What's the best way, in 2009, to beat breast cancer?

August 16, 2009 3:30 PM

My wife has breast cancer - the tumor, discovered only last week, is now just under 4 centimetres and it has reached at least one of the lymph nodes - probably caused by the breast biopsy itself, but a metastasis all the same. Please help us decide whether we're doing the right thing.

We've decided not to go anonymous, in the hope that any sympathy for her (Schweppes Girl) or for me would convince someone to help us.

Although we trust our surgeon here in Portugal and feel lucky for all the help we've received, we'd still like to have an informal second opinion, from oncologists and breast cancer survivors who know (or can guess) what awaits us.

Maria João is 41; has no family history of cancer; has never had babies and has a regular menstrual cycle.

The plan we've been given is as follows:

1) Chimiotherapy: 4 sessions, 3 weeks apart with steroids the day before before and docetaxere and daunomycim.

2) Lumpectomy in November

3) Radiation therapy (5 weeks, daily)

4) Tamixofen (an estrogen-blocking, menopause-induciing drug) for 5 years

5) More chimiotherapy after the surgery

We get the impression that the breast tumor is easy: it's the cancer that is difficult to prevent from recurring. Also that, since she's young and healthy, the cancer is more invasive and the treatment can be as aggressive as it possibly can be.

Is this too much? Is this too little? What can we expect? Maria João is very feminine (apparently just feminine enough for the greedy cancer) and it breaks my heart to hear her say she will never be the same woman again. Body change is the problem, since she's dysmorphic already.

We live in Portugal - it´s a small country with not that many specialists and a noticeable time-lag (and conservativeness) regarding the latest discoveries.

This is why we're appealing to you: not because we aren't grateful for the quality of the medical assistance we are getting. But because of the distance, in time, in space and in research.

Reassurance would be fine. Anything else would be wonderful.

Thank you,

Maria João and Miguel

posted by MiguelCardoso to health & fitness (17 answers total)

Based on what you've said about the tumor size and the spread, assuming it hasn't gone anywhere else, it would be somewhere around stage IIB or stage IIIA. Everything you've listed that they've suggested for treatment is pretty standard for either of those stages.

In some cases, she may still have the option of lumpectomy rather than mastectomy if the chemo she gets before surgery shrinks the tumor enough. Regardless of whether it shrinks enough to avoid mastectomy, chemo after surgery is something common to do, as is tamoxifen if her cancer is estrogen-receptor positive.

It is unusual, though, that a breast biopsy would cause the cancer to go to the lymph nodes. Did the doctor say that's the cause?

I would definitely contact the Liga Contra O Cancro. Their website doesn't seem to have a lot of information on cancer treatment in Portuguese, but they do also have an information phone number listed on their site.

Portugal is also a member country of Europa Donna, a European breast cancer organization, and they have a phone number for Portugal: 351 289 359 516.

Best wishes!
posted by ishotjr at 4:03 PM on August 16, 2009

Just wanted to add that I am not a doctor or a nurse, and the information is based just on what you shared, the stage could be totally different, especially depending on if they find the tumor is bigger or smaller when they do surgery, or find different info on the lymph node involvement, etc.
posted by ishotjr at 4:05 PM on August 16, 2009

It is unusual, though, that a breast biopsy would cause the cancer to go to the lymph nodes. Did the doctor say that's the cause?

No, ishotjr (and thank you so much for your kind answer and positive suggestions) - he said it might be the cause. From what I've read, removing a cancerous tumor causes the tumor to shed cancerous cells, falling wherever they fall, spreading the cancer to where they wouldn't have reached on their own.

Pricking the tumor in the breast might lead the "rubbish-bin" lymph nodes to catch and retain the dangerous cells.

But then removing these lymph nodes causes an horrendously new set of problems. Lymphedema is one of the nightmares.

Thank you ever so kindly, ishotjr!
posted by MiguelCardoso at 4:18 PM on August 16, 2009

i don't have any suggestions, but i wanted to offer my best wishes on a thorough fix and speedy recovery.

i have had cancer, and this is one of the things that i found reassuring when i was looking at treatments: for a cancer patient, statistics on cancer are *always* pessimistic. because those statistics are based on people who were treated in the past, and your wife will be treated in the present or the future.

good luck.
posted by rmd1023 at 4:43 PM on August 16, 2009 [1 favorite]

I am so sorry to hear about this devastating news. My thoughts go out to Maria João today.
posted by pluckysparrow at 5:00 PM on August 16, 2009

This sounds almost exactly like what one of my church friends went through several years ago. For what it's worth she is fine now!
posted by St. Alia of the Bunnies at 5:06 PM on August 16, 2009

Sorry to hear this. The latest American standardized guidelines and treatment algorithms can be found at nccn.org.
posted by gramcracker at 5:13 PM on August 16, 2009 [1 favorite]

It appears they are following the algorithm for what we know works best at this point in time.

