Starbucks, Sins, and the Lies about Breast Cancer

I was talking yesterday with friends about the headline news that Starbucks is giving their employees free tuition to attend college.

At first glance, this seems like a fantastic move, exactly the sort of thing corporations ought to do for their low-paid employees, the ones who do the hard work that guarantees those high executive salaries.  But the fine print of the agreement divulges the lie of the headline.  The tuition certainly isn’t free, and it’s not actually being paid by Starbucks. The more we dig below the glossy surface of the story, the more this “deal” looks like a marketing ploy by Starbucks and Arizona State University. So it turns out that the initial announcement and headlines were, essentially, a lie.

And so I got to thinking, what sorts of lies lurk under the surface of the news we read about breast cancer?

When it comes to lies, there are two kinds: lies of commission and lies of omission. Lies of commission are deliberate falsehoods told to cover up the truth.  Lies of omission neglect to disclose (or maliciously withhold) information and thus reshape the truth. The Starbucks story is an example of both – a headline that gives a false impression, and a withholding of details that disclose the full picture.

When it comes to breast cancer, the lies tend to be ones of omission rather than commission, and they are not usually intended to be malicious. Part of the problem in reporting on breast cancer is that the story is too wide and deep to be covered in the space of a computer screen.

The first lie of omission is that breast cancer is one disease. To date, researchers have defined 6 major types of breast cancer. These groups are then divided into many subtypes according to hormone receptivity, cell type, and other factors. Unfortunately, the information published about breast cancer in the mainstream media implies that all women with breast cancer are in the same boat, rowing with the same oar, dealing with the same disease, which is simply not true. Most studies are done on women with hormone positive cancers, which leaves people like me (with the triple negative variety) and those with other types (inflammatory, lobular, DCIS, etc.) out of the picture. Together, we make up as much as 25% to 30% of breast cancer patients, but yet the focus of news is on the hormones.

Now, take a look at the list of risk factors for breast cancer currently available on the Mayo Clinic website. (This list has changed significantly since I first was diagnosed 5 years ago.) Mayo is a highly regarded institution, and rightfully so, but even a perusal of the solid information presented here inadvertently introduces the sin of omission.

The fourth and fifth items on the list are a family history of breast cancer (mother, sister or daughter) and a genetic mutation. But neither of these items mentions the male side of the equation – men with breast or prostate cancer.  The genetic mutations that can lead to breast cancer in women can also lead to breast and prostate cancer in men. So to focus only on female relatives is to omit the real possibility that the genetic defect can come to you through your dad.

But the bigger lie here is the impression that many breast cancers are hereditary and this lie is heightened by celebrities who are opting for preventive mastectomies. In fact, 85% to 90% of breast cancers are *not* hereditary.

This list also says nothing about breast density, even though legislation in 17 states now requires doctors to tell women that they have dense breast tissue. We now know that mammograms, already questionable as an effective means of screening, are even less effective in finding tumors in dense tissue, and there is a suggestion that dense tissue itself might be a risk factor. The controversy on this topic will continue, and Dr. Susan Love interprets the current situation well.

The list also says nothing about the use of oral contraceptives, which has been a complex and controversial topic for a long time. Some studies have found a connection between use of the pill and breast cancer; some have not. Because of the changing nature of birth control pills over the years, research on the effects is rather like shooting arrows at a moving target.  Still, the question is worth addressing, in light of a recent study.

The Mayo list does raise the issue of childbearing, another area clouded with complexity. According to the list, having children late in life or not at all is a risk factor. But the finer points of this factor are explained by the Komen Foundation as follows:

“In general, women who have given birth to more than one child have a lower risk of breast cancer than women who have never given birth. However, women may not get this protective benefit of childbearing for triple negative breast cancers. On the other hand, although having a child at a later age tends to increase the risk of breast cancer, it does not appear to increase the risk of triple negative cancers.”

So it seems this risk factor might not actually apply in many cases, and so,  out of necessity, the site concludes by saying “these topics are under active study.”

There are some unusual omissions from the Mayo list: that risk increases with height, and that cancer occurs slightly more often in the left breast than the right.

Further down the Mayo Clinic’s risk list is exposure to radiation as a treatment during childhood.  The sin of omission here concerns the radiation women are subjected to through mammography. Most of the current research still indicates that the amount of radiation from mammograms is not of concern, even cumulatively. So this omission actually works against women’s peace of mind.

