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My learnings from the pre-treatment phase

It has been nearly one month since I was diagnosed with breast cancer.  Though my journey has only begun, I’ve collected a number of learnings from this pre-treatment phase (pre-diagnosis, testing, and diagnosis) that I share with you below.  I truly hope you and/or your loved ones find benefit from them.

  1. Do self exams:  If you’re a female, do them.  If you’re male, tell all your female loved ones to do them. It doesn’t matter if you or they are 30 or 60 – it can save their life.  Yes, I understand not everyone’s insurance covers MRIs and mammograms, but that is no reason to let a lump go undiscovered.  Many articles say to conduct self exams in the shower, but I recommend trying to (also) do them when lying down with your arm lifted creating a right angle at your shoulder.  My lump was best felt in that position and easily overlooked when standing up.
  2. Healthy paranoia can be your friend:  If you even think there’s a possibility you’ve felt something, act on it.  I knew my lump could easily be pregnancy-related -probabilistically it should have been.  Healthy paranoia, however, drove us to the OB-GYN’s office and eventually to a biopsy.  It was not only a great friend, it may have saved my life.
  3. Be forward-looking:  It’s perfectly fine to be shocked and to cry and to wonder how life can be so unfair.  Soon though, you realize it is more empowering to focus energies towards action.  Figure out what needs to be done and work towards doing it.  As Ash likes to recite – “Hope is not a course of action.”
  4. Emotions come in waves:  You never know when and where what emotion will hit you.  It can vary when sharing the news of your cancer with family and friends – sometimes I cried, sometimes I was very composed and just spoke matter of factly, and sometimes I kept laughing as a socially awkward defense mechanism.  Similarly, emotions will come in waves at the most unexpected time.  Despite only ever planning to have two children, I couldn’t help but cry when the doctor asked me if I’m done having children.  Though I know fertility treatment options are now available for those that want to improve their chances of preserving that ability, the thought that I might lose my fertility and not even have the choice to have more children, triggered an unexpected sense of mourning.
  5. You never know how someone might be able to help you if you don’t open up to them:  We got access to the leading team at Stanford because Ash shared the news with his assistant at work and it just so happened that her godparents are big donors to the breast cancer center and were able to call in a favor.
  6. Compile and retain a copy of all medical reports and imagery:  Collect all relevant medical records from past exams and request copies of the imagery on CD from each hospital’s release of medical information department.  When going to each new test/procedure, request a copy of the report and imagery at that time itself.  It may be given to you in that appointment or mailed to you later, but standard to be provided for you to retain in your personal records.  Carry these records to all doctors/institutions you are seeking opinions from, but never leave behind one of your original copies.  The doctor will be equipped to make a copy and return the original to you.
  7. Take time to find the right locus of care:  Though psychologically, you and your loved ones will want to move to action and get the tumor out as soon as possible, there is longer term value in taking the time to reasonably slow down and do your research to assess the right treatment plan and medical team.  As many doctors reminded us, when it comes to breast cancer, days don’t matter, months do.  Ultimately though, weeks are a grey area so take the necessary time, but be efficient when doing so.
  8. Take control of your own medical fate:  Do your own research, find the doctor with the narrowest and deepest expertise for your specific case / tumor, get a 2nd (maybe 3rd!) opinion, and don’t be shy about asking questions.  One family friend shared the story of her mid-30s friend who was diagnosed with and treated for Stage 1 breast cancer, only to be diagnosed with Stage 4 cancer just 4 months after she finished her treatment.  Perhaps her stage was misdiagnosed from the beginning or perhaps her treatment plan was insufficiently aggressive.  Regardless, multiple opinions and/or increased testing could have given her story a different ending.
  9. Ultimately, however, you have to put your trust somewhere and in someone:  The problem with being over educated and comfortable with data is that it’s easy to get caught up in a never-ending cycle of research and second-guessing.  We reached a point where we were reading and comparing the details of clinical trials to essentially identify our own treatment plan, only to further confuse ourselves since no perfect data exists for what we need to know.  Eventually, the science becomes an art and you have to trust that your medical team is competent and acting in your best interests.
  10. Stay positive and be thankful:  Step back and identify the silver linings in your story.  Recognize what you have to be thankful for, what you have to fight for, and ultimately, what you have to live for.

