And the Answer Is In

The phone rang promptly at 8 a.m. this morning and, still clad in my pajamas and robe, I noted the caller ID on the screen and knew the answer I’d been waiting for was on the other end of the line.

I let the phone ring a third time so I could acknowledge the moment I was in.  The next moment, when I picked up the phone, would change my future one way or the other.

Mercifully, the answer I got from the genetic counselor was the one I’d been hoping for.

Of the 17 genes tested from my blood sample, none showed a mutation related to breast cancer.  Not BRCA 1 or 2, not PALB2, not BRIP1, nor any of the remaining genes, too many to be named here, that increase the risk.

If you saw me today, you might have said that I stood a little straighter, breathed a little deeper, and felt a little lighter.  You often don’t realize how heavy a burden is until you can put it down.

 

Waiting for a Phone Call

 

phoneNext Thursday morning, at precisely 8 a.m., I will find out the next step in my ongoing journey in Cancerland, a place you can never really leave once you arrive. That is the time I have set aside for a phone call from the genetic counselor I met with before Christmas. This will be the third conversation I’ve had with the counselor, but this is the critical one because it determines what I do next: fall back into the web of anxiety and ongoing medical procedures, or take one very deep, free breath.

My first conversation with the genetic counselor was about 5 years ago, after I completed treatment for breast cancer. My oncologist suggested that I consider getting a genetic test to determine whether the cancer I had was related to a mutation in either of the two most popular genes that cause it. (I say “most popular” because, as geneticists are discovering, there are other genes involved in breast cancer).

On the appointed day, I drove the 90 minutes up the freeway to the counselor’s office, where we reviewed every piece of family healthy history that I could recall –which relatives had died and which were still living, the cause of death of each deceased relative, and the health conditions in the relatives still alive. I did my best to remember every story, every shred of health information I’d picked up over the years of being part of this family.

Yes, there is my grandmother who had an undefined breast cancer around 1970 that eventually recurred and took her life about 12 years later. And yes, there are various other relatives who had cancer of various types:  colon, bone, and skin. But no other instances of breast cancer and none of ovarian cancer, the two telltale markers of a genetic propensity for people like me.

This recording of my extended family’s health history took quite a bit of time that day. One advantage of having a large (nominally Catholic) family is that you’ve got lots of opportunities to spot any patterns of illness, cancer or otherwise. Among my 4 siblings, 9 aunts and uncles, and 35 cousins, my family health map was pretty clear of signs of a genetic problem.  The counselor thought it was not likely I had the bad genes. And so, I decided then not to have the test.

The next conversation with the counselor was about 3 years ago, when I learned a close relative had also been diagnosed with breast cancer. I called to determine whether that occurrence increased the likelihood of my having the genetic flaw.  But the other relative had a different type of breast cancer, at a different stage of life, and had been on hormone replacement therapy. The counselor’s answer was, once again, “not likely.”

So, you may be wondering, why the third conversation? Why ask again when the odds seem ever in my favor?

Here’s why:

The research on breast cancer is constantly evolving, and there is more and more evidence that the type of cancer I had – triple negative – is driven by genetics more often than the “garden variety” hormone-related breast cancers. Oversimplified media reports imply that most breast cancers are related to gene flaws, which is simply not true.  Only 5% to 10% of hormone-positive breast cancers relate to genetic deficiencies, but the burgeoning research on triple negative cancer shows that as many as 15% of these cases relate to genetics. Though that number is far from a majority, the possibility is great enough to make testing reasonable.

The other factor is that Myriad Genetics, the company that initially developed the genetic test for BRCA1 and BRCA2, was forced to give up its patent on these genes in 2013. This ruling by the U.S. Supreme Court meant that other companies were free to develop genetic tests for breast cancer (and Myriad could no longer get away with charging several thousand dollars for the test).

So, when my oncologist once again suggested the genetic test at my checkup back in November, I decided I’d bite the proverbial bullet and get it done, if for no other reason than to find out whether my children would have anything to worry about.

The test itself is simple – they draw blood and send it off for analysis. The results, however, may not be so simple.

