Tale of Two Breasts – A Cancer Story

2In September of 2004 my doctor found a lump. After several ultrasounds and mammograms, the concerns outweighed my age enough to necessitate a biopsy. At 26 years old, I wasn’t a likely candidate for a mammogram, let alone an open surgical biopsy.

The lump turned out to be many, but to my relief they were mostly simple fluid-filled cysts. However, it was because of those cysts that something of greater interest was discovered. The radiologist had seen several micro-calcifications that showed up as tiny white specks during my screenings.

In February, 2005, a fine wire localization biopsy was performed and a section was removed about the size of a stack of 6 toonies (a toonie is a Canadian two dollar coin). It was reviewed by the pathologist in Nanaimo and a diagnosis was unclear, so the slides were sent to a specialist at the BC Cancer Agency in Vancouver for consultation. According to his review, it was “a challenging case”. A month after the procedure, although I hadn’t actually seen the report, I was told that it was “not cancer”, but we should continue screening every 6 months to make sure nothing changed.

My experience with the BC Cancer Agency; Vancouver Island Centre didn’t transpire until one year later, once I was living in Victoria. I was in for a routine check up, and my new doctor requested my medical file from the previous clinic in Nanaimo. I had given him my version of the past 2 years’ events, so he was a little surprised to read my pathology report from the year before stating that I had been diagnosed with Lobular Carcinoma in Situ (LCIS), among other things. He made a call on my behalf, and within hours I was contacted by someone at the Cancer Agency here in Victoria.

I met with a specialist there a few days later and we went over my surgical pathology report to try to decipher exactly what it meant. He spent 3 hours with me going over the diagnosis, translating and even creating diagrams to help me understand. He was very thorough and helped put my mind at ease with the diagnosis.

Depending on who you ask, or what reports you read, LCIS is not considered cancer, as its name suggests. It has been explained to me that “in situ” means that abnormal cancer cells are present, but have not spread past the boundaries of tissues where they initially developed. LCIS is considered a red flag to allow both doctor and patient to keep an eye on things.

Essentially no invasive cancer was discovered, however several “markers” were found. Markers are indications of a heightened risk of developing invasive breast cancer in the future. There are several risk factors associated with the disease which include; age, hormonal risk factors, personal or family history, lifestyle habits and antecedent intraductal hyperplasia. Although neither my age nor lifestyle provide a heightened risk, my family history and the diagnosis of both intraductal hyperplasia, and LCIS do increase my risk significantly.

The implication of a cancer diagnosis is somewhat overwhelming, but the important message is that thanks to screenings made available through funding, I know about the risks and I am in control of my health care options.

Cancer in its early stages is difficult to detect without the use of screening tests. Thanks to concern from my doctors and a little diligence on my part, I am able to stay on top of my health concerns.

The BC Cancer Foundation raises funds so people are able to receive the care they need at any of the BC Cancer Agencies across the province. Their mandate includes research, prevention & education, early detection & diagnosis, and treatment & care. Visit their website bccancerfoundation.

The Basics

First of all, let’s try to understand what cancer is. Our body’s cells have genes which regulate the growth of said cells. A normal, healthy cell grows at a reasonable rate and eventually it dies out and is replaced by a new one. A cancer cell has the ability to divide at a rapid pace and produces many cells which form a tumor. A benign tumor is simply one that is made up of cells that are virtually normal and is considered harmless for the most part. The ones that concern doctors are malignant tumors which are cancerous and can continue to multiply spreading throughout the body.

Breast cancer is a malignant tumor that develops in the breast, usually in the lobules (milk producing glands) or ducts(tubes that carry milk to the nipple). I say usually because it can also develop in the connective tissues of the breast; which is the fatty part that surrounds the ducts and lobules.

Understanding the Lymphatic System is an important part to understanding how breast cancer can spread. Lymph nodes are an assembly of immune system cells which are connected by lymphatic vessels (small veins carrying lymph away from the breast. Lymph is a clear fluid that contains tissue fluid, waste products and immune system cells. If cancer cells enter the lymphatic vessels they can begin to grow in the lymph nodes. If this happens there is a good chance that they have also gotten into the bloodstream therefore spreading to other parts of the body. However, just because it has reached the lymph nodes.

Why?

Only 5 – 10% of cancers are hereditary (passed down from mother or father). The cancer itself is not inherited, but the gene that increases the risk factor for developing the cancer is inherited. The other 90 – 95% of cancers are sporadic.