Having faith

It was Sunday, July 13, the final day before I was to go on the offensive against my cancer.  My sister and her family came over to spend the day with us, and my sister had the lovely idea of all going to the temple/mandir.  We had not yet taken Mira since she was born, Diya LOVES mandirs (big fan of ringing the bell), and what an opportune time to pray and seek strength before I start treatment.

We went to the Jain Center of Northern California – a beautiful marble temple in Milpitas, CA.  It had been years since I’d gone to this particular temple, and I was struck by the beauty of the statues/murthis.  Without a second thought, I walked in, sat down in the front, placed my hands in a namaste position, and began to pray.  By habit, I began saying the Namokar Mantra, the primary mantra in Jainism that conveys respect to liberated souls, spiritual leaders, teachers, and monks to destroy all sins and obstacles.  I say “habit” because for years I have recited the Namokar Mantra every night before going to bed.  For me, it was never about the religious practice, but an opportunity to reflect on the highlights of my day and be grateful by expressing thanks to the greater being that my sense of spirituality believes exist.  I completed my prayers and executed the religious practice led by my mom of offering rice to and requesting blessings from every murthi.

As I finished, it dawned on me that I was expressing thanks and requesting strength and support from the same “God” that gave me cancer to begin with.

Interestingly though, I wasn’t angry.  This realization, however, gave me some perspective on my spirituality and sense of faith.  Perhaps it meant that I didn’t believe that there is a “God” that has entire control of what happens to us and how we deal with it.  Perhaps it means that I think there are some things in life that are inevitable (even out of God’s hands), but that I prefer to believe in a greater being and a greater purpose to help me get through those inevitably challenging times.  Yes, it sucks that I got cancer at the age of 31.  If that was a given to happen though, I’m relatively fortunate.  Multiple doctors have expressed surprise that I even noticed the lump at its current size.  My lump was biopsied in the very short window of time between me feeling the lump and my milk coming in.  The cancer was identified right after the birth of the second child that I had always wanted (side note, however, while I’ve always known I only wanted two children, it is surprising how the potential of fertility loss or early menopause can cause one to mourn the loss of something that they never thought they even wanted).  I’m supported by a number of amazing family and friends.

So, ultimately, why was I praying?  I believe it was because I am approaching this entire battle from a perspective of positivity.  Even in a suboptimal situation, I have a lot for which to be thankful.  I’ve always believed that everything happens for a reason, but sometimes it just takes time (and a rollercoaster of emotions) to realize what that reason is.  I prayed to nourish that positivity and have faith that there’s a greater power out there with a reason in mind.  Only time will tell.

The final test

There was a LOT of debate on whether we should re-biopsy the left lymph node and place a marker in it to track its location in the future.  Different doctors across institutions had different advice:

 

“You should definitely do a core biopsy to confirm if the FNA was correct on the lymph node status.”

“The lymph node status wouldn’t impact the course of treatment leading up to the surgery, so you can just confirm status at that time.”

“Obviously you should place a marker at the location of the suspicious lymph node so that in case it responds fully to the chemo, you can still identify the location of the relevant node at the time of surgery.”

“Placing a marker in the lymph node could actually increase the chance of metastasis because the gel around the marker expands and could rupture the lymph node, displacing the cancer cells and enabling the marker to float to a different location.”

 

Are you serious??  That’s the widest spectrum of advice ever.

We knew from all the imagery that the left lymph node was suspicious, but the PET/CT scan was the first to indicate some enlargement of the right lymph node.  So, we were back at Stanford for one final test before starting chemotherapy.  Dr. T ordered a bilateral ultrasound of the axillary.  Yes, UCSF had just done an ultrasound of the left axillary – Dr. R had emailed indicating she is “no longer concerned about the nodes”.  That was strange given the UCSF radiologist had seemed to indicate there was definitely something suspicious and that Dr. R would likely want to re-biopsy the node.  Since we are no longer working with Dr. R, we never got an understanding of why her perspective had changed.  At Stanford, Dr. W joined the appointment to see the ultrasound imagery compared to the earlier MRI from CPMC, and she and the radiologist agreed the left lymph node is definitely swollen, but not likely malignant.  They attributed the enlargement to the many changes my body has recently endured – I had been providing that explanation all along!  I’m still not sure why they suddenly joined that school of thought given the size of the node had not appeared to shrink over the last couple of weeks, but it meant that they did not want to conduct a biopsy of the left node.  Unexpectedly, however, they decided in the appointment that they want to do an FNA biopsy of the RIGHT node!  Umm…I was never told to be concerned about that node.  Apparently, there was a risk that it could be a second cancer since it was unlikely that the cancer cells from my tumor on the left breast would have floated to the right lymph nodes.  This was clearly troubling, but would not actually impact the planned course of treatment – it would, however, lead to a more concerning prognosis.

