The Treatment Plan and the Cardiac Pause

November 19th-20th, 2025. The day we’d been waiting for - meeting the medical oncologist at The Royal Marsden Hospital. This is where the treatment plan gets revealed. This is where we learn the roadmap forward.

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The Royal Marsden

There’s something about walking into The Royal Marsden. This isn’t just any cancer hospital - it’s the cancer hospital. World-renowned. Cutting-edge research. Expert teams. If you’re going to have cancer, this is where you want to be.

Dr. Marina Parton would be leading the charge. Consultant Medical Oncologist specializing in breast cancer. We’d heard excellent things.

Alex (husband) came with me. Two sets of ears are better than one when you’re about to receive a lot of information.

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The PET/CT Scan: Mapping the Whole Body

Before the first oncology appointment, one more crucial scan: PET/CT on November 19th.

This is the big one. The whole-body scan. The one that tells you if cancer has spread beyond the local area.

What it is: PET/CT combines two technologies:

• PET (Positron Emission Tomography) - functional imaging using radioactive tracer that shows metabolically active tissue (cancer lights up because it’s rapidly dividing)
• CT (Computed Tomography) - detailed anatomical imaging showing structure

Together, they create a complete picture: where in the body, and is it cancer?

What it feels like:

Preparation:

• Fasting for 4-6 hours before (affects tracer uptake)
• IV line inserted
• Radioactive tracer injected (fluorodeoxyglucose - FDG, a form of glucose)
• Sit quietly for 45-60 minutes while tracer circulates and concentrates in metabolically active tissues
• Empty bladder before scan (tracer concentrates in urine)

The scan itself:

• Lie on narrow table, arms above head
• Table slowly moves through the scanner (like a large donut)
• Machine makes mechanical sounds but not as loud as MRI
• Takes 20-30 minutes
• Must stay completely still
• Breathe normally except when asked to hold breath briefly
• Not claustrophobic like MRI (more open, and you’re moving through rather than stuck inside)

After:

• Drink lots of water to flush out radioactive tracer
• Avoid close contact with pregnant women/children for a few hours (you’re mildly radioactive)
• Tracer clears naturally within 24 hours

What they’re looking for:

Primary questions:

1. Has cancer spread to distant organs?

   • Bones (most common site for breast cancer metastases)
   • Liver
   • Lungs
   • Brain
   • Other organs

2. Local-regional extent:

   • Complete lymph node mapping (axilla, supraclavicular, internal mammary, etc.)
   • Any unexpected sites of involvement

3. Metabolic activity:

   • How “hot” is the primary tumor? (SUV - standardized uptake value)
   • Which lymph nodes are actively involved?
   • Any suspicious lesions that need investigation

4. Incidental findings:

   • Anything else showing up that needs attention
   • Sometimes finds things unrelated to cancer (heart disease, lung nodules, etc.)

This is the moment of truth: If distant metastases are found, it changes everything - from curative intent to management/control approach.

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The PET/CT Results: The News We Needed

Before we even sat down properly with Dr. Parton at the first oncology appointment, she had news.

The PET/CT scan from November 19th - the results were in…

“No evidence of distant disease.”

Let that sink in.

No cancer in bones. No cancer in liver. No cancer in lungs. No cancer in brain.

The cancer is localized - contained to the right breast and the local lymph nodes (armpit and neck area up to C7 vertebra).

Why This Matters So Much

In cancer staging, the difference between localized disease and metastatic (spread to distant organs) disease is enormous.

Localized disease = Potentially curable
Metastatic disease = Treatable but generally not curable

We’re in the first category. The cancer may be extensive locally (multiple lymph nodes involved), but it hasn’t traveled to distant organs.

This is huge.

What the PET/CT Did Show

Cancer detected:

• Primary tumor in right breast: 23mm, intensely metabolically active (SUV max 15.0) - confirmed malignancy
• Extensive adenopathy (approximately 15 involved lymph nodes):
  • Right axillary nodes (armpit) - levels 1 and 2
  • Right subpectoral nodes (under chest muscle)
  • High-positioned nodes above the axillary vessels
  • Right lower posterior cervical nodes (lower neck) extending up to C7 vertebral level

Translation: The cancer has spread through the local lymph node drainage system, traveling from the breast through the armpit and up into the lower neck. About 15 nodes total are involved. But it’s all stayed within this anatomically connected regional system. It hasn’t jumped to distant organs.