My sympathy to your wife and yourself; knowing there's cancer is rough even when there's a good plan.
posted by reflecked at 6:32 PM on August 16, 2009

Also that, since she's young and healthy, the cancer is more invasive and the treatment can be as aggressive as it possibly can be.

This is what my mother was told. She was diagnosed when she was in her 30s.

Possibly completely outdated and irrelevant, but at that time the standard care for younger women with breast cancer in Houston was:
1. Radical mastectomy, removing the breast and lymph nodes in the armpit.
2. Estrogen-eliminating drugs and surgeries (removal of ovaries; medicine to further reduce estrogen, because the estrogen made the cancer more aggressive)
3. Chemotherapy
4. Radiation

Steps 3 and 4, in that order, were repeated every time the cancer came out of remission.

I strongly recommend finding a doctor who can co-doctor with yours, who is affiliated with a leading cancer research center (the one I think of is MD Anderson, but that's in Houston -- but they will treat you). The benefit of doing this is, in a research center they have access to the very latest studies and research. For example, my mother was able to take tamoxifen before it was generally released -- it was called taxol, and we only knew it was a miracle from a yew tree. It gave her a 5-year remission, which she would not have had if she had not been part of a study. With the studies, they give you a known drug and an experimental drug at the same time, so you are not risking much.

I am sorry to hear about your wife. Maria João will not be less of a woman; she will be a strong survivor. These will be just a few war wounds from her courageous battle. Both of you will be brave, and fight this side-by-side.
posted by Houstonian at 7:07 PM on August 16, 2009

Maria João and Miguel,

Lady Widebottom went through the following Treatment Plan Last Year for Breast Cancer in Washington D.C.

She was Diagnosed on April 1st of 2008 (Age 41, No children, some history of cancer in the family). They gave her an MRI to locate the tumor and she had a Lumpectomy 3 weeks later. A couple of weeks after that she went into Chemotherapy: 8 Treatments, 1 every 3 weeks (Unfortunately, I do not remember all of the specific Drugs. One of them was Taxotere). 6 weeks after completing Chemo, she began 6 weeks of Full Breast Radiation (5 days a week). She will be on Tamoxifen for the next 5 years.

The Hospital performed a Sentinel Node Biopsy when they did the Lumpectomy to determine if any cancer cells had spread to the Lymph Nodes. It was explained to us that there are fewer problems with lymphedema with the Sentinal Node procedure, but I am not sure if it applies in your situation since they have already made the determination that some cancer cells have spread there.

From my understanding. Lumpectomy+Radiation yields the same recurrence rate as Mastectomy, so the Breast-Conserving surgery is preferred if the tumor is small enough.

Our surgeon proposed that we might want to use Partial Breast Radiation Therapy instead of Whole Breast, but our Radiation Oncologist told us that was not an option for us. Unfortunately, I do not remember why.

From the discussions we had with our doctors when we were determining the treatment plan, I would guess that your doctors are going with Chemo instead of Surgery first since they have found cancer cells outside of the breast. However, I am not a doctor, so that is just speculation.

We finally finished all the treatments in January of this year (except for the Tamoxifen). It has taken a while for her to get her energy back, but she has started to feel much more like herself in the last couple of months.


From Our experience (and in no particular order):

Ask Questions. If you are not certain you understand what the doctor said, ask until you do. Do not take anything for granted. Do not hesitate to wake a doctor up in the middle of the night if you have a concern. The Doctors work for you

The Lumpectomy was fairly painless, She was able to move around normally within a couple of days, though the breast and side/armpit area were tender until healing was complete.

The side effects of Chemo are cumulative. After the first treatment, she will probably feel tired and sick for a couple of days but fairly normal until the next treatment. Recovery time is longer after each one. If her being able to work weekdays during Chemotherapy is a concern, try to schedule treatments for Thursday/Friday.

After having chemo, Radiation therapy does not seem that bad (according to the Mrs). The main effects are tiredness and the feeling of having a permanent sunburn on the breast. The Doctor should give her some stretching exercises to do to help keep the muscles in the irradiated area from tightening up from the treatment.

Lady W gets hot flashes from the Tamoxifen and has gone into early menopause as a result of the treatments. From my understanding this is not a guaranteed outcome, but is generally likely.