With regard to risk factors, the biggest lie of omission is that any of these lists is comprehensive. (The Mayo list does at least state that many women who develop breast cancer have no known risk factors.) It’s easy to assume that, if none of these factors fit you, you’re safe.  That’s what I thought when those telltale signs showed up in me. Before my diagnosis, I had only two of the risk factors on this current list. And of the risk factors for triple negative cancer – younger age, African American heritage, genetic mutation, obesity – I have none. As a short, slender, middle-aged, white woman with no previous or family history or genetic mutation, who has eaten well and exercised for years, with normal hormonal changes and not taking HRT, I was not a likely candidate for breast cancer, much less the triple-negative variety. And I know of many other women in this same boat with me – not at obvious risk.

So here’s the obvious point:  if you’re female, you’re at risk.

Another lie is that women can prevent breast cancer through the hat trick of diet, exercise, and taking tamoxifen as a preventive, which implies that we have more control over the development of breast cancer than I believe we do. If you read only the headline and lede of this article, you’re given the impression that it’s easy — eat well, exercise, and take tamoxifen if you’re at high risk. The article never mentions that there are likely environmental and chemical influences at work, things that are out of control, things that Rachel Carson – who herself died of breast cancer — warned us of back in 1962. The organization that bears the name of her landmark book makes those environmental threats clear.

The underlying message with this disease is that it is somehow the individual’s fault if she gets cancer, that cancer is out there and it’s just up to us to figure out how to avoid it, like a pothole in the road. This continues our “do-it-yourself” and “blame the victim” ways of thinking. Although we do generally have control over how we live, there has been a constant focus on diagnosis and treatment, with more and more tips for prevention – all of which is valuable. But this approach omits a clearer focus on the causes and what we’re doing collectively, at the societal, environmental, and political levels, that leads to harm.

Medical researchers do the best they can to find the answers to our many health problems. But much of this research takes years and, because it usually takes place in hindsight, after we’ve defined the problems, it is at best always a step or two behind reality.  Despite what researchers actually do find and accomplish, when this information is brought to light by the media, it is often skewed to make headlines or garner hits on a website. The ever-increasing pressure for media to be first to the story means that the critical and often the most important news is passed over because it isn’t easily carved into the crystal of a sound bite.

To avoid the sins, whether of omission or commission, it’s up to us to read between the lines and ask what’s missing from the information published about cancer, breast cancer, and even Starbucks.

***

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Test Anxiety: The August Installment

This week’s mail brought two folded papers full of numbers.

These numbers are the results from last week’s visit with my internist for my annual check-up. Height, the same. Weight, the same. Cholesterol, TSH, vitamin D levels – all normal. The phlebotomist was so good I barely felt the needle stick in my arm — the right arm, ALWAYS the right arm, because it was the left side that was traumatized by the surgery and radiation. I still have to remind myself to tell the doctor’s assistant to use the right arm for the blood pressure cuff or needle. It’s not yet habit for me to remember this myself, and I don’t need to tempt another onset of lymphedema.

I didn’t expect to see anything scary on the report from my internist.  After all, I am in quite good health (oh, except for that bout with cancer).

The previous week, I anxiously awaited the results of the annual mammogram and MRI scan. The current guidelines for mammograms vary depending on whom you ask. Anyone who’s interested in or affected by these guidelines likely knows the ongoing controversy around the usefulness and timing of the test. Agencies and physicians change their minds frequently about what’s appropriate.

Given that mammograms are less reliable in people like me who have dense breast tissue, I am extremely reluctant to put my faith in them, especially since they did not show the tumor that caused me so much grief. Still, my oncologist insists I have one each year, and my radiologist says that, though it isn’t perfect, it’s the best test we have. (To which I say, it’s about time we come up with something better.)

So, every year around this time, I trek to the radiology center to undergo the test. Four years past my diagnosis, my anxiety about the test now only kicks in as I don the cape in the dressing room, not several days beforehand. And because the same radiologist has been viewing my images and so knows me (or at least my breast tissue) pretty well, he makes a point of coming to tell me the results before I can even leave the building.