So what does that mean? Well, our genes have many jobs and are in charge of telling our cells what to do and when to do it. If there is a mutation in those genes it causes the cells to do strange things. In the case of cancer, a mutated gene is telling cells to divide when they shouldn’t be which causes tumors (as discussed in The Basics). For the most part, gene mutations usual happen later in life and are a result of natural aging or exposure to things like smoke, hormones, certain viruses or chemicals and dietary influences. The damage to our cells doesn’t always lead to cancer because our cells are also equipped to repair damage and, as you may remember from grade 9 Science, we have 2 copies of each damage repairing gene (one from each parent). But if a mutation occurs in both copies of the gene, it can mean uncontrolled growth and can lead to cancer.

If a person is born with a mutation in one of the copies of a damage repairing gene pair, this means their risk for developing cancer is higher, known in the medical community as “genetic susceptibility”. That is because they only have one good protective gene remaining and if it is damaged in the aging process or because of other environmental exposures, it can lead to the gene communicating to its cells to divide and multiply at a rapid rate. Hereditary cancer, therefore, usually develops earlier in life.

When a cancer develops in someone who has no family history or “genetic susceptibility” it is called “sporadic cancer”. Since both copies of the protective gene which eventual mutate, start out in good condition, sporadic cancer usually develops later in life as it takes longer for both copies to become damaged.

The genes that are linked to breast cancer are called the BRCA1 and BRCA2 genes. Genetic risk assessment and genetic counselling are available to help you discover your risk for breast and other forms of cancer. Genetic Risk assessment will tell you if you carry the BRCA1 or 2 gene mutation, but it won’t tell you what your risk of developing breast cancer is. Genetic Counselling can help you to understand your risk for hereditary cancer by reviewing family history, discussing genetic testing and providing information and referrals to experts. Learn more about Genetic Counselling.

Symptoms or signs of breast cancer can range from lumps and swelling to changes in the skin. Non-cancerous cysts and infections often have the same symptoms. So how can you be sure?

Symptoms

Watch for the following symptoms:
*swelling of all or part of the breast
*skin irritation or dimpling
*breast pain
*nipple pain or the nipple turning inward
*redness, scaliness, or thickening of the nipple of breast skin
*nipple discharge other than breast milk
*a lump in the underarm area

Detection

Breast Self-Exam (BSE)

It is, in my humble opinion, the most important way to stay on top of your breast health – because it is something you can do on your own, and will get you familiar with your body. It is becoming quite a controversial subject. There was a study performed in Russia and China in 2008 of 400,000 women, which reported that BSE does not reduce the mortality rate and may cause more harm due to prompting unnecessary biopsies. It is my opinion that it’s better to be safe than sorry. According to Breastcancer.org about 20% of breast cancers are found by physical exams rather than mammography.

Breast self-examination can be frustrating at first, because you don’t know what to look for, and if you are like most women, there are many bumps and lumps in your breasts that are harmless. That is exactly why you should do this on a regular basis – every month. The best time to perform a BSE is a few days after your period when swelling has gone down. If you feel a lump don’t panic, it is most likely not cancerous. But have it checked out by your doctor and then keep an eye on it to see if anything changes. You may want to keep a journal with notes on where and when you found something suspicious. If a change lasts longer than one cycle see your doctor to have it checked.

Mammogram

It is one of the most hated words in the English language for women! But I’m here to tell you that they’ve been given a bad rap and they aren’t as horrible as they have been made out to be. They save lives after all! Doctors have been using mammography for the past 40 years to find and diagnose breast cancer. Mammograms have been shown to lower the risk of dying from breast cancer by 35% in women over 50 years old. Cancer Foundations world wide are now recommending that women over 40 be screened annually in order to find tumours before they are able to develop into invasive breast cancers. Early detection often means that the cancer can be removed without having to resort to a mastectomy (breast removal).

Of course, nothing is guaranteed and mammography alone can miss up to 20% of breast cancers because they simply aren’t visible. Breast Self-Examination and other techniques such as ultrasounds or MRI’s can also help detect problems.

Treatment

There are several types of breast cancer and your treatment can differ based on what your diagnoses is. Some of the most common types of breast cancer are explained below:

DCIS – Ductal Carcinoma In Situ

This form of cancer is considered non-invasive because it stays inside the milk duct. It can grow within the duct, but will not spread into the rest of the breast tissue or to the lymph nodes. If caught early enough, DCIS can be removed with a lumpectomy, which is the removal of just the area of the breast containing the cancer. However if the cancer is large, or appears in more places throughout the breast, a mastectomy may be necessary. In most cases a lumpectomy is followed by radiation, but a mastectomy is only followed by radiation if lab tests show cancer near the edge of the removed tissue.

