The A-Team

Professor Carol-Ann Benn explains why you don’t start your breast cancer mission until your personalised oncology plan has been formulated by The A-Team.

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Who hasn’t watched the movie or seen the series? That group of army dudes with diverse personalities that save the day. From Face (I can think of a few of those gorgeous guys and gals in the unit) and Howling Mad Murdock (yup know those) to B.A. Baracus (definitely sounds like a surgical trait) and of course ‘Kernel’ (Colonel) Hannibal. Sometimes when running the unit, I think the nut reference is more appropriate. However, keeping the teams rolling with attention to protocols and function is critical in any mission when cancer is involved.

Remember when you’re diagnosed with a breast cancer, don’t start your mission (treatment) until your personalised oncology plan has been formulated by The A-Team.

Preparing for a suspected mission

Before going on any mission, you need to have your travel kit (luggage), passport and visa. Whether you’ve felt a lump, have pain or nipple discharge, or going for your screening mammogram, your passport is the review of your clinical and radiology by a specialist review team. 

Too often I see women who have a mass; the mammogram and ultrasound aren’t done by a specialised radiologist or there is no review (passport) or visa (if you have a mass and no biopsy, you should have a minimum of a three-month follow-up ultrasound). Remember you pay for these. 

If you need a biopsy, breathe, there is no emergency here. Find out the cost, the type of biopsy and whether it’s covered by your medical aid. Don’t go for a surgical biopsy and know that you can attend a state unit to undergo a review and biopsy for a fraction of the cost.

The mission becomes official

The biopsy has come back as a breast cancer; this just means you need to go on a mission. To understand where you’re going and what obstacles need to be conquered, the biopsy needs to be analysed so that we know the biological type of the breast cancer. Is it a luminal A or B? HER2-enriched or triple-negative? All of these have subtypes too. That and the stage determine how we treat and with what (in other words what the mission will entail). So, how is this determined? 

Well after a clinical assessment, there should be a meeting of the clinical team. This is a bit like what I imagine the war room is in movies. The advent of COVID has resulted in this meeting being virtual and guess what? It’s now better because the clever techies can record it, more specialists can attend, and guest specialists who don’t have access to good multi-disciplinary meetings can attend too. All in all, the doctors have progressed from pagers to tech, and now Colonel Hannibal, you’re playing in the matrix. A plus is this is better for patient care.

War room discussion

What happens in the war room? In our unit, at least 45 people are involved looking out for you before you start your mission. Who sits in the virtual war room? Please insist you know this. 

In our unit, at least four radiology units; four pathology units; three surgeons (Marines); four radiation specialists (Navy SEALs); nine medical oncologists (Navy SEALs); two IT specialists; 10 navigators; five admin peeps; a survivorship specialist; complementary health specialists; palliative care specialists; geneticists; psycho-oncologists and health and beauty techs.

The clinical team doing the work on the ground are surgeons and reconstructive surgeons (Marines) and medical and radiation oncologists (Navy SEALs).

Don’t forget the tech team (specialist breast radiologists and pathologists). Those that are in the van talking through the coms, explaining where the dangers are.

The important ground team doing the behind the scenes essentials to make the ghostbusting successful (critical for any covert op) are the allied health specialists and complementary health specialists.

Planning the covert op

We discuss you, the patient, and help plan your mission. How is this done? Well, the first important information you should know is that you’re anonymised. This is ensured by the IT team; thus, protecting your identity on your mission. 

Important information is provided by the tech team as to what your journey map should look like and what surveillance you’ll need. This is a very detailed assessment and often requires requests for reviews. This is the most important assessment and may take about a week. You mustn’t be concerned that this time will jeopardise your mission. Rather, it provides you with the security that you’ll be sent in the right direction to ensure a successful mission.

Each hurdle in the mission is discussed. Surgery, oncology, radiation, survivorship, genetic profiling options of your tumour, as well as any complex issues that need special intel. Each week every part of your mission is supervised by the behind the scenes ground team (navigators). 

The ground team

Who are these important peeps that are critical to successful mission accomplishment? Firstly, they listen to all the options that the Marines and Navy SEALs give when the tech team presents your radiology and pathology. Secondly, they relay feedback to you. This is to ensure that the Marines don’t say our way is best, let’s go by land; and the SEALs don’t say let’s go by air or sea only. They help to make what is a frightening mission for you more manageable. 