They say your diagnosis is only as good as the radiologist reading the images. I’d also say, regardless of the diagnosis, the effect of the results on the patient is only as good as how (and how soon) the radiologist delivers them. The longer the wait, the higher the anxiety spikes.  A face-to-face conversation or a phone call the same day trumps a form letter a week later, even when the news is good.

People sometimes wonder why someone would not go to see a doctor if there is something wrong. It comes down to this – if you ask a question, you’ll usually get an answer. Anxiety is what tells you the answer might not be what you hope for. If you never ask the question, you never have to hear the answer, and so some people never ask.

Immediately after Dr. P came to report the results to me (“Everything looks OK”), I was taken to the other side of the building for an MRI, something I’ve asked for each year since the end of treatment. It’s not customary to have an MRI unless the doctor suspects there’s something to find, and the MRI has some inherent problems as well, but I have asked for it precisely because the mammogram is unreliable for me. And my oncologist has readily agreed. This is no small agreement as the test costs about 2 thousand dollars (which alone spikes the anxiety level) and, as my oncologist reported to me last time I saw him, he’s starting to see insurance companies refuse to cover the MRI unless the patient has current signs or symptoms needing attention. I can understand insurance companies wanting to cut unnecessary costs, but peace of mind is always necessary. With the results of the mammogram coupled with the MRI, I can be reasonably sure that we’ve got a good picture of what is (or isn’t) going on.

Lucky for me, our current insurance approved the test — at least for this year — and Dr. P reported, when he called the next day, that “All looks good this year.”

This year.

With this good news, and the normal numbers from the internist this week, my anxiety has dropped from stratospheric to just atmospheric, where it should stay till my check-up with the oncologist in November.

Reprieve?

In the mail a few days ago came the report of the results from my recent MRI. Along with the mammogram, the MRI is one of the ways the medical folks keep an eye on me after my cancer treatment. I am more than 3 years past the day I received the breast cancer diagnosis, and 2-and-a-half years past the end of chemotherapy. That’s when the countdown, for me, to that critical 3- and then 5-year mark began.

The MRI may seem like overkill, especially with its added expense and the dogged determination of the medical community to promote mammograms. But it’s necessary for me because the mammogram tends to fail those of us who have dense breast tissue — a factor that is finally starting to show up on lists of risks for breast cancer. Besides the annual mammogram and MRI, I visit my oncologist every 6 months for blood tests and a review of my status. My last 6-month check-up, back in April, showed only some lingering whacked-out red blood cells.

At that time, I had developed a new pain in my right abdomen, one that had hung around for a few weeks, consequently triggering my internal alarm. The pain had passed the 2-week mark I had been coached to observe. And so I followed the oncologist’s suggestion to have an abdominal ultrasound, which fortunately, like the mammogram and MRI, showed nothing wrong. (Cancer, the “gift” that can keep on giving — you just don’t know when.)

Although my body seems to be recovering well, is actually intent on reclaiming its good health, I am still struggling with the mental, emotional,and spiritual recovery. My body has its own mind. The mind itself needs to catch up.

The nurse had already called me to report the MRI results, but that wasn’t enough. I needed to see the full report in print on the page in my hand.  And in that small space of silence after reading the results, when I let out the breath I had been  holding, a tiny thought crept in. A new and, for me, startling thought.

It just might be possible to be cured of this disease.

The body will know when that happens. The mind might never be sure.

In Our Own Backyard

English: Statue of a dragon guarding one of th...

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This New Year’s Day brings us into the Year of the Dragon, and marks my second-year anniversary from the end of chemotherapy.  One more year and my risk of recurrence drops considerably.  But while I think of my great good fortune, in the past month, I have learned of four friends or acquaintances who are now facing a cancer diagnosis for the first time, a somber and increasingly common experience.

In my last post, I summarized global cancer statistics and trends. This time, I’m considering my own proverbial back yard.  The data you see here relate to cancer in the United States and come from Cancer Facts & Figures 2011, published by the American Cancer Society (ACS).

According to the authors of this booklet, “[t]wo major classes of factors influence the incidence of cancer: hereditary factors and acquired (environmental) factors… Environmental (as opposed to hereditary) factors account for an estimated 75%-80% of cancer cases and deaths in the US.”  This percentage breaks down as follows:

  •  Exposure to carcinogens in occupational, community and other settings – 6%
  • Tobacco smoking – 30%
  • Poor nutrition, lack of physical activity, and obesity – 35%

Add up these numbers (71%) and you’ll see that the specific environmental causes of a good number of cases are still unexplained.  (BPA? Pesticides? All those chemicals we ingest or pour into our water sources every year?)

