I got my pathology report back sooner than expected and was able to speak with my colorectal oncologist, Dr. Cannon, about it. After cutting the tumor (and my rectum, and the surrounding tissue) out of my body, it was sent to pathology for detailed analysis. 

Here’s what the report came back with:

1. Clear margins. The closest cancer cell was 0.5 cm from the edge of what was removed—meaning my surgeon got the entire tumor out with clear and negative margins.
2. Thirty seven negative lymph nodes. In colorectal cancer surgery, examining at least 12 lymph nodes is the standard benchmark. In my case, more than three times as many were removed and examined and there was no cancer seen in any.*
3. Lymphatic / Vascular invasion not identified. (No cancer seen invading lymphatic or blood vessels.)* 
4. Perineural invasion not identified. (No cancer cells seen growing in, around, or along nerves.)*
5. No tumor deposits identified in the surrounding tissue.
6. Tumor budding score: Low (0-4). I had one. (A tumor bud is a cell or small cluster of cells that have separated from the main tumor. Higher tumor budding is associated with a greater risk of local invasion, lymph node involvement, and distant spread.)
7. The remaining tumor extended into, but not through, the muscular wall of my rectum.
8. Post-surgical staging: ypT2N0. (y = staging after treatment, p = pathologic staging based on examination of the surgically removed tissue under a microscope, T2 = the remaining tumor extended into but not through the muscular wall, N0 = no cancer found in the lymph nodes.) This corresponds to yp Stage I cancer (pathologic Stage I after treatment). Before treatment, my clinical stage was Stage IIIB cancer: cT3N1M0.

*Why do these matter? Because lymphatic and blood vessels are pathways cancer cells can use to move beyond the original tumor. Cancer cells can also invade or track along nerves.

I also want to mention that, according to the operation report, one of the first things my surgeon did with the robot was look at my liver—the most common site of distant metastasis for colorectal cancer. The report says, “The liver appeared normal and no abnormalities were seen.” I appreciated that detail. For what it’s worth, my CT scan in January didn’t show anything there either.

The plan:

Since I’ve been following the PROSPECT trial protocol, Dr. Cannon would like me to do another six rounds of chemo—which he had told me to plan on doing. In PROSPECT, patients in the FOLFOX arm received six cycles of preoperative FOLFOX, and another six cycles of postoperative FOLFOX were suggested but not mandated. 

I’m a bit bummed about having to do another six rounds of chemo, but I have been expecting it all along so the blow didn’t hit too hard.

That said, Dr. Cannon’s not going to include any oxaliplatin in any of the rounds. As he said, “You don’t have neuropathy and I don’t want to give it to you.” There are other clinical reasons behind him making that decision as well, but in addition to not getting cancer again I would also like to not get neuropathy. That’d be a major hit to quality of life and I’m already getting enough of those.

Dr. Cannon also said that oxaliplatin accounts for 80% of the side effects of FOLFOX so these six rounds should be much easier than the last. I think that’s an astoundingly high number so I’m going to make my mindset “This will be half as bad.” Though, perhaps I should make my mindset, “We’ll just see what happens.”

The side effects and risks from the 5-FU I’ll be getting include:

• Fatigue (which hit me hard)
• Nausea (which also hit me hard)
• Other GI issues which may be exacerbated by—or difficult to distinguish from—my LAR surgery
• Mouth sores/mucositis (which set in for me mildly in round five last time)
• Hand/foot syndrome (didn’t get it the first time around)
• Blood count suppression (mine dropped but stayed safe through all six rounds last time)
• Skin/nail changes (was mild last time)
• Cardiac toxicity (yay chemo… good thing I’m already getting quarterly echo’s because of the cardiac toxicity risks of the Herceptin for breast cancer!)

Because we’re removing oxaliplatin, I won’t have the oxaliplatin-induced cold sensitivity or continue accumulating oxaliplatin-related neuropathy risk.

Dr. Cannon did give me the option of doing these next six rounds with a pill (capecitabine/Xeloda) instead of a pump (Sir Spits a Lot), but the pill may cause a higher likelihood of diarrhea and hand/foot syndrome. I declined and decided to do another six rounds with the devil I know. If I’m going into battle again I prefer to do it against a known (and now weaker) enemy. 

When we start:

Dr. Cannon’s going to give me a whopping five weeks and six days to recover from LAR surgery and I’ll start chemo again on September 7. I’ll be done by Thanksgiving, if I don’t miss any rounds for any reason.

What happens after that:

The plan is I’ll move to surveillance for the rectal cancer, with Dr. Cannon. That will involve two CT scans a year and quarterly appointments with him for the first two years, when recurrence risk is highest, then one CT scan and two meetings with him per year for three years, when the risk of recurrence continues to decline. We’ll do Signatera draws and other blood work all along, which can help detect recurrence earlier.

I’m not yet sure what my surgeon’s surveillance plan will be (she’ll do my colonoscopies), but I meet with her for a post-op next week so I should learn more then.

On the breast cancer side, I’m still on track to continue Herceptin through March 2027 and will at some point go on endocrine (hormone-blocking) therapy—type TBD—for five years. I meet with my breast oncologist this week and will learn more as the colorectal plan has now been set.

How I’m feeling:

Primarily? Relieved. There’s still a lot of treatment and treatment time ahead but the big stuff is now behind me… you know, once I recover from this major abdominal surgery and re-learning how my entire digestive function works. 

Honestly I’m also scared. In the meeting with Dr. Cannon I noticed a familiar thought pattern that went like this, “What am I going to do when this is over? I need to get a job, like, now!” After the thought I felt panicked. Memories of last fall—and from even back in my marriage during all those years where I felt like I wasn’t working or contributing enough—came flooding back. It’s taken a couple days to talk myself down from that and re-orient to what’s important now.

Finally, I am so grateful. My team is incredible. I am so lucky to have them all. 

And, as I’ve told my closest friends and family, I promise I will also sit with the fact that so much of this success is actually my doing. I did this too.

 

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