Mammary gland at 40x under lab microscope (Accessed July 2016)
Beginning with this post, we will be following the progress of my friend Diane, who is currently undergoing treatment for breast cancer and has generously agreed to tell her story.
Along the way, we will provide reliable information and resources to help others following “the patient path” while dealing with, and managing, their breast cancer.
Also see:
Diane’s Story Part 2—Diagnosis
INTERACTIVE POST: Highlighted/underscored text, images, and media contain links to reliable external resources. The stories, information, and resources on this site are intended to supplement—not replace—the advice of your clinical team.
A Lady–& Gentleman–Killer: A Few Breast Cancer Statistics
Based on the American Cancer Society’s (ACS) Cancer Facts and Figures – 2016 and American Cancer Society’s (ACS) Interactive Cancer Statistics Center – 2016, the Susan G. Komen breast cancer organization and BreastCancer.org report the following breast cancer statistics in the US, based on a current US population of about 324 million (third in a world population of about 7 billion after China and India):
WOMEN
In 2016, it is estimated that among US women there will be:
- 246,660 new cases of invasive breast cancer. This includes new cases of primary breast cancer among survivors, but not recurrence of original breast cancer among survivors. The two most common types are invasive (infiltrating) ductal carcinoma (IDC), which represents approximately 80% of all breast cancers, and invasive (infiltrating) lobular carcinoma (ILC). (See the figure below.)
- 61,000 new cases of in situ breast cancer. This includes ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). Of those, about 83 percent will be DCIS, a non-invasive breast cancer. LCIS is a condition that increases the risk of invasive breast cancer.
- 40,450 breast cancer deaths.
MEN
Breast cancer in men is rare, but it does happen, at about one-hundredth the rate in women. In 2016, it is estimated that among men in the US there will be:
- 2,600 new cases of invasive breast cancer. This includes new cases of primary breast cancer among survivors, but not recurrence of original breast cancer among survivors.
- 440 breast cancer deaths.
Invasive (Infiltrating) Ductal Carcinoma (IDC) – BreastCancer.org
Breast profile:
A Ducts
B Lobules
C Dilated section of duct to hold milk
D Nipple
E Fat
F Pectoralis major muscle
G Chest wall/rib cage
Enlargement
A Normal duct cell
B Ductal cancer cells breaking through the basement membrane
C Basement membrane
Invasive (Infiltrating) Lobular Carcinoma (ILC) – BreastCancer.org
Breast profile:
A Ducts
B Lobules
C Dilated section of duct to hold milk
D Nipple
E Fat
F Pectoralis major muscle
G Chest wall/rib cage
Enlargement
A Normal duct cell
B Lobular cancer cells breaking through the basement membrane
C Basement membrane
According to the GLOBOCAN 2012 fact sheet from the International Agency for Research on Cancer (IARC) and World Health Organization (WHO), more than 1.7 million new cases of breast cancer occurred among women worldwide in 2012 (most recent data available). Global outreach is also available at Susan G. Komen.
The National Cancer Institute (NCI) reports that breast cancer ranks behind only skin cancer as the most common form of the disease in US women, again with an incidence of only about one-hundredth the number of cases in men: in 2010, about 2,300 new cases of breast cancer were reported in men compared with about 230,000 new cases in women. In 2016, NCI’s Surveillance, Epidemiology, and End Results (SEER) Statistical Fact Sheet on Female Breast Cancer, like the ACS report, cites the number of cases in women as 246,660, with a death rate of about 40,450.
The Centers for Disease Control and Prevention (CDC), using 1999–2013 cancer incidence and mortality data, also cites breast cancer as the top-occurring cancer among women (with skin cancer the most common form across genders), occurring in 123.7 per 100,000 women of all races and Hispanic origins in the US (Hispanic origin is not mutually exclusive from race categories). It further reports that breast cancer is the leading cause of cancer death in 20.7 per 100,000 American women.
The NCI also states that the most common type of breast cancer is ductal carcinoma, which begins in the cells of the mammary glands (see the microscopic enlargement of a duct at the top of the page). Breast cancer that begins in the cells of the lobules and in other tissues in the breast is less frequent. Invasive breast cancer is cancer that has spread (metastasized) from where it began in the ducts or lobules to the surrounding tissue.
Anatomy of Female Breast. National Cancer Institute. Click to enlarge.
The CDC says that some women are at higher risk for breast cancer than others because of their personal or family medical history or because of certain changes in their genes.
