Sunday, April 3, 2011

Conversation with a Brave Fighter, Read Full.

BrustImage of Percentage of Breast Cancer Seen In each of the Four Quadrants and Nipple.It all started from a Friend Connect in Facebook and progressed to a conversation that can be posted as a FAQ on my blog. I, of course sought permission from the brave fighter, a lady, who gracefully agreed to it. For privacy reasons, I do not include her name.
I invite you to fully read the conversations between her and me. It wandered from a disease called breast cancer, the role of government, the helplessness felt by many folks without access healthcare, emotions, a few little offbeat remarks and conclusion.
It was morning in India and night in America, when a new friend revealed that she suffers from cancer.
Me: Dear, you look healthy too.
She: LOL - given that I just went about four rounds in the boxing ring with cancer, thank you! I think I FEEL amazingly good, all things considered!
Me: What cancer?
She: Breast cancer. Caught early, though.
Me: Ohh. When it was?
She: Diagnosed in December.
Me: December? Which year?
She: Um, last year. A few months ago. I had surgery in late January to get rid of it.
Me: I think you must have taken all measures in investigating the disease. You must be on some medications, I suppose.
She: Nope. Well, nothing I wasn't on beforehand. Surgery got it all. It was kind of drastic, but I don't like to mess around - and I didn't want this thing ever to come back. I didn't want to spend my life looking over my shoulder, wondering if it did.
She showed me a photo taken just a few days ago, following the second of several planned “reconstructive” surgeries.
Me: You look pretty well. Perhaps you should take tamoxifen or raloxifen or letrozole; mostly not to have a future problem.
She: What future problem? How would any of that help if I've had a bilateral mastectomy? And actually, I did take tamoxifen for a couple of years - it also helps with benign cysts. But I didn't have the cancer then, either. (And thank you. That was a sweet thing to say.)
Me: Ok. Sometimes some microscopic cells might have escaped into the blood stream. Of course your doctor is your best guide. Sweet thing is you look pretty good.
She: Yes, that concerns me a tiny bit, those microscopic cells...but none of my doctors seem at all concerned. And I have three of the BEST surgeons. The one who did the reconstruction surgery worked at MD Anderson for two years, too. Lymph nodes were tested - all clear.
I may ask about a consult with an oncologist, but no one seems to think it necessary at this point.
I think I'm more at risk, now, for skin cancer.
Me: There is so much research going on. Your docs must be learned enough. Still, perhaps some sort of preventive as suggested may be good. Do not get frightened.
She: Oh, I don't frighten easily.
Me: It is said that even during surgery there is chance of spread of minimal number cells, or even before that. Not detectable. What was the hormonal receptor status before surgery?
She: Not hormone receptive at all.
Me: I do not understand! Is it all negative?
She: Yes. High grade DCIS – ductal carcinoma in situ (which, as you know, means there’s no sign that it has started to spread from its original location, so it’s considered “stage 0”).
Me: Means negative for all the standard hormone receptors?
She: Not hormone receptive at all.
Me: Is that triple negative breast cancer ?
She: At least double negative - I didn't see where they ran a HER-2/neu (whatever that is). But estrogen and progesterone negative.
[For biomarkers in triple negative breast cancer go here.]
Me: Still consult once again your oncologist for supplementation with letrozole or tamoxifen.
Tamoxifen can be beneficial in some of the cases. Can be taken long term. Perhaps get a PET done.
She: But I thought tamoxifen wouldn't help if it's not estrogen receptive?
Me: It helps even in some ER negative cases.
[For more information and conflicting opinion go to]
[Explanation: Though tamoxifen is recommended for receptor positive cases of breast cancer, some research do state that it may actually help triple negative breast cancer patients to some extent. That is because the method of assay to detect the receptors may not be full proof and sometimes may miss those proteins; ascribing a negative status to a breast cancer positive for receptors. And secondly, it acts on insulin like growth factor, which has a role in sustenance of breast cancer.]
She: I had no side effects while taking it for fibrocystic changes, a few years ago (other than blessed relief swollen cysts and menstrual cycles and unfortunate heavy bleeding if I missed a couple of days). It was helpful, even though I did not have cancer then. Hmm. Okay - I'll ask about that. Thanks!
Me: You have researched many things. Only my suggestion is a whole body PET.
She: Well, I'll ask - but I have a feeling everyone will say it isn’t necessary, and they'll want a couple of thousand bucks out of pocket if I insist on my own.
Me: You must have insurance. That is in vogue in your country.
She: I have insurance - unfortunately, such procedures are expensive here and insurance gets a say in whether they agree they are "medically necessary." If not, they don't pay. Insurance itself is expensive.
Me: Still convince your doc.
She: Thanks - I'll take a look. What will a PET scan show? Is it better than an MRI? I’ve heard that it can be, for some things.
Me: PET detects deposits in any other places in body. Better than MRI for the purpose. Hopefully, it will be negative in your case. I hope so.
We spoke about family history of cancer for a bit. One of the lady’s relatives is currently dying of lung cancer.
Me: Lung cancer has a bad prognosis at present. We are poor here financially in India. Many people do not have access to good treatment, leave aside PET, MRI. I do not engage in private practice, and find a lot of time to write. I am in a government sector.
She: It's true for many in the U.S., too - but not as bad. We have first class healthcare, if you're rich; employed full time; or poor and on Medicaid (which is really hard to get approved for and onto). If you're unemployed and middle class, you might as well die.
But I remember my grandmother coming back from a trip to Calcutta when I was a child - describing the dying on sidewalks. The image has stuck with me. And that's why I'd like low-cost or no-cost healthcare for all, in this country. Seems to work in France, and pretty much so in Canada.
Me: I personally feel the same. And healthcare should be the responsibility of government, maybe with a little health tax on rich.
She: Yes.
Me: It is nice to talk to you.
She: But I'd want my tax money going to the doctors, the hospitals - not the insurance middlemen or claims processors. Nice talking to you, too.
Me: May it go to a selfless doc. He will live out of it. It is bad to see we doctors have to get paid from diseases the people may suffer from.
She: I think we still have a few of those here – selfless docs. Not as many as I'd like, but a few. Unfortunately for me, one of mine moved some years ago to work in a border town near Mexico, treating the poor in a low cost clinic. Good man... I have access to great specialists, though.
Me: Very nice.
She: I'd better get to sleep now - it's going on 1:00 AM, and I should do a better job of getting back to more normal hours, now that I'm off leave and back to work.
Me: Ok. Good sleep. It is 11.10 AM here. Bye.
There is tremendous research going on breast cancer and new modalities of treatments are coming up. Among those in the field of triple negative breast cancer are the inhibition of VEGF (Vascular endothelial growth factor)  by Cetuximab and EGFR (Epidermal growth factor receptor).by Bevacizumab.
High level of vitamin D may also prevent breast cancer recurrence and has a tumor suppressing activity.
Besides these in alternative system curcumin found in turmeric may help in regression of breast cancer.
Physical exercise has been associated with reduction in obesity and reduction in breast cancer incidence; and also independently has protective effect.
Please do not get disheartened being affected by the disease. Things are moving with high pace to conquer the disease.
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