The booklet goes on to note that “even a small percentage of cancers can represent many deaths: 6%…corresponds to approximately 34,320 deaths.”  And “the burden of exposure to occupational and environmental carcinogens is borne disproportionately by lower-income workers and communities, contributing to disparities in the cancer burden across the population.”  The ACS figures that, if racial and economic disparities in the United States were eliminated, there would be 37% fewer deaths from cancer, leading the agency to conclude that poverty is a carcinogen.

Elsewhere in the book, the authors note that “questions remain about the role of exposures to certain classes of chemicals (such as hormonally active agents) during critical periods of human development.” Answers to these questions might eventually explain why birth control pills have not been conclusively tied to cancer but hormone-replacement therapy after menopause has.

Here are some interesting data on the most prevalent cancers – lung, prostate, and breast:

Lung cancer alone is responsible for 27% of all cancer deaths, and is the number 1 cause of cancer deaths for both men and women. The ACS notes that, “[s]ince 1987, more women have died each year from lung cancer than from breast cancer.” And yet, we don’t see nearly the same amount of energy put toward races to cure lung cancer as we do for breast cancer. (See more about this disparity here).

This is just one of many examples of how data about health and disease is skewed by marketing forces. Breasts and the color pink are palatable (though honestly, I’m tired of women being defined by their breasts for any reason and pink being chosen as the color to represent women). Apparently, lungs and their color – pearl – are not so sexy.  Yes, more women are diagnosed with breast cancer, but more die of lung cancer.

Prostate cancer is the second leading cause of cancer deaths in men. Anticipated new cases for 2011 total 240,890, with 33,720 deaths. African-American men and Jamaican men of African descent have the highest rates of prostate cancer in the world, and the disease is more prevalent in North America and northwestern Europe, less so in South America and Asia.

Breast cancer is the second leading cause of cancer deaths in women. For 2011, the ACS estimates 230,480 new cases of invasive breast cancer among women, 2140 in men. This number does NOT include the type referred to as DCIS, which is not usually invasive, and has been referred to as the “good” breast cancer.

Notice the statistics:  In 2011, more men will have been diagnosed with prostate cancer than women with breast cancer, but fewer men die of prostate cancer.

The list of risk factors for breast cancer contains the usual suspects (obesity, physical inactivity, and alcohol, which acts like an estrogen in the body).  But I see that the ACS is finally listing dense breast tissue as a risk factor along with high bone mineral density and a breast irregularity called hyperplasia (especially atypical hyperplasia).  They also note that there is some evidence that women who work night shifts seem to have an increased risk of breast cancer.

But as always with breast, and perhaps other cancers, there is a caveat.  These factors relate primarily to the hormone-driven breast cancers (ER+, PR+ Her/2-, or any combination of these).  Those of us dealing with the triple-negative type might have an entirely different set of risk factors that has not yet been determined.  I’ve seen preliminary reports that a too-low body mass index and having had children at all are risks for triple-negative disease.

By state, the incidence of breast cancer pretty much follows the trend of national totals for all types of cancer, with California and Florida at the top of the list, followed by New York and Texas. Here in Washington, the projected number of new cases of breast cancer for 2011 is 5,630. In my native Ohio, it’s 8,970.  The number of deaths from breast cancer are also similar, led by California and Florida, then Texas and New York.  In Washington, that number is 800; in Ohio, it’s 1730.

In the flurry of all these numbers, don’t get confused.  The numbers by state may reflect only that one state has a higher population than another, not that there are necessarily more risks tied to location. The number of new cases for each state is pretty high, but the number of deaths is significantly lower, which only means there are many, many survivors of breast cancer out there.

Certainly we know by now how bad smoking can be for us, but here are some interesting details about the exposure to second-hand smoke: “Each year, about 3,400 nonsmoking adults die of lung cancer as  a result of breathing SHS [secondhand smoke]” and “SHS causes an estimated 46,000 deaths from heart disease in people who are not current smokers.”  Perhaps this is because SHS contains about 7,000 chemicals, “at least 69 of which cause cancer.”