Again from what we were told, Hair loss from chemo is not guaranteed, but is generally likely. Never fear, it will grow back.

During and after Chemo, she had to deal with some problems from having a compromised immune system. Specifically, she developed a couple of skin infections on the treated breast. This was also a bit of a social hindrance since we felt we had to be careful who she was exposed to.

Once you have completed all the treatments, there is still recovery time. It was frustrating for us because we had mentally set ourselves up to think "It's over", but she did not immediately start feeling better. It took a couple of months, but we got to a point where she was noticeably more energetic on an almost daily basis. Be patient.

Miguel, There is going to be a lot of stress and frustration for you because it may feel like there is not a lot you can do except be there to support her and take care of the things she cannot do for herself. This will effect your health. Be aware and try to find some time to take care of yourself.

Your Friends and Family can be a huge resource in getting through this. Let them help you.

-----

There is no nice way to put it. The next year is going to be hard for your family. One of the most difficult things for both of us was that it was not a problem that we personally could solve. Instead, it was something that we had to endure. There will be times when you are frustrated and angry because you want it all to be over with. Just remember that it will pass. You will endure. You both will make it through. Do not doubt that for a second.



-Scott and Caroline
posted by Lord Widebottom at 7:51 PM on August 16, 2009 [6 favorites]

Sounds similar to what my mom is going through right now.
I don't know all the drugs she is taking. She is in Houston, for what it is worth. Houston has some of the best hospitals for cancer (MD Anderson and Methodist)

They removed the tumor and 1 lymph node.
She is now going through Chemo. 6 rounds, 3 weeks apart. Blood work every week.
I know that she is taking all kinds of stuff before her treatments.
Then she will go for 5-6 weeks of daily radiation.
Then some sort of hormone blockers.

We have no family history of breast cancer. She was told it was an aggressive form of cancer.
I am glad you are so supportive. Keep it up. She will need it. Mom can get very emotional. She has highs and lows. She knows it is from the Chemo but that doesn't help. Some days she feels fine and other days she doesn't leave the house (emotions and physical pain).

Check out the site: I'm Too Young For This! it is for young people with cancer.

best of luck.
posted by nimsey lou at 7:57 PM on August 16, 2009

Doing chemo before the surgery strikes me as a bit unusual--the several friends I have who have experienced breast cancer have done it the other way around--but there may be a good reason for this in this case. It's something to think about asking the doc, though, or perhaps getting a second opinion.

Another thing that strikes me as unusual, again from second-hand experience, is the suggestion of a lumpectomy for a cancer that has lymph node involvement. As a close friend's health care proxy, I was part of all the discussions with her surgeon, and one of the things that surgeon said was that if there was lymph node involvement, she (surgeon) felt that total mastectomy was a must. Of course, that's one surgeon's take on it, but my friend's oncologist definitely held the same view.

Again, every case is different, but I am assuming that this is the kind of feedback you want. The friend whose health proxy/after-surgery companion I was has been cancer-free for two years now, and I wish the same good short-term outcome, and a long and healthy life, for Maria João.

The body dysmorphia thing is so real and so difficult, but the good news is that there are lots of psychiatrists and other counselors who specialize in helping women work through that. Reconstructive surgery has also advanced tremendously, so that's a possibility to keep in mind for the long term.

You will both be in my thoughts.
posted by Sidhedevil at 8:00 PM on August 16, 2009

I'm a breast cancer survivor -- 9 years cancer free. My situation was as follows:

I was 41 when the cancer was found' no family history; 2 kids

I was also told that breast cancer in pre-menopausal women is considered aggressive and is treated aggressively

I had surgery first, a lumpectomy (sometimes called a partial mastectomy or segmentectomy by my surgeon)

Then I had radiation, 5 days a week for 5 weeks

Then chemotherapy, 4 times, 3 weeks apart. I lost all my hair, but it didn't bother me too much. And when the new hair grows in, it's beautifully soft.

Then 3 years on Tamoxifen. I was originally told I would be on it for 5 years, but I started having some menstrual problems and it was thought Tamoxifen might be the cause, and 3 years was considered adequate.

I found the surgery the easiest to recover from and was away from work for only 2-3 weeks (can't remember exactly now!). I got very tired from the radiation, although I went to work every day. I'm not sure if it was the radiation or just the daily routine: leave work, take the bus to the hospital, get undressed, wait, have treatment, and then the whole thing in reverse back to work. The chemo was somewhat difficult although I worked through the first two treatments taking only a few days off after each, but then took the entire 6 weeks off for the last two treatments. I found eating popsicles (frozen juices), particularly citrus flavours, very soothing and helpful with the nausea.

