaceHealth Cancer Center. Her job is to coordinate and support lung cancer patients. Dr. J. said "she knows more about cancer than I do." (He mentioned that he usually has her in the room when he has one of these appointments and wasn't sure why he hadn't called her; but she happened to be in the office.)

Kathy reiterated much of what Dr. J had said (she did say it was adinocarcinoma, not squamous, but said they are similar). She explained that she had been working behind the scenes and had helped coordinate the biopsy Yvonne had on Monday, and was central in bringing in Dr. Jensen who apparently performed the biopsy. She said that biopsies on both sides at the same time are "really really risky" but that Dr. Jensen is something of an expert in the field and had "felt confident" that he could do it.

Kathy will work on getting approval (I assume from Medicare) for the brain MRI and appointments with the two oncologists. She thought she could get the MRI scheduled within a week. She gave Yvonne a bunch of information to read.

At one point I asked, and I think this is the bottom line to remember now: "So nothing major is going to change in the next couple of months, it looks like?" and the doctor confirmed that. We just need to take things one step, one day at a time.