IDC – Invasive Ductal Carcinoma

This is the most common type of breast cancer, making up about 80% of all cases. It begins in the milk ducts and spreads to surrounding breast tissue. If left untreated it can spread to the lymph nodes and other areas of the body. Invasive cancers are given a stage to describe how far it has spread from its original location. It is based on the size of the tumor, whether or not it spread to the lymph nodes and other parts of the body. It can range from stages 1 to 4, where 1 is the earliest stage and 4 is the most advanced stage.

Your doctor will order a variety of tests to help determine which stage the cancer is at and to help determine the best treatment regime. Typically the patient would undergo surgery to remove the tumor and determine whether the cancer has spread to the lymph nodes. This surgery can range from a lumpectomy (removal of only the lump or tumor) to a radical mastectomy (removal of the breast[s] and all the muscle under the breast[s]) or somewhere in between. Radiation may be recommended after the surgery to destroy and remaining invasive IDC cells. This has also been shown to reduce the risk of recurrence.

Chemotherapy is used to treat many higher stage cancers where the cancer has spread to the lymph nodes or other parts of the body. Chemo (for short) is a medication (or combination of medicines) which enter the bloodstream to travel throughout the body interfering with rapidly dividing cells. For the most part they are the cancer cells, however there are also many healthy cells in your body which divide rapidly, such as those in your blood, mouth, intestinal tract, nose, nails, vagina and hair. Therefore the chemotherapy will also affect them causing symptoms ranging from hair loss to osteoporosis.

Your doctor may also recommend hormonal or other targeted therapies. As with any major medical diagnoses, there is follow up care that will be important to your continued health. Regular exams and tests will be required by your doctor.

LCIS – Lobular Carcinoma In Situ

Like DCIS, LCIS is not considered an invasive cancer as it does not spread into other areas within, or outside the breast. It is considered a marker for breast cancer, meaning that the person is at a higher risk for developing an invasive breast cancer in the future and should be monitored with regular mammography and ultra sounds. It is usually found in pre-menopausal women aged 40-50. It is difficult to estimate the risk of a patient with LCIS developing an invasive cancer because LCIS can go undetected, however it has been estimated that your risk increases from 12.5% for the average women, to 30-40% if diagnosed with LCIS.

LCIS is usually diagnosed when a biopsy is performed because of an abnormality in a mammogram. It does not require typical cancer treatment but should be carefully monitored to watch for early signs of invasive cancer. Talk to your doctor about medications and treatments which may help to reduce your breast cancer risk.

ILC – Invasive Lobular Carcinoma

This is the second most common type of breast cancer, making up about 10% of all cases. It begins in the lobules and spreads to surrounding breast tissue. . If left untreated it can spread to the lymph nodes and other areas of the body. ILC tends to be found in more than one area within the breast and is likely to affect both breasts. It is slow to spread outside the breast and tends to show up in the stomach, intestines and ovaries and has been known to eventually spread to the brain spinal cord tissues.

Treatments and care for ILC are similar to that of IDC and will vary depending on the stage of the cancer cells.

Some other, less common forms of breast cancer are Inflammatory Breast Cancer, Male Breast Cancer and Recurrent and Metastatic Breast Cancer.

Coping

Once you have been diagnosed with a form of breast cancer, you have so many questions that you don’t even know where to start. Most of them are likely about your health and what your options are. But there are many other factors in your life that are affected by breast cancer besides your health. Such as how will I pay for my care? What if I can’t work? How will my family cope? How will my life change?

You will need more than just medical support, you need mental and spiritual support. Who do you talk to about your cancer concerns? The same people you talk to about your everyday concerns. You should have a support group that can help you through the difficult times. If you don’t feel that you have anyone close to you that you can talk to, there are still options. Talk to a social worker or psychologist. It is important to get your thoughts and fears out in the open, and as long as you have a sympathetic ear, it will help you let go of some of those fears.

There are many support groups of other people with breast cancer and cancer survivors who can lend an ear, and can also benefit from talking with you. Ask you doctor about support groups in your area, or go the discussion boards on Breastcancer.org.

I found that being involved in fundraisers was also a great way to feel like I was in control, like I was dictating at least one part of how this disease affected my life. Last year I took part in the CIBC Run for the Cure in Victoria and raised almost $5,000 towards helping research in my area.