I am fully recovered. The affected breast is half the size of the unaffected breast, but I don't bother with a prosthesis. You have to be looking at me pretty closely to notice. I don't care -- it's not like I have anything to be ashamed of.

This may be too much informationm but I include it as sometimes it's this sort of concern that couples have. My husband and I did not really have sex during my treatment, apart from cuddling and holding each other, not because he found me unattractive but because I didn't feel especially well and I was too wrapped up in my own treatment to pay him much attention. Tamoxifen can also lead to vaginal dryness but any standard lubricant can remedy that. Things between my husband and me are completely as they were before I had cancer.

Every person is different, and cancer treatments change as new research is done. But if I can help, please send me a MeFi mail. Good luck and best wishes to you both.
posted by angiep at 8:05 PM on August 16, 2009 [4 favorites]

Anti-inflammatories, in particular, coticosteriods, before docetaxel, are standard -- it's a cytotoxin, it's hard on the body. It seems to have a positive syngestic effect with radiation therapy. It will probably give the classic cancer side effects -- loss of hair, apparently the trick of cooling down the hands and feet helps prevent loss of nails.

Daunomycim is somewhat suprising here -- that's mre commonly used in leukemia, not breast cancer, but I don't know, and your oncologist does, what the exact form of cancer Maria João has. It is part of a class of drugs -- anthracyclines -- that are used to treat breast cancer. They are a two faced coin. They are very effective antibiotics and anticancer agents, but they are very hard on the body - cardiotoxic, nauseating, and damaging to tissues. Ask your oncologist about Dexrazoxane/Cardiooxane to help protect against heart damage.

The late lumpectomy is becoming more and more common, from what I gather -- the idea being to knock the hell out of the beast, then excise it. You end up with less tissue loss, and make it less likely to spread after the lumpectomy. The old-school way would be a radical mastectomy, to try to remove all the areas it could have spread to, then radiation and chemo to knock it back.

It certainly looks like a plausible and rational treatment plan. It also looks like a pretty hard one, which is good, in the sense of most likely to work, but bad, in the sense of you have to live through it.

There's a reason it's called remission, not cure -- it can come back in later times. It's a long, hard road -- I dearly wish I could tell you it was easy, but I can't. It will be a long, hard fight, and it might be one that you lose.

The easiest way for you and her to lose is this -- for her to lose hope. You can't take the meds, you can't lose the hair for her, you can't throw up for her (and nothing makes your live suck like the fourth day of repeated vomiting.)

She will be caught in the storm. You must be her anchor. The stronger you are, the more she can lean on you, which means she can deal with the harsh treatments that are the best chances she has. So what you will need is someone you can lean on -- you can let your fear be known to, you can scream at, you can cry with -- so that when she needs you for those things, you can be there.

The best thing you can do to be her anchor is to have your own anchor.

It's a long road -- but it can be crossed. You can beat this. I won't lie -- you might not. She might die of this, soon. But it is not *certain* that she will, and the more than you can convince her that it is worth fighting, the more she can fight, and the more likely that you two will win.

This is going to be hard -- no way to dodge that.

I wish you the best, and I'm looking forward to you telling us exactly what drinks you are having at the five-year remission celebration.
posted by eriko at 8:06 PM on August 16, 2009 [1 favorite]

A good friend had the same treatment a few years ago, with full breast removal and removal of some suspect lymph nodes.
A year later she went on a two-month walking tour with vim and vigor.

The treatment is rough (chemo was the worst), but the outcome can be very good indeed.
posted by Billegible at 8:15 PM on August 16, 2009

I remembered from a past question of yours that you are Jewish. If Maria João is also Jewish, and especially if she is Ashkenazi, it is possible (but not likely) that she carries a genetic mutation that could predispose her to some forms of cancer, including breast and ovarian cancer.

Here is some more information on the BRCA genes. I don't know if it is standard practice to test for this in Portugal, especially given the relatively small Jewish population.

I don't mean to add to your anxiety, and I imagine that the chances of this being a factor are very small. But it is better to know and be sure so the treatment can be tailored appropriately.

Holding a good thought you for and your wife. I'm sure having such a thoughtful husband is helping her immeasurably right now.
posted by charmcityblues at 8:30 PM on August 16, 2009

Thank you for your generous help and solidarity.

We are less afraid now. And have more to think about.

Bless you all,

Maria João and Miguel
posted by MiguelCardoso at 1:24 PM on August 17, 2009