In our unit, we have radiology navigators that ensure your tests are booked and reviewed, and that you’re given feedback. There is a navigator to book your surgery and any specialist tests you need, to mark where the cancer is.

Another navigator is there to help with finances, medical aids and register your oncology benefit. There is a techie for managing holistic and complementary health; your physical needs from massage to what you should put on your nails and face during treatment, as well as that very concerning issue: your hair.

Another manages your diet during your mission (rat packs and special meals) and we have an oncology navigator to help with all your concerns around oncology treatment, including helping select the best Navy SEAL that will suit you and ensure that you’re successful. She has a clever code: red, yellow or green system that helps assess what your changing needs are.  

An important techie is the one who helps with fertility; age specific navigation; co-ordination with geneticists, psycho-oncologists, nutritionist; hyperbaric or unusual treatment referrals, such as cryo-surgery; complementary navigation referral; gynae assessments; palliative care and the list goes on. She acts as a point man along the journey.

Which A-team member do you see first?

The usual starting point before a successful mission requires a map for the mission. This is provided by the radiologist, the techie in the van who should be in contact with you all the time, making sure they are mic’d up and in contact with you on your mission, providing intel about where you are and how you are doing.  

Mapping out the battlefield

Starting the mission requires a map and may involve you needing a mammogram, an ultrasound (high-tech binocs), an MRI (the Google map), and sometimes repeat ultrasounds to double-check something seen on the Google map. 

You may require markers to demonstrate strategic areas of concern, such as V-markers, Magseed dyes or traces, into areas of the breast or lymph nodes. Unfortunately, most missions have some mapping hiccoughs. 

This is why visualising the mammograms, ultrasound, MRI in the multi-disciplinary meeting (war room) is essential. 

We sometimes have a cheat code and that is a biovision (real-time radiology machine in theatre). This amazing machine, standing in the corner of our theatre, allows the areas removed to be analysed at fast real-time to assess the correct area and the presence of markers. 

Spotting any obstacles

The mission always revolves around pathology (the issue is always tissue) and the biology of the tissue obtained from the core biopsy will determine what obstacles (treatments) you will need to deal with on your mission. And remember your mission will be different from the next person’s. 

The pathologist is your eye in the sky; that clever visual drone that is critical to a successful mission. Without the level of detail seen by the pathologist, you can’t know what the right mission or outcome is.

So, no, there is no specific order as different missions require different teams and starting points. They all need the war room though (meeting of minds), even though they may come from different disciplines (sea, sky and land). Remember, some missions will require a sea-start, others land and some sky.

Land-start mission

With changes in our ability to start the kill process with all cancers, we can prove the concept of a successful mission. If you’ve a land-start mission, this doesn’t mean you won’t need the Navy SEALs (they are my favourite, all books have a hot Navy SEAL that saves the day). The land-start is surgery. We are really the basic troop. So, who starts with surgery first? Generally, if the cancer is lazy (luminal A and B) with the important T&C of it not being in the glands (lymph nodes). Rarely lazy triple negatives. All decisions are made in the war room prior to starting surgery.

Sea-start mission

When do you start with the Navy SEALs? Well today almost all awake cancers (invasive cancers) and some sleeping cancers (DCIS) can start with some form of SEAL assistance, even to just give you time to plan aspects of your mission so that it doesn’t completely mess up your day-to-day life. 

The pandemic has resulted in oncology teams becoming more flexible and realising that sometimes slowly at the start of the mission isn’t necessarily detrimental to the mission.

SEALs often start with a variety of oncology drugs from hormonal to targeted and cytotoxic (chemotherapy). Remember, although you’re the most important part of the mission (the mission is to save you), sometimes this may involve some scary rescue tactics (diving out of planes and freezing cold swims (chemo)). Nonetheless, you will get through it because the behind the scenes ground team (navigators) will talk you through the scary parts of the mission, and the Navy SEALs know their stuff. They have many different weapons that they understand how to use, as well as new developments in their weaponry all the time.

Whenever there is a hiccup on your mission; your mission plan is reviewed again in the war room, and guess what? You can request this too, as well as options of changing SEAL teams or Marines. 

As the nutty ‘kernel’, I can ensure you, “We love it when a plan comes together”, and our aim is mission accomplished.