Delthia Ricks, M.S., is a senior medical writer for Newsday in New York. She has also been a medical writer for The Orlando Sentinel in Florida and a national science correspondent for United Press International. Her stories not only appear in Newsday but are disseminated worldwide through the LA Times-Washington Post News Service and via the Tribune-Knight Ridder News Service and the Associated Press. Ricks has received numerous awards for science and medical writing and has been awarded fellowships to study medical journalism, cancer, heart disease and genetics at Harvard, Case Western Reserve University of Medicine, and MIT. She speaks frequently before groups of patients and at meet-the-press gatherings in New York City. She lives in Huntington, New York.

Breast Cancer Basics and Beyond

TREATMENTS, RESOURCES, SELF-HELP, GOOD NEWS, UPDATESBy Delthia Ricks

Hunter House Inc., Publishers

Copyright © 2005 Delthia Ricks
All right reserved.
ISBN: 978-0-89793-454-1

Contents

Foreword………………………………………………………………………………………..xiIntroduction…………………………………………………………………………………….11: Diagnosis…………………………………………………………………………………….72: A Postdiagnosis Checklist………………………………………………………………………423: Facts, Fiction, and Urban Legends……………………………………………………………….684: Types of Breast Cancer…………………………………………………………………………895: A Primer on Risks, Part I: Age, Genes, and Ethnicity………………………………………………1246: A Primer on Risks, Part II: Obesity, Hormone Replacement Therapy, and Other Exposures…………………1567: Surgery………………………………………………………………………………………1748: Radiation Therapy: Medicine’s High-Energy Treatment……………………………………………….2079: Chemotherapy………………………………………………………………………………….23310: Hormone Therapy: Counteracting Estrogen…………………………………………………………26511: Recurrence: If Breast Cancer Comes Back…………………………………………………………28212: A Final Word: Life Beyond the Odyssey…………………………………………………………..292Appendix: Researching Breast Cancer and Finding Support via the Web……………………………………304Notes…………………………………………………………………………………………..310Suggested Reading………………………………………………………………………………..315Resources……………………………………………………………………………………….321Index…………………………………………………………………………………………..355

Chapter One

Diagnosis

I wanted it to be a lie. I sat down and stared out the window and imagined that if I sat very still all of this would just go away. But of course that didn’t happen. –Diahann Carroll, actress

When word of the diagnosis comes, however it comes-face to face with your doctor or from a nurse over the phone-life splits instantaneously into distinct parts: the time before breast cancer and the time afterward. There’s no moving backward in time. A breast cancer diagnosis brings the meaning of mortality front and center. Life from the point of diagnosis onward, survivors say, is viewed through a different lens.

From a medical viewpoint your diagnosis is a sequential process that very likely may have begun with you. You may have noticed a telltale sign such as a lump, a discharge, or a reddening or deeper discoloration of the skin. But as is often the case, the symptom may have been invisible and painless, revealed to you and your physicians only after a routine test, such as a mammogram or ultrasound.

Naturally, reactions vary to the prospects of breast cancer. No two people respond identically. You may react calmly to the news or respond with a sense of shock, disbelief, sadness, rage-or some indescribable combination. The diagnostic process may mark your first encounters with myriad medical tests and the likelihood of surgery.

Mindful of all these possibilities, this book is intended as a resource for anyone who has been told that she-or he-will be treated for early breast cancer (which involves a tumor that has not spread to a distant site). Your cancer may have been discovered at any one of several stages, from the very earliest point in a tumor’s evolution to a stage in which it has invaded deeply in the breast. Your adjoining lymph nodes, in the armpit, may show evidence of the cancer or may be free of the disease. Whatever the case, this book has been written to help you.

In this chapter you’ll meet people who recount the moment when they found a lump or were told of a suspicious shadow on a mammogram. Later in the chapter you’ll learn what doctors think about the role of mammography and other imaging procedures. The purpose of the biopsy is discussed, as is the range of emotional responses that occurs with the conveyance of unfavorable health news.