This extensive lymph node involvement is why the surgeon would later refer us to the neck specialist - we need precise mapping of exactly which nodes are involved, up to what level, for optimal treatment planning.

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The Treatment Plan Unveiled

With the PET/CT confirming localized disease, Dr. Parton outlined the battle plan.

The Strategy: NACT

Neoadjuvant Chemotherapy - chemotherapy BEFORE surgery.

Why this approach?

1. Shrink the tumor - make surgery less extensive
2. Treat it early - address any microscopic cancer cells throughout the body
3. Test in real-time - see how well the cancer responds to treatment
4. Best chance of pCR - pathological Complete Response

The Regimen (As Initially Proposed)

Phase 1: Dose-Dense EC

• E = Epirubicin (anthracycline chemotherapy)
• C = Cyclophosphamide
• 4 cycles, given every 2 weeks
• Duration: 8 weeks

Phase 2: Weekly Taxol

• Paclitaxel (taxane chemotherapy)
• Weekly infusions for 12 weeks

Throughout: Phesgo

• Pertuzumab + Trastuzumab (HER2-targeted therapy)
• Subcutaneous injection
• Starts with chemo, continues for about a year
• This is the targeted therapy specifically for HER2-positive cancers

Then: Surgery

• Remove any remaining tissue
• Examine under microscope
• This is the pCR moment - are there any cancer cells left?

Finally: Radiotherapy

• Post-operative radiation
• Standard protocol

The Goal: pCR

Dr. Parton was clear about the target.

pCR = Pathological Complete Response

When the surgeon removes the tissue after all the chemotherapy and they examine it under the microscope: no cancer cells found. Not in the breast. Not in the lymph nodes. Complete response.

Why we’re aiming for this:

• Best possible outcome
• Associated with excellent long-term survival
• Dramatically reduces recurrence risk
• For HER2-positive cancers with modern treatment: 70-80% achieve pCR

That’s not a pipe dream. That’s a realistic, highly achievable goal with this treatment combination.

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The Unexpected Finding

But then came the complication.

While the PET/CT scan was looking for cancer, it showed something else:

“Heavy coronary artery calcification for age.”

Translation: Significant calcium deposits in the heart’s blood vessels - particularly in the LAD (left anterior descending artery), one of the heart’s main vessels. The report also noted calcification on the aortic valve.

This degree of calcification is unusual for a 48-year-old - that’s what “for age” means in medical speak. It suggests underlying coronary artery disease - cholesterol buildup in the blood vessels that supply the heart.

I have a cardiac murmur - have known about it for 20+ years. But it was always described as benign, nothing to worry about, never really investigated.

And I have high cholesterol - cholesterol over 11 at one point, fifteen years ago. Started statins briefly but stopped for some reason I couldn’t even remember.

Now, seeing this on the cancer staging scan, suddenly my heart health became relevant to my cancer treatment.

Why This Matters for Chemotherapy

Epirubicin - the “E” in EC chemotherapy - is an anthracycline.

Anthracyclines are incredibly effective against cancer. They’re part of the standard treatment for many cancers, including HER2-positive breast cancer.

But they’re also cardiotoxic. They can damage the heart muscle. The risk is higher if you already have heart disease.

And Phesgo (the HER2-targeted therapy) can also affect heart function, though usually reversibly.

So here’s the dilemma:

• The best treatment for the cancer (with anthracyclines) poses risk to the heart
• There’s an alternative regimen (without anthracyclines) that’s safer for the heart but has more side effects and potentially less effective

Dr. Parton’s preference: Give the anthracycline-based treatment (EC followed by Taxol). It’s more effective, fewer overall side effects, two different types of chemotherapy working together.

But: We need to know if it’s safe first.

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The Urgent Referral

Dr. Parton made an immediate decision.

“I’m making an urgent referral to Dr. Alex Lyon at Royal Brompton Hospital. He’s a cardiac oncologist - specializes in heart issues in cancer patients.”

URGENT PRIVATE REFERRAL - marked with that designation.