First, there’s a choice of which test to take:

  1. the one that checks for only BRCA 1 and 2
  2. the one that also looks for other genes implicated in breast/ovarian cancer (PALB2, BRIP 1, and another whose name I can’t recall)
  3. or the one that finds every genetic anomaly you have (as far as they can be currently identified)

In other words, the choice is this – how much anxiety do you want to introduce into your days?

In my situation, it no longer seems enough to look for just BRCA1 and 2. But I also don’t need to worry about a bunch of genes that might not be functioning properly but aren’t causing trouble and about which I can do nothing. So I chose the second option.

Ten more days to wait for a phone call.

Forget the Pink: The Real Cure is Prevention

Here it is again, October, which is designated breast cancer awareness month. This is the month when all is awash in pink.  At this point, plenty of bloggers have pointed out the hypocrisy and pitfalls of the “think pink” movement, so I leave it to them to continue to beat that drum.

Today, I’d like to present two sources that are helpful in understanding and combating breast cancer. The first is an interview on the NPR program “Fresh Air,” in which Terry Gross interviews Dr. Elisa Port. Maybe some of you have already heard this interview. I happened to catch it during drive time around town. Although Dr. Port doesn’t cover all the intricacies of the various types and treatments for breast cancer, she gives an up-to-date overview of the topic, including a good discussion of the current state of research and treatment related to genetic mutations. I found the interview helpful because it is grounded in the facts, not the myths and rumors, about breast cancer. You can find the interview here.

The second source appeared in my e-mailbox just this evening. I don’t know the fine details of the Rethink the Pink organization behind this website, but I was ever-so-glad to see the focus on prevention beyond the usual “diet-exercise” discussion. This site addresses the environmental factors related to breast cancer, specifically the chemicals in health and beauty products that have never been tested or specifically labeled as carcinogenic. Caveat: It does promote products, but with the purpose of giving alternatives to the usual chemical-laden products we find on store shelves. You can find the site here.

Enough of the pink parties. Let’s get serious about real prevention that offers effective alternatives and doesn’t make us feel guilty.

Ordinary Moments

About 6 years ago, I noticed changes in my breast that eventually led to a diagnosis of triple-negative breast cancer. Six years later, I am ever grateful for the simple fact that I am alive.

But over these past 6 years, I’ve been plagued by the idea that – having survived a potentially deadly disease — I should be doing greater things with my life. This idea, I suspect, is one of the unmentioned after-effects of cancer, promoted by all the smiling faces on survivorship posters, the Facebook people who post their travel photos, the TV ads that show active people feasting on the very air. Look at all those survivors  – starting foundations, running marathons, changing the way the world spins.

And here am I, doing the dishes, going to the grocery, taking the car in for repairs. These are the activities that occupy what seems to be an excessive percentage of my days. I don’t know how to start a foundation. What’s more, I don’t have the drive or energy to find out. I gave up running long ago, a casualty of laziness and sensitive joints. Sometimes, it’s all I can do just to put three somewhat healthy meals in my mouth in the course of a day.

Make no mistake: I have great faith and belief in the everyday work I do – teaching, writing, looking after my family – simply because I believe these activities are important, if only to me. (No one has ever accused me of lacking ego!) But always there is the nag in the back of my head who says: “Why aren’t you doing more with your life?”

It’s a never-ending trap, this idea that we should always be doing something more – that who we are and what we do is somehow never enough. The size of this trap expands exponentially once you’ve been seriously ill, the product of the idea that contemplating death imbues a life with greater meaning and therefore greater action. This trap can be as psychologically damaging as the illness itself because of the guilt attached: “I’ve survived, so surely I’m supposed to solve world hunger?”

And that’s why I’m glad to see a change in focus in the ads now broadcast by a nearby cancer treatment center. Finally, here’s an ad that dismantles the trap, that reflects the reality of most of us who survive treatment. We mow the lawn, we make toast, we sort the laundry. I don’t like the implication in this ad that cancer is now an everyday occurrence – a speed bump on the way to the grocery —  and I chafe at ads that pit a center’s survival rates in a marketing competition against others. But I am glad to see the expectations made realistic. Life after cancer is pretty much as it is beforehand — full of ordinary moments.

