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The cancer is gone. Her surgery went well and she was at home recovering, drinking a cup of aromatic coffee while sitting in her favorite wicker chair amongst her treasured plants, beneath a canopy of leaves, basking in the sunlight of her special room.
She was relieved to have the surgery behind her and was eager to move on to the next stage of her treatment. But there was this “thing” that she had discussed with her surgeon; this “thing” called “margins.” The surgeon thought her “margins” looked negative during surgery, but the report from the pathologist, that doctor who does the biopsy and looks at the cancer under the microscope, spoke of “ink on tumor.”
At her first visit with the surgeon, she was told that her cancer would need to be removed with a rim of healthy tissue surrounding the cancer and only then could we be assured that no large amount of cancer was remaining in her breast. Still, the truth is that there is always some cancer remaining in the breast. Radiation therapy can be used to treat these nasty cancer cells that have spread away from the main tumor, but only if this is a small amount of cancer cells. When a large amount of cancer cells remain, radiation therapy is ineffective and the risk of recurrence is too high.
When the surgeon removes the tumor, the tumor is sent to the pathologist, who will first paint ink on the tumor. This ink lets the pathologist know where the cut or “surgical” margin is located. If there is healthy breast tissue between the ink and the cancer, then there is not a large amount of cancer cells remaining in the breast and the small amount that remains will respond to radiation therapy. However, if there is “ink on tumor,” then there is a risk that a large amount of cancer cells remain in the breast and the risk of recurrence will be high. More breast tissue will need to be excised and a return trip to the operating room is in order.
Surgeons and radiation oncologists have always argued about what amount of normal, healthy breast tissue needs to exist between the ink and the cancer so that we can be as assured as possible that only a small amount breast cancer cells remain in the breast. Much as Abraham asked God, is 5mm enough? Is 2mm enough? Is 1mm enough? Is “no tumor on ink” enough? A recent review of studies by a committee of breast surgical oncologists and radiation oncologists concluded that “no tumor on ink” is all that is needed to ensure that only a small amount of breast cancer cells remain in the breast, an amount that can be treated with radiation therapy.
Our lady returned to the operating room and had some more breast tissue removed by her surgeon. Some more breast cancer cells were identified by the pathologist but the new surgical margin had “no tumor on ink.” Once she healed from surgery, she received radiation therapy to kill those few remaining breast cancer cells in her breast and lived happily ever after. The end.