The short video animation below shows you how cancer forms in the breast. Going forward, we will dig deeper into this scary disease—but we will do it with hope. Medical science and personal heroism are doing much to blot out this blight on our health and well-being landscape. See Basic Information & Statistics below for more educational and informational resources.
Breast Cancer Animation Video
Click to view on YouTube
Now let’s follow one woman’s courageous journey with breast cancer, starting from where I learned about her story. . . .
Diane’s Story—Invasive & Non-Invasive Lobular Carcinoma, Right Breast
“To say that I was shocked by my diagnosis is an understatement. When the doctor told me, I actually said, ‘But I climbed a mountain this morning! How can I have cancer?’”
This was the first thing Diane told me about her breast cancer news: that she couldn’t believe it. A common reaction, I felt the same way when I was diagnosed with uterine (endometrial) cancer in 2013. Diane and I lost touch back then, but two months ago I learned from a mutual friend that Diane had breast cancer, and I emailed her to offer support. Through additional emails, I began to see that Diane’s approach to dealing with and managing her cancer was similar to mine: positive and proactive. She was definitely on “the patient path” as an informed, involved member of her healthcare team.
We met for lunch on a lovely day in mid-June in downtown Flemington, NJ, a few blocks from the courthouse where the Lindbergh baby kidnapping “Trial of the Century” took place in 1935. Sporting a flattering wig, Diane looked as healthy, strong, and youthful (she’s in her mid-fifties) as the last time I saw her a few years ago. A believer in healthy eating and nutrition, she chose a restaurant that offered fresh and healthful menu options. We had a delicious meal and a fun, inspiring catch-up chat.
Tall, slender, and attractive, Diane is someone I had secretly envied because she has always been committed to a rigorous health regimen, covering all the basics—a balanced diet, a regular exercise routine, a healthy lifestyle, and sensible hours. Except for this “little thing called cancer,” it paid off in general good health and well-being. The one thing she couldn’t control was the amount of estrogen flowing through her body.
Estrogen—Friend to the Young, Foe to Those of a Certain Age
After a biopsy on March 30, 2016 confirmed that she had stage two, grade three invasive (infiltrating) lobular carcinoma (ILC) and also lobular carcinoma in situ (LCIS) of the right breast, Diane consulted an oncologist. He told her that her cancer is estrogen-positive, and estrogen was a high risk factor in my uterine cancer as well. (See the discussion of Diane’s pathology results in Part 2–Diagnosis.* Click to read more about types of breast cancer.)
In an email, Diane said to me: “I believe 
you and I had a discussion at some point about how my late menopause put me at risk for uterine (endometrial) cancer. I have been going to the doctor regularly and was monitored for that, and all was OK.”
Diane went on to say that she had read the list of risk factors for uterine (endometrial) cancer on this blog, and excess estrogen is a component of many of them. “However, the late menopause also put me at risk for breast cancer. Per my oncologist, all that estrogen circulating through my body each month for so many extra years was actually feeding the cancer. This and the denseness of my breasts were the only risk factors I had.” (See Breast Cancer Risk Factors for more information.)
She also said that rereading the list of uterine cancer risk factors “reignited my concerns with my doctor’s recommendation of taking tamoxifen for 5–15 years after [breast cancer] treatment. I feel I am at very high risk for developing that [uterine cancer] as well.”
Tamoxifen (TMX), the generic name of Nolvadex (pill) and Soltamox (liquid), is the oldest and most-prescribed selective estrogen-receptor modulator (SERM). It is approved by the US Food and Drug Administration (FDA) to:
- treat women and men diagnosed with hormone-receptor-positive (but not negative), early-stage breast cancer after surgery (or possibly chemotherapy and radiation) to reduce the risk of recurrent cancer;
- treat women and men diagnosed with advanced-stage or metastatic hormone-receptor-positive (but not negative) disease;
- reduce breast cancer risk in women who haven’t been diagnosed but are at higher-than-average risk for disease.
Although according to the ACS, tamoxifen acts as an anti-estrogen in breast tissue, it acts like an estrogen in the uterus. In women who have gone through menopause, it can cause the uterine lining to grow, which increases the risk of endometrial cancer. This risk may be low (less than 1% per year), but I, too, would be concerned if I were in Diane’s shoes. (In fact, at one time I took tamoxifen for a brief period for bad PMS symptoms, long before developing uterine cancer.)
*See Johns Hopkins Breast Center – Breast Pathology for information on interpreting your own pathology report and My Breast Cancer Coach for a personalized information guide based on your pathology results.