Must See TV

This short entry is to encourage those of you who are interested to watch the upcoming PBS special on cancer this week (March 30-April 1 — check your local listings for times). The 3-day, 6-hour special is produced by Ken Burns (that same Ken Burns who has documented the Civil War, baseball, and jazz) and is based on the Pulitzer-prize winning book (in 2010) The Emperor of All Maladies: A Biography of Cancer, by Siddhartha Mukherjee, M.D.  You can see a trailer and read a summary of the project on Burns’ website.

Given Burns’ previous work on the Civil War, it is fitting that he would take on the topic of cancer.  Although Richard Nixon initiated the “War on Cancer” in 1971, far too many of us know that war has not been won.

I purchased a copy of Mukherjee’s book about a year ago, but decided that I would postpone reading it, for a couple of reasons.  It’s a big book — approaching 500 pages — and includes descriptions of the science and research involved with this disease, from the earliest records of its appearance in ancient Egypt to the present day. In other words, it’s not light reading.

But it is well worth reading for a better understanding of what the disease is, why it has been so hard to eradicate, and why, unfortunately, we may never be able to do so. The more we know about cancer, the more there is to know.  And although some cancers are now curable, many are not, largely because each instance of cancer is a unique illness in a unique host.

Even if you haven’t been affected by cancer, the book is worth reading for a larger understanding of a disease that is projected by the World Health Organization to increase drastically in coming years. If you’re not currently affected by cancer in some way, there’s a good chance that you eventually will be.  And though cancer once used to be considered a disease of aging, greater and greater numbers of younger people are affected by it.

The other reason I held off reading the book was my own lingering fear of the disease. To read about a topic does not mean that you will be affected by it, but too much of our talk about cancer is still fraught with fear and superstition. I had to get past that magical 5-year mark of survival before I could set aside enough of the fear to read.

If you’re not inclined to read the book, but are interested in the topic, take the shortcut.  Watch the film.

Five years on: What does survival mean?

December 31, 2014, was not just the last day of last year. For me, it was a significant point in my cancer journey – that landmark day that marks 5 years since the end of chemotherapy, the point at which my oncologist started the survivorship clock.

Those 5 years have brought me from a place of terror to one, I hope, of realistic adjustment to the idea that I won’t live forever and that, regardless of appearances, the only real control I have over my life is within my small realm of influence – what I choose to do or not do. I still think about having had cancer every day, sometimes throughout the day, but these thoughts echo from the back of my mind; they rarely take a position in the front.

I still occasionally wonder what I did to bring on the disease, though a recent study suggests what I’ve ultimately come to believe — that in many cases, cancer develops simply as a matter of “bad luck.” Still, although I’ve changed habits that might have led to my developing cancer, I can be prone to that same panic I felt at my initial diagnosis when some new pain shows up.

Why do the cancer gurus set the critical point to determine survival at 5 years and not some other time? After all, I know a few people who were given a clean bill of health at the 5-year mark, but later were taken from us by a recurrence of the very cancer they thought had been conquered.

Here’s what the Mayo Clinic has to say about those 5-year survival statistics, which clarifies the factors influencing survival about as much as they can be. If you want even more details, especially about those long tails in the survival curves, take a look here. And as noted in this chain of posts, lots of factors influence the choice of a 5-year time point for analyzing survival.

Whatever the reason, it’s a date to acknowledge. In my own case of triple negative breast cancer, the more critical time point seems to be 2 to 3 years after diagnosis when (statistically speaking) the cancer is more likely to recur. Although I passed that mark a while ago, the 5-year point is equally important. Besides being the cut-off for the data, this is the point when oncologists tend to turn the care of cancer patients back to their primary care doctor. So the 5-year time point also marks the end of a long-term relationship with the doctor who served as a guide and security blanket during a harrowing time of life.