Stanford conducted the ultrasound guided lymph node FNA biopsy in a much more hospital-esque way.  The team collected themselves and repeatedly confirmed information as if we were going into surgery.  A cytotechnologist was present in the room to confirm real-time that a sufficient sample size was collected during the biopsy.  I received a call from Dr. W herself later that afternoon – the biopsy was negative.  No cancer in the right lymph node!  Again, the little wins must be celebrated.  Thank goodness for not having to wait through the weekend for those results.

The moment was finally here.  The moment when all the diagnostic testing and research was complete and we were shifting to action.  Treatment was scheduled to start the coming Monday, July 14.  Game on.

Wig shopping

Today was a fun, productive day.  Mom, Dad, Mira, and I went to Stanford’s monthly wig bank, followed by their class on chemotherapy.  While Dad and Mira held back outside the wig bank, Mom and I went to have fun with wig shopping.  It was abundantly clear as soon as we walked in that the volunteers at the wig bank were not certain whether my mom or I was the patient.  Yes, this 31 year old who is often confused with looking like a high school student is in fact the cancer patient.  At one point, one of the cancer patient customers (of your more standard elder woman demographic) asked me what brought me here.  After I shared my diagnosis, she took my hand in hers and wished me all the best, trying to comfort me that all will work itself out.  She herself was now battling her second bout with cancer, but I think she felt more sorry for me than herself.  I was not bothered by the pity, but it was interesting to observe.

There was a limited selection to choose wigs from, but still enough.  The key questions were what length/style and what color hair?  Is this time to go shorter than ever before?  Longer and more glamorous than usual?  Colored hair/highlights since I’ve never had that done to my natural hair?  Mom and I narrowed our choices to three – and then we sent WhatsApp pictures to Dad, Ash, and my sister for input.  Pictures of our final selection are below.  Stay tuned to find out which one we eventually picked! 🙂

Just as we finished up at the wig bank, it was time for Mira’s next feed.  I sat in a chair directly outside of the wig bank and fed Mira her baby bottle.  The lady who had been helping me all along in the wig bank, a cancer patient herself, happened to walk out and see me feeding Mira.  “Is that your baby??”  Oh yes, not only am I 31, but I have a one month old newborn.  She quickly shifted her emotion and expression to commenting on how adorable Mira is, but not fast enough for me to see the pained expression on her face.

It’s OK – I understand the sorrow and the pity.  It’s definitely not a standard situation, nor an easy one.  Doesn’t mean I can’t have fun wig shopping though 🙂

 

New style!

Short hair with bangs!

 

New color??

Long brownish hair with bangs!

New glamour!

Long black hair with bangs!

The path of least regret

A big decision needed to be made. On July 8, it was nearly a month since the original biopsy of the lump, and we needed to shift gears from research and consults to treatment plans and action.  We spent the entire long Fourth of July weekend struggling, both intellectually and psychologically, with the decision of what treatment plan to proceed with and with which doctor.  To add to the chaos, we had multiple unofficial phone or email consults with medical breast oncologists/surgeons from around the nation that our friend network had connected us to, as well as a team from Private Health collecting research to inform our open questions.  While amazing to feel like you have top doctors from around the nation looking at your case, one thing had become very clear:  oncology is much more of an art than a science and there are many ways to treat breast cancer.  If you ask 8 different doctors for their opinion, you will get 8 different answers.

Ultimately, we narrowed our focus to the following decisions:

  • What treatment plan do I want to pursue:  UCSF’s recommendation to do Taxol + Carboplatin followed by AC if the lymph nodes are positive vs. just Taxol + Carboplatin if the lymph nodes are negative vs. Stanford’s recommendation to pursue the more cutting edge treatment plan of CarboGem regardless of lymph node status.  UCSF’s recommendation was based in the “standard care” for TNBCs, but would be highly toxic.  Stanford’s recommendation was based on Dr. T’s belief that CarboGem would be uniquely beneficial for BRCA1+ TNBC, as effective but with lower toxicity (and that we can always switch to higher toxicity if the tumor is not responding)
  • Where do I want to pursue my care:  UCSF vs. Stanford based on comfort with doctors, institution, and environmental/logistical factors

After days of debate and research to answer our open questions, that only resulted in the realization that no clear data exists, I realized my decision came down to one powerful question:  What would be the path of least regret?  Specifically, if the cancer were to recur in 5 years (which it has a higher chance of doing for TNBCs than other forms of breast cancer), what course of action would I least regret?