In my home state of Ohio, the overall estimated number of new cancer cases for 2011 is 65,060.  In my adopted state of Washington, that number is 35, 360.  Quite a difference, but some of that has to do with population (Ohio has about 11,542,645 residents while Washington has 6,664,195).  The state with the highest overall estimate is California (with 163,480 estimated new cases), followed by Florida (113,400) and Texas (105,000).  Wyoming has the smallest number (2,680).

There is much more information and data in the ACS booklet, so much as to be overwhelming.  To make better sense of the numbers, here’s a wider perspective:

  • Heart disease is still the most common cause of death in the United States, with cancer second.  Cancer has killed about 499,564 people so far this year, but heart disease has killed 593,819.
  •  About 1500 people die of cancer each day, compared to about 2200 for heart disease.
  • As of January 2007, the estimated number of cancer survivors in the United States is 11.7 million, which means about 4% of the population has had the cancer experience.

According to the Stand Up to Cancer organization, 1 out of every 3 women and 1 out of every 2 men are at risk of developing cancer in their lifetime.  I guess I’m one of those who is “experienced.” Now, I’m looking to that dragon to protect me.

Put Down that Cell Phone

Various cell phones displayed at a shop.

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Put down that cell phone, lest you end up with a brain tumor.

So says the International Agency for Research on Cancer (IARC), an agency within the World Health Organization (WHO), which just published a report that cell phones are a “possible” carcinogen. The 31 international scientists involved in this research have concluded that excessive use of cell phones may increase your risk of two types of brain tumors:  gliomas, which are malignant, and acoustic neuromas, which are not.  (Malignant or not, a brain tumor is something you’d rather not have.)

This news, of course, made headlines in newspapers and on broadcasts around the world. After all, the IARC estimates that there are 5 billion cell phones in use globally, and many of us are implicated in that number.  According to the Huffington Post, the declaration about cell phones puts these devices in the same category as coffee, pickled vegetables and talcum powder, all of which are designated “possible” carcinogens.

Just to clarify, the WHO designates three levels when researching substances related to cancer:  possible, probable, and known.  Like coffee and those pickles, cell phones possibly cause cancer, while chemicals used by hairdressers and barbers probably do, and alcohol, tanning beds, and hormone replacement therapy are definitely known to cause cancer.

So what are we to make of the pronouncement about cell phones?

If the conclusion is so indefinite, did the news really deserve the headlines it garnered?

As with much of the news related to cancer, breast or otherwise, the answer is complex.  Maybe cell phones do cause cancer, maybe they don’t. To solve the complexity, there needs to be more research and studies of longer term. Until such studies are concluded, the truth is anyone’s guess, and the volumes of discussion that have taken place just since the announcement a week ago point out the difficulty in coming to any easy conclusions.

Given the numbers of substances and factors that might lead to cancer, perhaps the best we can do is pick which evils to avoid.  Giving up cigarettes seems obvious, and maybe you can forego your morning cup of joe. But even picking among the evils is hard when you consider that Tamoxifen — the prominent drug taken by women with estrogen-positive breast cancer to prevent recurrence — is also a known carcinogen. And one of the risk factors for breast cancer that has not yet been widely recognized is dense breast tissue, which is not something you can choose to avoid.

More complexity.

More confusion.

What’s an enlightened person to do?

The best I can manage is to keep my eye on the research that addresses my specific variety of cancer and cancer research in general to follow the studies and see their results (more on that in the next post).

In the meantime, I’ll step away from the cell phone.

Everything and Its Dog

Here’s a quiz.

Which of the items listed below is something you *do not* want to see on a pathology report after a breast biopsy?

A.  Fibrocystic changes
B.  Hyperplasia
C.  Microcalcifications
D.  Columnar cell change
E.  Atypical hyperplasia
F.  Sclerosing adenosis

The answer is E.

Thankfully, item E did not show up on the pathology report from the two biopsies I had of the right breast two days ago.  This was the good news Dr. L delivered when I answered my buzzing cell phone this morning.  Every other term listed here appears on the report. I had no idea there were so many varieties of benign cell changes in the female breast. Some of them sound pretty awful, but even hyperplasia is OK as long as it’s not atypical, a situation that could indicate the beginnings of cancer.