But take a deep breath. No treatment decisions have to be made within a week or so after diagnosis, even if you are facing care for invasive breast cancer. The key to emerging from the jolt of the diagnosis is to understand where in this medical odyssey you’ve been and where along its paths you have yet to go.

Noticing a Lump or Other Symptom

Finding a mass, the symptom most often associated with breast cancer, is a sobering discovery. You may have noticed the abnormality during a routine self-examination. Your doctor may have found it during a physical, or your spouse or partner may have come upon it during lovemaking. Palpable growths are not the only way breast cancer makes its presence known. Symptoms of the disease are numerous and insidious.

Your lesion may have been discovered on a mammogram and may be far too small to palpate. Or it may have developed in a nearby lymph node, producing a nodule in the armpit. Some people notice a dimpling in the breast, pronounced changes in skin texture, a discharge, or an eczema-like rash affecting a nipple.

While breast cancer usually develops silently and produces no discomfort, some patients do report episodes of breast pain preceding their diagnosis. Certain forms of the disease have very conspicuous and striking symptoms. Paget’s disease, a very rare form of breast cancer, can cause a crusting and scaling around the nipple. Inflammatory breast cancer can trigger an intense reddening on the chest. Some patients who have been diagnosed with inflammatory breast cancer report itchiness and swelling among their symptoms, which they initially mistook as the prelude to their menstrual cycle. Paget’s disease and inflammatory breast cancer will be discussed in greater detail in Chapter 4, “Types of Breast Cancer.”

Most who seek medical attention do so after discovering a suspicious lump. Forty-five-year-old Lynne J. discovered one while showering.

I had been really busy. I’d noticed a couple of times while taking off my bra that my left nipple seemed to point a little off center. I somehow thought my bra was too tight and I needed to buy new bras. One day in the shower, while soaping up, I felt a hard, gravelly lump in my left breast. I made the immediate connection with my nipple’s appearance and knew that the lump shouldn’t be there, and it was probably bad news.

I was traveling at the time. For days, I kept touching my breast to see if the lump was still there. It always was. When I got home, I called the doctor’s office right away, but at first I let them talk me into an appointment far in the future for a “checkup.” My fear of having this lump confirmed as breast cancer had to battle my fear of not having it looked at and treated. I finally called back and got an earlier appointment.

Lula F., a nurse for more than four decades, noticed an abnormality only after she developed an itchiness that wouldn’t stop. What seems unusual now, she says in retrospect, is that the itch seemed to come on suddenly, as though it were a bug bite.

My tumor was about an inch in diameter. It was at the base of my breast, just where my bra sits. I discovered it when it started itching quite a bit, and automatically I started scratching and scratching. When I looked to see what was causing the itch, that’s when I noticed the lump. That’s what takes your breath away, when you first discover it, and you think, “Where did that come from, it wasn’t there before.” I was sixty-one. This was on a Saturday. All evening I kept touching it. It was stationary. It was not moveable. That’s when I thought, “Oh, no, this is serious.” On Monday, as soon as I thought his office was open, I went to see my doctor. I explained that I had found a lump, so they ordered a mammogram. My doctor did a needle biopsy that day. That weekend I was scheduled to go to San Diego with my daughter. I didn’t say anything to her about it. When we got back, she heard the message as I was listening to my answering machine. She started asking questions: “What’s so urgent that you have to call your doctor right away?” That’s when I told her about the lump, and it was no longer a secret. She said if she had known about the lump, we would not have gone to San Diego.

Gayle-Marie A., who gave birth for the first time at age forty-two, also noticed a lump but assumed it was associated with breastfeeding, despite having weaned her son a year earlier.