Besides the legion of thoughts about survival, my diagnosis of cancer left me with the feeling that I should be doing greater things with my life — establishing a non-profit foundation, for instance, or helping to solve world hunger. But here I am, going about my days much as I did before – getting the kids to and from school, teaching writing classes, walking the dog (sometimes).

Outwardly, my life looks very much like it did before my diagnosis, and even my hair has returned to its normal state (albeit with a few more gray hairs). Inwardly, the course of my thoughts is very different. I worry more about possible health risks for my family, yes, but I am also better at recognizing the value of my work, my relationships, and even the boring minutes of the day.

In his book Man’s Search for Meaning, Viktor Frankl notes that “What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person’s life at a given moment . . . Man does not simply exist but always decides what his existence will be, what he will become in the next moment.” In other words, I can decide that, at this moment, what I’m doing has meaning simply because I have decided that it is meaningful. I may not be in a position to solve world hunger, but I can do what I can where I am.

Let the Eye Rolling Begin

skirt2Here comes October. And with it comes the once-again heightened focus on breast cancer. I am suffering eye strain just from the reports I noticed in the past two days — not from reading the reports, mind you, but from the involuntary eye-rolling that took place.

The first report correlates a woman’s skirt size with her risk of breast cancer. OK, we get it: increasing weight increases the risk, but really – skirt size? Given how arbitrary clothing sizes have become over the years, how can this be a reliable measure of anything?

In my college days, I wore a size 8 skirt. Though neither my height nor my weight have changed much in the 30-some years since then, I seem to have dropped a number of skirt sizes, and still somehow ended up with breast cancer. So here’s the conundrum. If clothing sizes for women have been decreasing over the years (so we can all feel better about ourselves), just what does it mean to say that increasing skirt sizes heighten a woman’s risk of breast cancer? The implication is not flattering.

One of the authors of this report says, “We were pleased to find an association between skirt size change, which is easy to recall, and breast cancer risk in post-menopausal women.”

Pleased to find? Easy to recall? Is there some part of a woman’s brain that automatically records her skirt sizes over the years? Would the authors have been displeased if they found no correlation? Do we really need to take this approach — focus women’s attention even more on body image, which is reflected, in this case, by clothing size?

Plenty of studies already document the association of increasing weight with increasing risk of breast cancer for post-menopausal women, so this report is nothing new. But being overweight before menopause seems to lower the risk of breast cancer, so this study makes even less sense. (It’s OK to be fat till you hit menopause? As if any of us knows when that’s going to happen.) And there’s no mention of the similar pattern seen in men who develop breast cancer, whose increasing weight also puts them at risk. Maybe that’s because, unless they wear kilts, they don’t know their skirt size.

“It’s a nice measure for women, something they can easily relate to,” said one of the study authors.

All together now, 1..2..3…, let the eye-rolling begin.

The second report, yet another study of alcohol consumption and the risk of breast cancer, comes from Canada. This study concludes that “Women who have as little as two drinks a day are at an increased risk of breast cancer. . .Those women — classified as low-level drinkers — are 8.5 per cent more likely to develop breast cancer than if they had abstained from alcohol, the study says. Hazardous drinkers, who have more than three drinks a day, face a 37 per cent risk increase.”

Photo courtesy of Getty

No word, however, on whether there’s any increased risk for those having more than 2 drinks but fewer than 3. (If I fill that third glass only half full, does that count?)

Again, this is not news. Dozens of studies have examined the relationship between alcohol and cancer risk (and not just breast cancer). Some have found a correlation, some have not, but even one of the authors of this study commented that “It’s hard to say in any one person that it was just alcohol” that leads to breast cancer. The news article also notes that, in Canada, “between five and 10 per cent of breast-cancer deaths are attributable to alcohol.”

Well then, what about that other 90% to 95%? It’s hard to see alcohol as a “major” risk factor – as one author of the study called it — with such skewed numbers. And what, then, do we make of a report that says having dense breast tissue is the “single greatest risk factor” women face?

What disturbs me most about these reports is the rampant splitting of hairs. Yes, weight and alcohol consumption have an influence on our health, and not just with regard to the risk of cancer. Now we can add the risks associated with a low level of vitamin D and possibly melatonin, which is tied to working night shifts and a disruption of circadian rhythms.