The biopsies were the result of some “suspicious findings” (as the pathology report puts it) on the right side on the 6-month follow-up MRI scans I had taken last week.  (Skipped those dastardly mammograms, thank you, and went directly to the big machine.) Fortunately, all is clear on the left side where surgery was done a year ago. Dr. L gave me the choice of having the biopsies or waiting another 6 months and checking again.

Look, I’ve learned a lot about mastering anxiety over the past year with stones, yoga, prayer and all those “woo-woo” techniques, but I’d have to be nuts to just wait.  So there I was again a few days later, face down on the MRI table, arms overhead as in a poorly executed dive, breasts inserted into their appropriate slots, allowing Dr. B to poke me with large needles.

This biopsy differed from earlier ones in that it was stereotactic, which means the technician calculated the exact locations of the “suspicious findings” using a computer and the MRI images.  The previous biopsies were done with me on my back while the radiologist located the problem areas using ultrasound.  A stereotactic biopsy is called for when the abnormal areas are too small to be located on either mammogram or ultrasound. The computer lines up the coordinates and the doctor can extract what is needed  for analysis and place a tiny clip in the spot that was biopsied for future reference.  Dr. B took  6 samples from a spot at the 8-o’clock position on the breast, and 12 from the spot at the 10-o’clock position.

You’d think that, with all the holes poked in my breasts by now, anything nasty would just leak out. If we keep going at this rate, I’ll be down a cup size, but I don’t think bra manufacturers make anything smaller than what I’ve already got.

By itself, the MRI procedure is nothing to fear.  No sharp instruments, no radiation. Just some loud banging and knocking. Though your position may not be the most comfortable, you do at least get a headset and your choice of music to listen to.  During the initial scan, I chose classical music, and was nearly in tears when Tchaikovsky’s “Waltz of the Flowers” came to my ears.  It’s not that I particularly love Tchaikovsky or  the over-sentimentalized “Nutcracker,” but what it brought to mind in that moment were the many dance recitals of my childhood, on the stage in my costume under those hot lights. (Surely every ballet student has danced that waltz.) In my dread of what the MRI might find, the music reminded me of a childhood long since gone.  Beauty and happiness are often recognized only in hindsight.

Next, as if to remind me of the task at hand, came The 1812 Overture. It must have been the day to play Tchaikovsky’s greatest hits. The knocks and bangs of the MRI fit nicely with the cannon shots in the music.

But there was no music during the biopsy, and when I sat up at the end, it was mildly disconcerting to see a puddle of my own blood on the tray below where my breast had been.  The MRI may be able to pinpoint a tiny lesion, but it can’t tell you where the nerves and blood vessels are, and these structures can become “collateral damage” during the procedure.  The 8-o’clock spot in particular kept bleeding, so the nurses applied a large compression bandage — lots of gauze and adhesive tape — that instantly doubled my breast size.

Frankly, size can matter, but bigger is not better.

While they were applying the bandage, Dr. B came back in to speak with me, and I asked him the question I’m sure every doc hates to hear:  “What do you think it might be?”

Without test results in hand, it’s almost unfair for a patient to try to pin a physician down to a diagnosis.

Dr. B is a soft-spoken man with the delicate lilt of a North Carolina accent who raises llamas in his off hours. He has done 4 of the 5 biopsies I’ve had. If things keep on as they have, we will become good friends. As he put it, MRIs light up “everything and its dog,” and produce a fair number of false positive results, which is one of the reasons insurance companies don’t like to cover them for people like me (not to mention they’re much more expensive than mammograms).

Based on what he saw on the images, he guessed that the enhanced areas were not likely to be trouble, but we couldn’t be sure until the pathology report came back. Some of what appeared on the images had been apparent back in January and could be attributed to hormonal changes, but now that I’ve been forced into menopause by the chemotherapy, the doctors figured those changes should have disappeared.

Well, y’know, I can be a little slow sometimes.

The technician who runs the MRI told me they do about 5 stereotactic breast biopsies a day, largely for people like me with dense tissue. Numbers like these (25 a week, more than 1200 a year) for tests that produce many false positives are as disturbing as the false negatives of mammograms. Clearly, we need more accurate methods of diagnosis.

Stories from the Infusion Center

A gloomy day and week coming up.  From that long freeze and blue sky of last week, we’re now back to typical Northwest grayness and rain, which makes skiers happy because it means snow in the mountains.

