The patient described below is fictitious, but the cancer is real.
Two months ago when it was as hot in Kansas as any place in India, a 39 year-old woman noticed that her left breast felt sore when she bent over her bathroom sink one morning to brush her teeth. She didn’t give it much thought at the time for she often had intermittent breast pain, and she was due for her period in another few days – just the time when her breast pain would typically set in.
But when she took off her nightgown to get dressed for the day and put on her panties and bra, she felt that her left breast was “thicker” than normal. Again, she ignored it as part of her pre-period melodrama.
Her breast got harder over the next two months. She didn’t dare to think about it. She did not feel a mass. She didn’t care to look at it in the mirror. But her husband said something to her one day that prompted her to finally go to the doctor: “What’s wrong with your nipple? It looks like it’s pulled in.”
Her doctor was alarmed when she saw the patient’s breast, for left breast was smaller than the right. The nipple was retracted – yes, it was “pulled in” toward the chest. The skin was thick compared to the other side, but there was no redness noted. By now the doctor could feel a mass in that breast. He also felt a large lymph node under her left arm (axilla). He also felt a suspiciously enlarged lymph node in her right axilla.
A mammogram and breast ultrasound were ordered. The patient was terrified. Only her husband knew what was going on. Her three children were too young to be involved in the unfolding trauma. They were wrapped up in the end-of-summer soccer camps and what superhero backpacks they might have when they went back to school. She wouldn’t think of disturbing them with news they could not understand and that would only frighten them. She was afraid to tell her mother for fear that the wall of courage that she had wrapped around herself for the moment would come crashing down in tears.
The mammogram showed microcalcifications in the left breast that were suspicious for malignancy. That is, they were clustered, tiny flecks of calcium of different sizes and in a variety of orientations: it was an image that was consistent with breast cancer. The enlarged lymph nodes were also seen. A mass could be seen in the left breast on mammogram, but the breasts were very dense which somewhat obscured its borders. The mass was clearly seen on ultrasound, and it looked like cancer, no doubt about it.
A breast MRI was ordered. The entire left breast “lit up” – consistent with extensive breast cancer.
A PET/Ct was ordered to assess evidence of any metastatic disease. It lit up too: the patient had extensive metastases in her bones and liver. But she had no symptoms to report related to these other satellites of disease.
A needle biopsy was done of the mass in her left breast. The pathology showed a cancer and that the tumor did not express estrogen or progesterone receptors. However, it did express Her-2 receptors. Which is to say, the kind of receptors seen on the surface of her tumor would not likely respond to anti-estrogen therapy, but the cancer might be halted or slowed down in its growth if she were given anti-Her-2 drugs.
There was no history of breast cancer in her family. She was tested for a BRCA mutation and was negative.
A gene array analysis of her tumor was sent to a special laboratory. It showed that her tumor is highly aggressive.
The questions that come immediately to mind are:
Should this patient have surgery?
If so, what kind of surgery and when?
Should the patient have chemotherapy?
If so, what kind of chemotherapy and when?
Should the patient have radiation therapy?
If so, when?
Here are the answers, as best we can determine at this time.
The patient should have chemo, absolutely, with a combination of at least four drugs. Why? Because her breast cancer is extensive and it’s spread to her bones and liver: it’s galloping away with her life. Chemotherapy is the best intervention of the three we have (surgery, chemo, and radiation) for getting rid of cancer and saving a patient’s life. So, she should get that best chance first.
Her chemotherapy would include at least one drug that targets the Her-2 receptors on her cancer cells. She might do better if she were given two different anti-Her-2 drugs. That’s been shown to be more effective in these cases than using one anti-Her-2 drug, or waiting until later to give her anti-Her-2 therapy.
As to the question of her surgery: yes, she would benefit from surgery to control the disease localized to her left breast and both axillae. But this final decision about her surgery ought to wait until after she has first had her chemotherapy so that the doctors can see how well it works in reducing what is called her “tumor burden”.
Yes, tumor burden is an apt description. But it doesn’t begin to describe what this breast cancer has done to the patient, her life, or her family and friends.
If she were to do well with her chemotherapy and have a good reduction of her tumor burden – a good “clinical response” as we say – and if she were to then have surgery that was thereafter deemed appropriate to the stage of her cancer following chemotherapy, she would certainly benefit from radiation therapy to the surgical sites. This would help with “local control” – help prevent the breast cancer from recurring.
Does this sound like an extreme case of breast cancer to you? It does to me.
Does it sound like the kind of case that is unusual? Well, it used to be unusual. I’ve been in practice for 23 years. I’ve taken care of a few more than 10,000 patients! What I’ve been seeing in the past year is an astonishing increase in the number of aggressive breast cancers occurring in women of all ages. What is going on? Is this my imagination? Is this increase real?
I’ve spoken to my colleagues about what I’m seeing. They’ve been seeing it, too. We need to reassess. Let’s begin to count again from, say, 2015 to see if this pattern is a fluke or a trend that needs attention.
If breast cancer is caused by a virus, and I happen to think that the scientific data support this hypothesis more than undermine it, then it’s certainly possible that the virus (the human mammary tumor virus, HMTV) has mutated and is spreading more virulently as a result. Is that hyperbole? No. Laboratory studies documented long ago that MTV is more than capable of mutating. Influenza does; why not MTV?. Viruses share or steal their tricks for becoming more deadly and effective. Like other terrorists, it’s what they do.
I’ll end this case by asking a final question: What shall we do to understand this threat and defend ourselves?
Here’s part of the answer: Watching is not an option.