My point is that there is rarely just one factor at work, and the media does society no favors by randomly spotlighting isolated factors, especially the same ones over and over, to make headlines. So, instead of focusing on these recycled, guilt-inducing reports about breast cancer, I’d like to focus on some positive research currently taking place.

First, there’s the Legacy Girls Study, the goal of which is to “provide insight into the relationship between lifestyle factors, puberty and development, and breast cancer risk” in young girls. Given that the factors that lead to cancer often happen long before the disease appears, the information this study gathers should help us see how those factors interact and set the stage for disease development later on.

The second report comes from the UK, where researchers are analyzing DNA in an attempt to do away with chemotherapy treatments of cancer altogether. If they succeed in their work, they say, “We will look back in 20 years’ time, and the blockbuster chemotherapy drugs that gave you all those nasty side effects will be a thing of the past.”

Wouldn’t that be terrific?

With cancer rates in general expected to increase 57 percent in the next 20 years, it’s pretty clear that drinking less alcohol and counting dress sizes aren’t going to solve the puzzle.

October approaches. Expect to see the pink ribbons flying any day now.

I expect my eye muscles to be quite strong and flexible come November 1.

 

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The note below comes from a reader of my blog. I’m passing along this information about another women’s cancer concern at her request:

Power Morcellation May Be Doing More Harm Than Good!

Since September is Gynecological Cancer Awareness month, taking the opportunity to stay informed about possible risk factors can play a critical role in avoiding potentially harmful situations or even save lives. In the spring of 2014, the Food and Drug Administration (FDA) issued warnings to the medical community about significant risks associated with power morcellation, a technique used in certain routine gynecological procedures.

Power morcellation uses a tubular-shaped medical device known as a power morcellator to sever tissue during procedures. The tissue is then suctioned out of the body through an abdominal incision for removal. This technique has been used in certain laparoscopic surgeries, specifically hysterectomies and myomectomies, both of which are gynecological in nature. Hysterectomies involve the removal of the uterus and/or ovaries and myomectomies is the removal of fibroid tumors from the uterus.

An unforeseen complication due to power morcellation is the inadvertent impact on undetected cancerous conditions. Women with undiagnosed reproductive cancer such as leiomyosarcoma, an aggressive and life-threatening form of uterine cancer, that undergo power morcellation are at risk of triggering an acceleration of cancer growth. Cancerous tissue may be present during the process of fragmenting targeted tissue. The fragments may then be dispersed throughout the abdomen, resulting in an exacerbation of the cancerous condition.

The FDA issued an alert to hospitals, cancer centers and medical device manufacturers, warning the medical community of the harmful consequences of using power morcellators. Heeding the warnings, Johnson & Johnson, an American manufacturer of medical devices, pharmaceuticals and other goods, recalled its manufactured power morcellators, advising customers to avoid further use of the devices and return them to the company. Johnson & Johnson does not plan to resume the manufacturing of this device due to the potentially life-threatening ramifications of its use.

Such a catastrophic outcome to what should be a simple, minimally-invasive procedure is alarming to both the medical profession and to the patients undergoing treatment. The healthcare industry is here to help not harm. Despite this effort, unfortunate circumstances do develop. Being a proactive participant in one’s own health care is critical. Research and ask questions about diagnoses and treatment options, and opt for second opinions when necessary. Tragic situations may be avoided when patients stay informed and advocate for their rights to good care. The medical community needs to do its part as well: Providing quality, thoughtful and individualized care to its patients.

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An addendum: The Scar Project

October 10, 2014

In one last attempt in this post to stem the Pink Craze of October, I’m including here a link to The SCAR Project, a site that focuses on the experiences of young women facing breast cancer.  The photos on the site are moving, but not for the faint of heart.  If you’d like to donate to a worthy way to help document and, we hope, change the experiences of young women with this disease, whose numbers are growing worldwide, boycott the Susan G. Komen marketing ploy of pink drill bits and give to this project.

 

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