Yesterday’s ice and snow had me skiing (figuratively) through the morning much like the beginner I am — frantically trying to stay upright at high speed while the ground slips out and away from me. My daughter thought she had to be at school early and so my husband dropped her off on his way to work. Turns out the weather brought a 2-hour delay at school so I had to fetch her and bring her back. My son was home with a cold, my household assistant was running late, and when it came the real time to take my daughter in, the repairman who’d come to fix the neighbor’s furnace was blocking the driveway, fearing to move forward because his van was sliding downhill on the ice, getting no traction backward to get off it. (I’m reminded of lyrics from a Jethro Tull song:  “Skating away, skating away, skating away on the thin ice of new day….”) By contrast to the events at home, the infusion center, where I arrived almost an hour late, was an oasis of tranquility.

The hummingbirds continue their regular visits, though a hummingbird in the snow appears incongruous to this Midwesterner, where all hummingbirds vacate for the freeze. I discovered that hummingbird food doesn’t freeze, but does make a nice sugary slush. Of course we’ve had to name the two new ones: Tinkerbell and Flip Flop.  This morning, I’m watching another, stranger bird — a float plane — doing low figure 8s over the bay.  Fascinating, but not nearly as gracefuI as Tinkerbell.

This week’s white count, 6.5; hemoglobin, continuing its climb, at 9.4. After the initial burning sensation in my hands last week, there seems to be little neuropathy, but my nails are more spotted and discolored so I’m trying to protect them.  Two more rounds of Taxol to go.

The Popsicle Report: So as I’m settling in to my pod, glad to be able to just sit and breathe, I notice the man opposite me. He is my compatriot — bald (perhaps by choice since he also has a mustache), fingers in pans of ice water, iPod buds tucked into his ears. And on his feet, over his own white socks, he has a second pair of white socks encasing packs of ice. He said that his first series of chemotherapy (another veteran!) bothered his toenails so this time he was trying ice on his feet too. His tall, dark-haired wife was folded into the chair beside him quietly reading. I went off to get my usual “appetizers” — green tea and a Popsicle (blueberry lemon again). Shortly thereafter, the man’s wife left the pod and returned in a moment with a Popsicle for her husband (strawberry orange).  He said when he saw mine, he thought it would be a good idea. I sure can’t argue with that.

My nurse for the day was Therese, a Swiss woman who has worked at the center for 10 years. She is just one of the many nurses at the center, and all are heartening examples of how serious illness can get incorporated into life without dragging you down. These nurses choose to work among seriously ill patients every day. Therese did admit that it sometimes is hard to watch what happens to patients (the nurses compensate with a lot of black humor during break periods), but she said it is a privilege for her to help each patient along the path, no matter which way it leads. So while they work and educate patients about drugs and side effects, they also talk about everyday things: which is better for roasting turkeys, a regular oven or an electric roaster?  They wear smocks adorned with flowers, butterflies, Disney characters and even Betty Boop.  And when a patient finishes chemo, they gather, clap and sing, much like waiters at a restaurant attending to a birthday guest (though none plays the harmonica), a modified version of the 12 days of Christmas (“two needles poking…”).

Can’t wait for my turn to hear them sing.

This week, as she was working with me in her smock covered with polar bears, Therese turned to the small woman seated in the chair next to mine and spoke to her in German.  I’d seen this woman several times before, in her colorful outfits and fuzzy pink-and-purple hat. Today she wore the hat again, with a yellow T-shirt and a leopard-print scarf wrapped around her neck.  She sat in her full makeup and large glasses, quickly crocheting a bright yellow blanket that was spread across her lap. I decided to forego listening to my iPod in lieu of a conversation with her.

Uta had come to the U.S. from Germany after marrying an American military man. Her husband, John, came and went from the pod as Uta’s infusion took place.  He was a short stocky man, clad in one of those signature black baseball caps embroidered with “U.S. Veteran” and “Vietnam” and he had adorned it with color bars, several American flag pins and one pin of the flag of Germany. Several more flag pins were attached to his vest. He was chatty, referred to himself as a “Warshegonian” in origin, and entered and departed our conversation in the same way he exited and entered the pod frequently.