Using this paradigm, the answer was resoundingly clear – go aggressive.  Regardless of treatment plan, we would be targeting a 100% pCR or pathological complete response (i.e., the tumor disappears through the course of chemo).  The open question, however, is would a 100% pCR in a “standard care” treatment plan result in similar levels of recurrence risk as the CarboGem routine?  Unfortunately, given how relatively new CarboGem is for breast cancer, the history of data is not yet available to answer this question.  Therefore, if I pursue the most aggressive treatment plan now, and still have a recurrence down the road, I can tell myself that I just happen to be part of the ~5% of pCR patients who experience a recurrence.  If I pursue CarboGem and have a recurrence down the road, however, I would always wonder if that recurrence would have still happened if I had just gone aggressive from the beginning.  I would never want myself or my loved ones living with that regret.  The obvious tradeoff is the intensity of the side effects over these coming months of treatment.  My father-in-law once told me, however, “days go by slowly, but years fly by.”  How true that is, and it is in that truth that I find comfort with this decision.

Dr. R had been amazing through this process being responsive to emails and working to setup appointments at UCSF.  At the very end, however, I decided that my proximity to Stanford would be an important factor in reducing the stress level of my weekly treatments.  We checked with Dr. T whether she would be comfortable going with a more “standard care” approach of treatment for my case and she totally understood me not wanting to have any regrets.  After apologizing to Dr. R for any inconvenience and thanking her for her tremendous help, we finalized our treatment plan and locus of care.  An action plan was finally in effect – recovery, here we come!!

A revised definition of “good news”

Amazingly, Stanford was able to squeeze us into an early PET/CT scan appointment on July 3.  It’s the kind of procedure where you lie on your back and get rolled into a massive tube, hoping you don’t suffer from claustrophobia.  There’s no pain or pressure, and goes relatively fast once the scanning begins.  The contrast they injected into my IV for the CT scan resulted in a warm feeling spreading through my body.  It’s hard to explain how awesome it feels to have heat literally generate itself in the core of your body and then just spread everywhere.  As someone who loves sweater wraps and Snuggies, I was in heaven for those brief seconds of warmth.  Unfortunately, all good things come to an end, and I was feeling chilly once again soon after.  The radiologist would be reading the images that day and we expected to receive a response that evening itself on the results.  Ugh…waiting…

We then rushed over to UCSF for an ultrasound of the left armpit that Dr. R had requested.  Yes, this ultrasound had already been done at CPMC and yes the suspicious node in this armpit had already been biopsied to be negative.  That said, Dr. R’s recommended treatment plan was so dependent on the status of the nodes that she understandably wanted more information to triangulate confirmation that the node is in fact negative.  After another frustrating experience in terms of waiting time and the radiologist team not initially understanding what they were supposed to do in this appointment given they had my full medical history showing the past results on this armpit, the imaging was eventually conducted.  The doctor seemed very confident that the left armpit appeared to have 2-3 lymph nodes fused together, again indicating “suspicious activity” and that Dr. R would want to re-biopsy the node.  We would find out whenever Dr. R reviews the imagery. Ugh.  Will the testing ever end??

Later that night we heard the results weren’t ready and we wouldn’t hear back until after the long Fourth of July weekend.  Are you serious – I’m going to spend days waiting to find out if I have Stage 4 cancer?  Unexpectedly though, Dr. T emailed late at night (love it!) indicating the preliminary PET/CT scans showed that the cancer has NOT spread.  YEA!!!  Celebrations were in order.  You know your life has changed dramatically when the definition of “good news” is to find out that you are not dying after all.