The letter she sent explained the situation:

• 48-year-old woman
• Extensive but localized HER2-positive breast cancer
• Should respond well to treatment based on cancer type
• BUT: Cardiac murmur, untreated high cholesterol, significant coronary calcification
• Need urgent assessment: Can we safely give anthracycline-based chemotherapy?

Two treatment options laid out for the cardiologist:

Option 1 (Preferred):

• EC x4 cycles → Weekly Taxol x12 + Phesgo
• Most effective, fewer side effects
• BUT requires heart to tolerate anthracyclines

Option 2 (Cardiac-Sparing):

• TCHP: Weekly Carboplatin + Taxol with Phesgo
• Avoids anthracyclines
• BUT Dr. Parton noted it causes more neuropathy and diarrhea

The question for cardiology: Which regimen is safest?

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The Emotional Whiplash

In the space of one consultation, we experienced:

The High: No distant disease! Cancer is localized! Highly treatable! Clear path forward! Goal of pCR is realistic!

The Low: Can’t start treatment yet. Heart problem. Need more tests. Don’t know if we can use the best chemotherapy regimen. Treatment delayed.

Target start date: December 12th, 2025

But: Only if cardiology clears us. Only if the heart can handle it.

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What Happens Next

Immediate actions:

1. Cardiology appointment - Dr. Lyon, Royal Brompton Hospital
2. Cardiac testing - full workup of heart health
3. Neck ultrasound referral - specialist neck radiologist to precisely map lymph nodes extending to C7 (from PET/CT findings)
4. Genetics referral - also arranged with Dr. Zoe Kemp (due to young age at diagnosis)
5. Pre-treatment prep - Port-a-Cath arrangement, baseline tests

Waiting on:

• Cardiac assessment and clearance
• Neck lymph node mapping
• Final decision on which chemotherapy regimen
• Complete pre-treatment workup

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The Genetic Testing Angle

Dr. Parton also referred us for genetic testing.

Why? Because I’m only 48. Breast cancer at this age raises the question: could there be a hereditary genetic factor?

Testing for genes like BRCA1, BRCA2, and others that increase breast cancer risk.

If positive:

• Explains why I got cancer
• Informs future cancer risk
• Important for family members
• May influence treatment decisions (PARP inhibitors if BRCA positive)

Another appointment. Another test. Another waiting period.

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Processing the Mixed News

The good news is genuinely good:

• Localized disease means potentially curable
• HER2-positive with modern treatment means excellent pCR rates
• Royal Marsden expertise means world-class care
• Clear treatment plan exists

The frustrating news is frustrating:

• Can’t start treatment yet
• Heart complication we didn’t know about
• Uncertainty about which regimen we’ll get
• More tests, more appointments, more waiting

But here’s what I held onto: We have a plan. Even if that plan now includes a cardiac detour, we know where we’re heading.

The goal is pCR. The path is chemotherapy (in some form), then surgery, then radiation.

We just need my heart to cooperate so we can get started.

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The Week Ahead

Next steps:

• Phone consultation with Dr. Lyon (Cardiology) - scheduled for November 23rd
• Cardiac testing (echo, CT coronary angiogram, blood tests)
• Genetics consultation
• Wait for clearance

Timeline pressure: Every day of delay feels like the cancer gets another day. But rushing into treatment that could damage the heart isn’t the answer either.

Trust the experts. They’re coordinating care across specialties. This is what world-class cancer care looks like - considering the whole person, not just the tumor.

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Date: 19-20 November 2025
PET/CT Scan: November 19, 2025 - Whole-body staging scan
Oncology Consultation: November 20, 2025 - Royal Marsden Hospital, London
Oncologist: Dr. Marina Parton
Excellent News: PET/CT shows no distant disease - cancer is localized
Local Disease Extent: Extensive lymph nodes (axilla, subpectoral, lower neck to C7)
Treatment Plan: NACT with goal of pCR (regimen pending cardiac clearance)
Incidental Finding: Coronary calcification on PET/CT
Referrals Made:

• Urgent cardiology referral (Dr. Lyon, Royal Brompton Hospital)
• Neck specialist referral (detailed lymph node mapping)
• Genetics referral (Dr. Kemp)
  Target Treatment Start: 12 December 2025 (pending cardiac clearance)