Over the years in her new country, Uta taught herself English, raised 2 children, worked as a nurse’s aid, ran a restaurant, taught German, and cleaned houses (5 a day at the time she was diagnosed). She has been coming for infusions for 10 years for chronic leukemia, which was discovered by accident when she tried to donate bone marrow at the age of 50. Though her treatments have been more intense in the past, she now comes once a month to the infusion center.

Our conversation ranged across many topics: German food (how to make a good torte and a spinach sauce, and the advantage of a breadmaker to knead dough when you no longer have the strength to do so), how women have harder lives than men (John nodded vigorously at this comment) but she wouldn’t want to be a man. Men may know more but women understand more (John nodded vigorously again). We talked about how it is good to be small (she’s no bigger than I), and I told her a comment someone made to me once upon a time: Little people are like chihuahuas; we make a lot of noise because we’re afraid we’ll get stepped on. She thinks the tradition of naming sons after fathers ridiculous. John agreed that it’s a problem being named after his father. The boy feels he either has to live up to or totally deviate from his dad’s performance to carve out an identity for himself.  But that didn’t stop John from naming his own son after himself. And his grandson is now John the fourth.

Japanese do not have this custom of naming sons after fathers, though they do sometimes number their sons.  Ichiro, a common male name in Japan, is known especially here because of the star player for the Seattle Mariners. But the name Ichiro actually means son number 1.  When my son was born, my former boss, who knows the customs of Japan, teased me that we should name him after his father, with the “junior” appendage.  Well, we know how Indiana Jones took to that idea.

Uta and John brought to mind the neighbors I had when I was teaching down in Laredo, Texas, many years ago. Mario was a Mexican-American man who had served in the Special Forces in Vietnam. (He proudly showed me a map of these operations which were  emblazoned on a black T-shirt he wore one day.) His wife Inge and he had met in Germany when they were both working as spies, he for the Americans, she for the Germans. They both liked to tell me their stories, Mario about military service, Inge about her views of life. She recommended that, if I marry, I choose a man who is good looking, makes good money and has hair.  In her opinion, those features were the only things that make up for the trouble they cause. She took pity on me, a single woman living alone, grading essays late into the evenings, and cooked German food for me. (Though I am of German descent I’d never had sauerbraten before.) In trade I looked after their parrot when they went out of town.

But back to the days at hand.

I’m still poking around on the Web for answers to my questions, but spend less time there because the information becomes repetitive (and discouraging) and there’s nothing new for my situation, though there are some promising agents — PARP inhibitors and two types of growth factors — being tested. I did find an article I should have read when it was published, back in 2007, about dense tissue being a risk factor for breast cancer: http://health.usnews.com/usnews/health/articles/070204/12breast.htm.

Like the woman described in this article, I wish I’d known about the implications of dense tissue sooner. I might have pushed for different screening tests, kept a closer watch. This article appeared 2 years ago, but dense tissue still doesn’t show up on those risk factor lists we see today.

At breakfast on Sunday, my son asked the rest of us what we dreamed about the night before. No one else could remember, but I had dreamt that, on the upcoming trip to visit family for Christmas, no one wanted to be in the same room with me because of my bald head (which is not so bald anymore but resembles a newborn’s with faint, fuzzy hair of indistinguishable color). Then I recalled: we’d watched Rudolph the Red-Nosed Reindeer on TV the previous night. Perhaps I was empathizing with Rudolph, fearing no one would let me play reindeer games.

But in the spirit of Christmas (and fundraising), here’s an idea for those billiard-playing aficionados on your gift list who really do have everything. By purchasing it, you can also support research for triple-negative breast cancer: http://www.shopmcdermottcue.com/McDermott/M88B.html.  Pool cues. Now this is corporate sponsorship I can get excited about. Don’t mind the price; shipping is free!

I’ve attached a few more photos. Despite all my talk about hair and baldness (the only obvious outward sign of my current experience), I’m not one to think my hair is my identity. But I have discovered that its loss opens up an interest in playing with identity and disguise.

In this first photo, taken last summer, I tried out the military look.

Here, like Uta, I am disguised as a colorful fuzzy gumdrop.

Besides my fuzzy head, this is the hat my daughter likes to pet.

Here is the fashion hummingbirds prefer.  This is the scarf that prompted the hummingbird attack last summer.

And here, I’m a Muslim on her way to iHop.