 

The rollercoaster continues

We were finally able to meet with Stanford on July 1.  Dr. T was out of the country the week before, so scheduling had been a debacle, but we finally got fit in.  The overall experience was essentially the opposite of UCSF.  The drive down 280 and approaching a suburban hospital was incredibly more relaxing.  Like at UCSF, we also spent an unexpected 3-4 hours at these appointments.  Unlike UCSF where the bulk of that time was waiting, however, at Stanford those hours were efficiently spent meeting with doctors or getting a blood test done.  We first met with Dr. W, a recommended breast surgeon.  She had amazing bed side manner.  Maybe it’s because it’s a teaching institution or maybe it’s just her style, but she very methodically walked us through what’s going on, what the different reports mean, and what the implications are on the treatment options available, as well as patiently responded to my many questions.  She confirmed that based on the reports’ indication of the size of my tumor, the negative lymph node FNA results, and the resulting minimal likelihood the cancer had metastasized, we are dealing with a Stage 1 cancer.  Score!

The medical oncologist, Dr. T, then joined us and they proceeded with the clinical exam.  They did a physical exam of my neck and collarbone area, tapped my vertebraes, and checked my breathing, and confirmed I wasn’t experiencing any symptoms potentially indicating metastasis.  They then did a physical exam of my breasts and armpits.  This is when the appointment took a turn for the worse.  They both had rather serious expressions on their faces.  Upon physical exam, the tumor felt more like it was larger than 2cm – was it really that big (note all the ultrasounds and imagery indicated it to be more like 1.5cm) or was it just swollen from the bruising caused by the biopsies?  More concerning, the physical exam of the left armpit indicated such a “suspicious” texture and shape of the lymph node that Dr. T was compelled to believe the lymph node FNA biopsy was wrong and that the left node was in fact positive for cancer.  WHAT???  Perhaps the FNA didn’t capture enough cells since no cytotechnologist was present at Dr. G’s office at the time of the biopsy.  Perhaps the correct lymph node was never sampled.  All we know, is that the lymph node continues to be suspicious and she felt it’s better to operate under the presumption that it is positive.

Believing the lymph nodes are positive would mean we would definitely do chemo first since observing and measuring the tumor’s and lymph nodes’ reaction to the chemo would provide a better sense of prognosis.  It would also mean there’s a risk that the cancer has already spread and we need to confirm that with a blood draw and PET/CT scan as soon as impossibe.  It would not, however, influence her recommended chemo plan.  Dr. T’s research focuses on TNBC amongst BRCA carriers and she pitched a treatment plan composing of Carboplatin+Gemcitabine for 6, 21 day cycles.  She strongly believed in the effectiveness of this plan and pitched the benefits of its lower toxicity (e.g., no hair loss!).  What we found so exciting is the option to start with CarboGem, observe its impact on the tumor, and switch to a more aggressive treatment (e.g., follow the more “standard of care” plans involving ACT) in a month or so if needed.  While we were bummed to hear about the Stage 2 news, we were uplifted by this cutting edge treatment plan available.  We left Stanford with mixed, roller coaster emotions.  Had the cancer actually spread?  Could a less toxic treatment plan work for me?

The great efficiency of Stanford demonstrated itself that night.  Though we had spoken with Dr. T for hours until 7:30pm, she sent us straight to the lab for the blood draw to assess if there was any impact on the liver, lungs, etc.  She emailed later that night with the results – the blood draw looks good overall, but there’s slight elevation of the alkaline phosphatase level and she recommends a PET/CT scan.  Whoa.  What does “slight elevation” mean?  An immediate PET/CT scan – are we seriously concerned the cancer may have metastasized elsewhere?  How could I have been told I have Stage 1 cancer earlier that evening, to then be wondering if I have Stage 4 cancer just hours later?

Finally – a win!

After weeks of uncertainty, we got the results on June 26 that the lymph node FNA biopsy results were negative – the cancer had not spread to the lymph nodes!

The day before, we received the MRI and mammography results that confirmed there was inflammation in the left lymph node consistent with metastatic disease.  What does that mean?  Does it mean it definitely has cancer cells?  Does it mean it’s inflammated like a cancerous lymph node would be, but we don’t actually know what’s causing the inflammation?  Apparently it was the latter.  The node was “suspicious” – an entirely useless word that provided no clarity on the stage of my cancer and the resulting treatment plan.  Only the biopsy would be able to provide concrete results on the lymph node status.  The MRI was only useful to provide indication of whether there might be a tumor elsewhere in the breasts or something suspicious going on with the node.