Chemotherapy First—Surgery Later
By the time the tumor was biopsied on March 30, 2016, it measured 4 cm (a little more than 1½ inches). Diane said “it was significantly smaller when I went to my gynecologist about it last August.” This means the tumor grew quite a bit since she first felt it the year before. So her breast specialist (surgeon) referred her to an oncologist for chemotherapy to reduce the size of the mass before surgery.
Diane saw the oncologist the next day, April 5, 2016—eight months after she first detected the lump on August 4, 2015 (see Part 2). Her doctor ordered several scans before beginning chemo the following week, including:
- A multigated acquisition (MUGA) scan, which some people may need before chemotherapy to find any pre-existing heart condition. Also, some types of chemotherapy, such as anthracyclines, may damage the heart during cancer treatment (see Adriamycin below). Using zinc as a contrast material, the scan creates video images of the lower chambers of the heart (ventricles) to check for any abnormalities in size and whether they are pumping blood properly through the heart. Other names for this test include cardiac blood pooling imaging, nuclear heart scan, nuclear ventriculography, and radionuclide ventriculography.
- CAT (computerized axial tomography) scans of the bones, liver, and lungs—the first places cancer spreads to, the brain being the last. She had three CT scans, one after the other, which took over an hour. Although no physical pain was involved, Diane said, “It was difficult emotionally, because so much of my future depended on the results. I just kept trying to focus on the fact that both my breast specialist and oncologist felt the cancer hadn’t spread.”
After her scans and pre-operative tests came back normal, Diane had her first chemo treatment by IV the following Monday, April 11, 2016. Her chemo port was inserted surgically under general anesthesia the following week by her breast specialist, and a sentinel node biopsy was done at the same time. Diane said her doctor could feel that this lymph node was not enlarged and probably not cancerous, and when she talked to her surgeon the following week, she learned that “the sentinel node, the first node the cancer would hit as it left the breast, was negative for cancer cells—a huge positive and some good news the day before my birthday (April 28).”
That same week, Diane began receiving her chemotherapy drugs through the port, which she says is painless. But just to be sure, she smooths Lidocaine ointment on the skin overlying the port and covers it with plastic wrap so she won’t feel the needle insertion. She also puts her hands and feet in ice during the treatment, which lasts an entire morning, because some believe this helps prevent peripheral neuropathy (numbness, tingling, or pain in the extremities). (See Before You Begin Chemotherapy for some helpful information to help you prepare for treatment.)
Her chemotherapy protocol consists of 4 doses of a combination drug—AC—and 12 of a third drug—Taxol, for a total of 16 treatments. AC is a cocktail of two chemotherapy drugs: doxorubicin, which goes under the band name Adriamycin, and cyclophosphamide, whose brand name is Cytoxan. Adriamycin belongs to a group of chemotherapy drugs known as anthracyclines (a type of antibiotic). Cytoxan is one of another group of chemotherapy drugs known as alkylating antineoplastic agents, which damage the DNA of cancer—as well as normal—cells, particularly cells that divide frequently, such as those in the gastrointestinal tract, bone marrow, testicles and ovaries.
Diane said the four treatments with AC were the worst she experienced during her chemo: “AC knocked me out for about a week after I had it. It’s not for sissies.” Known as “the red devil,” AC has “many nasty side effects,” including hair loss, lowered blood counts, nausea, fatigue, and mouth sores. “I experienced all of these side effects. AC treatments, which are supposed to be the hardest (I certainly hope so), are pretty brutal, but I got through it. I actually asked my oncologist if any of his patients ever died from the AC. He just chuckled in response. I said ‘Is that a no?’ He said yes, it was.”
One of the most dangerous side effects of chemotherapy is leukopenia, or a low white blood cell (WBC) count, which can lead to decreased immunity and increased infections. Counts are measured in thousands of WBCs per microliter (mcL) of blood. According to the Mayo Clinic, a normal range is 3,500 to 10,500 mcL. Diane said, “At their lowest point, my WBC counts were .8.” (This translates to 800 mcL, less than what the Mayo Clinic calls the “concerning” range below 1,000 mcL.) “I used to edge away from people in the waiting room when I got these results. In addition, for three out of four of the treatments, I ended up on antibiotics due to infections contracted as a result of the lowered WBC count.”
At this point, Diane is finished with her 4 doses of AC and is now halfway through her 12 weekly doses of Taxol, the brand name for paclitaxel. This class of chemotherapy drugs, known as taxanes, interfere with the ability of cancer cells to divide.