I kept thinking it would go away. I had always heard that if you breast-feed your baby you won’t get breast cancer. So every time I noticed it, I thought it had something to do with being a new mom. I ignored it. It was a lump, yes, but I never knew about breast engorgement or what that was like until I had a baby. That’s why I thought the lump had something to do with all of those things you experience as a mom. It was only after I asked other mothers at the day-care center if they also had a lump after they had finished breast-feeding that I realized it wasn’t normal. No one else had gotten anything like that. That’s when I went to the doctor and they found out it was cancer.

Sometimes the initial sign that breast cancer is present eludes everybody-doctor and patient. Pat G., thirty-six, had a nagging pain that bothered her when she walked or sat. She describes it as an achy feeling that would not go away. The persistent discomfort was something she and her doctor at first assumed was an orthopedic problem.

I had a pain in my hip; that’s why I went to an orthopedic doctor. He gave me medication for it, but the pain didn’t go away. He didn’t take a bone scan or anything like that. Then about two weeks later a red area showed up on my chest, and I went to a different doctor. This doctor immediately recognized it as the “burn.” That’s what we call the redness that develops on your chest when you have inflammatory breast cancer. I was lucky because the doctor recognized inflammatory breast cancer when he saw it. I know it takes a long time for some people to get a diagnosis for this kind of breast cancer because it isn’t easy to diagnose.

Barbara G. experienced no symptoms whatsoever. Her diagnosis came after undergoing a routine mammogram.

There were no symptoms. No lump. Nothing. I felt fine. I was in perfect health. So it was very difficult hearing him tell me I had something life-threatening. I couldn’t believe it. You’re never prepared for this moment. I thought, “There’s something wrong here-he’s got it all wrong.” I was almost forty-four. I had no family history of breast cancer. So how could this happen? That’s what I was thinking.

Yvonne M., fifty-one, found she was facing cancer after an annual mammogram, a test she never thought would find evidence of cancer.

I had just gotten my yearly mammogram. I was very proactive about getting them, really consistent. It had been ten months since the last one. And I guess I never expected to have breast cancer-well, because it didn’t run in my family. But the people giving me the mammogram seemed to have some concern. The same day I got the mammogram, they did the biopsy. I was thinking the lump they saw was from drinking coffee, because I had heard that coffee can cause cysts and all kinds of other breast problems. It was February when I went in for the exam, and the doctor didn’t call me for a week. My friends at work kept telling me it was probably nothing. But he called and said, “We just got your results, and it’s not a death sentence-but it is cancer.”

Geraldine M., sixty-four, also didn’t notice any symptoms and discovered her lesion inadvertently. Apparently, a well-developed mass was growing in her right breast. It had been detected a few months earlier during a routine mammogram. No one at her doctor’s office bothered to tell her about the need for further diagnostic testing.

I went in there for a sprained ankle and came out with an Ace bandage and breast cancer. That shouldn’t have happened to a dog, but it happened to me and the Lord has kept me here to tell the story. It seems that somebody forgot to give me a call. They had filed away my chart with the breast cancer information in it. But as far as a symptom is concerned, I’d have to say it was the sprained ankle. Divine Providence put that broom handle on the back steps and made me fall. I’m told it was a pretty big tumor. But I didn’t know it was there. I didn’t feel a thing. They saw it on the mammogram.

Arriving at a Diagnosis

If your mass was not discovered on a mammogram, generally your doctor’s first step after physically examining a lump or other symptom is to put in an order for a specific set of images, called a diagnostic mammogram. This series of films will include two images of each breast. Additional images of the area involving the mass are also taken. Mammograms provide information about the position and size of the abnormality.

Studies conducted by the Centers for Disease Control and Prevention demonstrate that among women who undergo routine screening, a mammogram generally detects tumors 1.7 years before they can be felt by hand. Mammograms also spot the tiniest of lesions, including the malignant growths known as ductal carcinoma in situ (DCIS). These growths are composed of abnormal cells in the lining of a milk duct. And while they can grow to a size that you or your doctor might be able to feel as a lump, for many women these clusters are so small that it takes mammography to bring them into view. See Figure 1 to see the average tumor size found using different detection methods.