Finally, the clarification had been made.  We all had been anxiously awaiting all day for the lymph node FNA biopsy results, but when evening came it was looking more likely that we wouldn’t find out until the next day.  I pinged Dr. G to see if she had heard anything.  First response indicated the lab was closed and she would follow-up tomorrow.  Soon after though, we got another unexpected response saying the pathologist had been working late and the results are in – negative!  The celebration began.  High-fives, hugs, call, text messages, WhatsApp messages were rapidly exchanged with family and friends.  Finally – a win – confirmation that we’re dealing with Stage 1 cancer.  The risk of spread has been minimized and a less toxic treatment plan is on the horizon 🙂  Whoo hoo!!

Who to trust with my medical case?

Though my testing to date had been at CPMC, we heard repeatedly that it is best to go to teaching institutions for these types of cases since they are on the more cutting edge of research.  The main question though, was do we get our care at UCSF or at Stanford?  UCSF has an experienced, leading medical oncologist, Dr. R, who focuses on TNBCs, while Stanford has a less experienced, but well reputed oncologist who specifically focuses on BRCA carriers with TNBCs.  There are so many factors to consider when deciding where to get your care:

  • The breast cancer medical oncologist you’re most comfortable with (critical when doing chemo before surgery)
  • The breast surgeon you’re most comfortable with (likely to be the team quarterback if leading with surgery)
  • The plastic surgeon you prefer (key player if doing a double mastectomy followed by reconstruction)
  • The recommended treatment plan you prefer (levels of aggressiveness vs. toxicity; access to clinical trials)
  • The responsiveness and efficiency of the institution and medical care team (active on email, fast turnaround for testing appointments and results)
  • The logistical dynamic of the institution and how stressful or relaxing you find the ambiance (commute time, parking, hospital’s environment – may sound petty now, but is unnecessary added stress, especially when going in for weekly treatments)

On June 24, we had our consult at UCSF where we first met with breast surgeon Dr. A, then Dr. R.  Logistically, it was a frustrating experience.  What should have been a 1.5 hour appointment across the two doctors, we were at the hospital for four hours – most of which was spent waiting either in the reception area or in the hospital for the doctors to come.  Then there was another ~20 min of waiting time as the valet needed lots of time to bring the car back.  While waiting for the doctors, we never had a good sense of when they might come in – should Ash step out to pick us up some lunch?  Should he cancel the important work calls he had scheduled since the appointment was supposed to have been done by now?  In the end though, we did really like Dr. R.  She came into the room with this large presence that made me like her rather immediately.  We discussed my case and different treatment options – she definitely used terminology just assuming we know what it means, but given the levels of research we had been doing to this point, we were able to follow along quite easily.  Similar to Dr. WW, her suggestion of treatment plan options was also dependent on lymph node status.  While for Dr. WW the status influenced whether surgery first was an option, for Dr. R, chemo first was guaranteed and the question was what combination of drugs to pursue – ACT+Carboplatin if lymph node positive or just Taxol + Carboplatin if lymph node negative.  That’s a two month difference in the duration of the chemo plan and significantly different in the intensity of the side effects.

So once again, it all comes down to the lymph node status.  Sooo frustrating there’s such a delay in getting the procedures done to figure that out!!

 

To wean or not to wean

As I mentioned before, I knew I would eventually have to stop breastfeeding before starting chemo.  Given how much uncertainty there still was in terms of our treatment plan though, I figured I’d still have plenty of time.  There is something psychological, however, about breastfeeding your child when you have breast cancer.  I was repeatedly reassured that it’s medically fine, but I had still shifted to only nursing out of my right side.  I then learned though that I would have to pump and dump for up to 48 hours following the MRI given the contrast agent they would have to inject into me.  While it was earlier than I had expected to wean, I knew it wouldn’t make sense to pump and dump for 48 hours just to nurse out of one boob for a few more days.  So, in parallel to all the discomfort I was enduring with the testing, I now got to add weaning and engorgement to the list.  I was walking around with chilled cabbage leaves in my bra to slow down the milk production.  I was holding ice packs to my chest in the car between appointments.  I was returning home exhausted only to have to start up the pump for a few minutes to relieve the soreness.  Fortunately, my daughter was young enough that she didn’t struggle in her transition to the bottle.  After having nursed my first daughter for over a year, my second daughter would be formula fed.  I am thankful for the two weeks I was able to nurse her for, and believe the nutrients she received during that time were better than none at all.  Many mothers can’t, or choose not to, breastfeed for a variety of reasons, and their formula fed babies turn out just fine.  I know my little darling will as well.