She reports: “Taxol, is much easier for most women, including myself, to tolerate. I have had no nausea and much less fatigue. My biggest problem is that my mouth is burned from the chemo (I also had this with the AC), and there are many foods that I can’t eat (anything with any spice, citrus, vinegar, and on and on). Also, my nails have stopped growing. However, overall, I feel much better on this one.”
When we met last month, Diane was already into her Taxol treatments. And she really did look great, although she has had to adjust to her altered appearance. “Just about all of my hair is gone, including eyelashes and eyebrows, and a few of my nails are coming off. I sometimes actually flinch when I look in the mirror. I often can’t believe that bald woman with no eyebrows or eyelashes is me—it’s surreal sometimes.” But the good news? Her tumor has shrunken. “I am doing fine,” she says. (Personal observation: Diane shares; she does not complain.)
Diane describes her current life in generally positive terms: “I’m feeling a little isolated right now, although I do have extraordinary support in my life. I am not working for the first time in many years . . . so I am hanging around the house more than I would like.” But she says she is happy to have this opportunity to slow down after a lifetime of raising and family and pursuing a career. “I am currently on disability, so I have lots of time on my hands, which I have to say is kind of fun (yes, even with cancer) after so many years of never having a free moment.”
And she does appreciate a little help. Diane told me about two organizations that assist women undergoing active treatment for breast cancer: Cleaning for a Reason, a volunteer group that offers free monthly housecleaning, and Look Good Feel Better, also a volunteer group that does makeovers and offers free beauty products. Not only that, but she learned about a respite home, Mary’s Place by the Sea, where women undergoing cancer treatment can stay at a beach house free of charge for up to three days and be nurtured and pampered. Diane said, “While there, we can participate in yoga, meditation, counseling, reiki, massages, and other activities. I was so excited to find it and immediately signed up.” I wish I had I known about these services a few years ago! See more under Services & Support below.
Happily, Diane also has her daughter’s wedding to look forward to next month. Just yesterday, checking in about her chemo status, she said, “I am ten down, six more to go (yea!). I started chemo on April 11 and am scheduled to finish on August 22. This is provided that my counts continue to hold up and I can get my treatments every week. If they do, I will probably ask to skip it the week before the wedding and finish up on August 29. Then I have three weeks to a month to ‘get stronger’ per my doctor and then surgery.”
I am looking forward to getting together with Diane soon for another healthy meal and also a walk in the park—although I already know I won’t be able to keep up with her.
Upcoming Surgery and a Cautionary Tale—Trusting Your Instincts
Diane is getting proper and appropriate chemotherapy before her breast surgery, which will probably be in early fall. “I am not sure at this point if it will be a mastectomy or lumpectomy. We will know more about that after I get a repeat breast MRI.”
She also, wisely, plans to get second opinions from another oncologist and another surgeon about her options before committing to a surgical and further treatment plan. “Sources like your blog are an enormous help. It’s especially good for me to be reminded that I am in charge here and can be my own advocate.”
But her experience with getting properly diagnosed early on cannot be described in very positive terms. As we’ll see next time when we look back at the start of her story, Diane’s instincts were intact and were ultimately more trustworthy than her gynecologist’s and breast specialist’s early opinions.
We leave you with this final thought for now: Cancer is a disease that can be managed and very often conquered. As Diane said to me, “It’s wonderful to hear that you are recovered from your [uterine] cancer and are doing well. I so love success stories! These are the kind of things that help me so much.”
Here’s to the success of all our sisters (and brothers) with breast cancer and our sisters with any of the gynecologic cancers.
Click for a Comprehensive List of Breast Cancer Resources
Also see:
Diane’s Story: Part 2–Diagnosis
Diane’s Story: Part 3–Surgery
Breast Cancer Risk Factors
INTERACTIVE POST: Highlighted/underscored text, images, and media contain links to reliable external resources. The stories, information, and resources on this site are intended to supplement—not replace—the advice of your clinical team.
The Patient Path 
Thank you for this post, Pam. Excellent presentation. I, agree, Diane is beautiful, strong and admirable. Your collaboration with her will benefit many. Cheering you on, Diane–get well, be well, stay well. 💖💕
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Thanks so much, Pat. I am grateful to you for informing me of Diane’s condition. She’s traveling a very rough road, but doing so with strength, dignity, and resolve. I’m so happy she is sharing her story for the benefit of others.
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