Dr. Lloyd B. Greig, a gynecologist at Cedars-Sinai Medical Center in Los Angeles, says that to obtain the best possible images a breast must be compressed to flatten it somewhat during a mammogram. To do this, a technician must position the breast on the machine’s lower metal platform. The upper one, which is made of see-through plastic, is then eased downward to compress the breast, allowing the image to be taken. Although women have remarked that some technicians can be too aggressive with compression, Dr. Greig says few patients have complained of severe pain after the procedure. “The compression is necessary to get the full diagnostic value of the mammogram,” he explains. “If this weren’t done, then an abnormality could be missed. Fortunately, it doesn’t take much time, just a few seconds. So that’s a few seconds of discomfort for taking the right steps. A diagnostic mammogram is a very important part of getting the right information about the abnormality.”

For most patients, Dr. Greig continues, the initial visits to a physician will be to a primary care doctor-a family practitioner, internist, or gynecologist-who will not only help you understand early suspicions but also get you started on the path to additional testing. Some women, he says, find it easier to pose questions and voice fears to someone they’ve known for many years. “We are familiar with the patients,” he says. “We’ve known them, sometimes for many, many years. So we can answer a lot of their questions. This is a very difficult time, and we know that it is important for patients to feel as comfortable as possible-and as confident as possible-as they face their next steps.”

Among these initial steps, he tells patients, is the need for the taking of a complete medical history, during which the following series of questions is asked:

* Is there a history of breast cancer in your family?

* What about other forms of cancer?

* Have you noticed a discharge or anything else unusual about either breast?

A complete physical examination also is required. Such simple steps are pivotal, Dr. Greig says, as patients make progress toward obtaining a definitive diagnosis.

At Cedars Sinai, he and other gynecologists work closely with specialists in the medical center’s breast-care center, where all types of breast conditions are diagnosed. A vast number of growths detected on mammograms turn out to be benign, according to Dr. Greig. And even when an abnormality turns out to be cancer, a mammogram-an X ray-cannot determine whether a tumor has spread to a distant site, such as the bones, liver, or lungs. Laboratory tests as well as additional imaging procedures, such as a ductogram, ultrasound, or MRI, may be needed to better understand your lesion.

A mammogram provides a picture only of the breast’s interior and often does not easily distinguish between tumors and other types of growths that can develop in breast tissue. The radiologist who reads your mammogram will be the first physician to view the contours of the mass and to evaluate where it is situated in the breast. The radiologist, however, does not have the final word on whether the abnormality seen on the mammogram is malignant. Any suspicions must be confirmed by laboratory testing.

In the process of diagnosis, each advancing step either confirms or rejects suspicions from the previous step. The linchpin in the diagnostic process is the biopsy, a test in which a small amount of tissue is removed from the breast to be closely examined in the laboratory.

What Cancer Specialists Think about Mammography

Doctors involved in virtually all aspects of your care will want to know the results of your mammogram as well as the findings from the tests that follow. The mammogram, therefore, is of importance not only to the radiologist. Viewing the mammogram also ultimately helps direct the surgical oncologist in how best to operate to remove the cancer. With such a detailed image of the breast’s interior, the surgeon essentially has a map, and thus in many cases is enabled to perform a more precise, breast-sparing operation.

Dr. Lisa Newman, director of the Breast Care Center at the University of Michigan’s Comprehensive Cancer Center in Ann Arbor, says the mammogram is critical as patients embark upon each of the steps involved in a breast cancer diagnosis. She says, “When breast cancer is suspected we do not want to leave any stone unturned. The workup is intense, and I think patients appreciate that fact. The mammogram is very important in the overall scheme of things.”

(Continues…)

Excerpted from Breast Cancer Basics and Beyondby Delthia Ricks Copyright © 2005 by Delthia Ricks. Excerpted by permission.
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