Fighting breast cancer
It takes more than just medical intervention to lick a killer disease
By Sunly Coo, Contributing Writer
Pearl Imperial was in her late forties and neck-deep running her bridal-gown business when her world grounded to a sudden halt. She was diagnosed with breast cancer, something no woman wanted to hear, and needed to undergo a mastectomy immediately.
"I wanted to cry, but I couldn't. Thoughts ran in my head-where to get the money, and how my mother would take it. She's already 86 years old. I was also all alone. And of course, I was thinking about vanity, how I would look afterwards," she says.
She had to, one day before the operation, organize her finances and take care of anything at the shop that needed her attention. She also had what she called her "last supper with mom," but she couldn't let the old woman know about her condition. Instead Pearl told her that she and her friends were getting an extensive checkup that required an overnight stay.
On the eve of the surgery, she asked God for a sign, a message. She opened the Bible to a random page and found Isaiah 41:10, "Fear not for I am with you," she recalls. And it was all the reassurance she needed.
The operation was a success, but the battle had only just begun. Pearl was scheduled for chemotherapy a month later, yet it took her three months to start with the regimen. She had read about the aggressive nature of the therapy. "It's very toxic. It's like a flush flood, like PacMan," she says, referring to the indiscriminate destruction of both good and bad cells. Hoping to avoid chemotherapy, she spent the next three months exploring alternative medicine, until her progressively complex herbal treatment, not to mention its escalating cost, began to raise serious doubts of its efficacy in her mind. Afraid to gamble further with her health, she finally returned to the folds of western medicine.
She remembers how the first chemo was the hardest: "It was really bad, especially the first two to three days. I stayed in bed for one to two days. I experienced nausea, gastric pain, had no appetite, my nails were discolored, and my skin looked like eggplant." Since she lived alone, she had herself confined in the hospital for her initial therapy, just in case she needed medical attention. Fifteen days after, she ran her fingers through her hair and was shocked to find a handful of locks coming off. It was the moment she dreaded-she was going bald.
Pearl had never seen herself naked after the mastectomy, but when she finally lost all of her hair, she made herself stand in front of the mirror and really look. The stranger in the mirror was she. It was a painful and sobering moment. Drawing from the same strength that had brought her thus far, she calmly accepted the reality and solemnly vowed to take care of herself, because "no one else will."
And she kept that promise. Her diet changed radically. "It was mostly vegetables, fruits, smoothies, and shakes. "Gumanda ko nun," she says. Everyday, she would walk in Quezon City Circle or do aerobics. She joined other locals in organic gardening, and communed with nature. She learned to adjust to the chemotherapy, without having herself admitted to the hospital. After each chemo session, she headed straight to the mall to enjoy herself before the side effects set in. When they did, she used music or visualization-a white sandy beach, or PacMan eating away at the malignant cells-to block out some of the pain. She made sure that she looked good at the start of each day, with makeup and a wig or a bandana. Surprisingly, she was able to hide her disease from her mother for about a year.
Now, seven years later, Pearl serves as a living testament to a woman's resilient spirit. She has through all those years been an inspiration to many, having actively promoted breast-cancer awareness through the Philippine Foundation for Breast Care and given support to cancer patients through her Breast Friends Support Group (see sidebar). Looking at her, you would never have guessed she had waged the battle of her life. Instead, she seems to exude a rather youthful glow about her, one owing ironically to the disease. Since then she continues to maintain a nutritious diet of fruits, vegetables, and fish (she recently had a seven-ounce steak, and that would already be her red-meat quota for the entire year), and she keeps stress at a healthy, manageable level. But perhaps the biggest sea change is her different outlook in life. For her, it's about living in the here and now, being appreciative of what she has, and reaching out to others. She says, "I thank the Lord for the cancer, because I'm happier now."
Risk factors
The Philippine Cancer Society estimates that in 2005, breast cancer claimed 6,357 Filipino women and more than 14,000 new cases were diagnosed. It is the most prevalent in Asia, the World Health Organization said. Unfortunately, many Filipinas are not aware that they are at risk of the disease, particularly if they have the following factors:
Age. The incidence of breast cancer rises with age. According to the United States National Cancer Institute (NCI), most cases involve women over 60.
Family history. Having relatives, especially a mother, sister, or daughter, who had breast cancer increases a woman's chances of developing it herself. The risk is further elevated if the immediate family member was hit by the disease before 40.
Gene mutations. Studies have shown that changes in specific genes-tumor-suppressors BRCA1 and BRCA2-heighten the risk.
Abnormal breast cells. Women with either atypical hyperplasia or lobular carcinoma in situ (LCIS) cells in their breasts are more vulnerable to the disease.
Breast density. Having breasts that are packed with more dense tissue than fats places older women at a greater risk of developing cancer.
Reproductive history. Long-term exposure to estrogen is linked to breast cancer. Since the body's production of estrogen declines during pregnancy, being pregnant for the first time after age 35 puts the woman at risk. The later the initial pregnancy, the greater the threat. Never bearing a child amplifies the risk.
Menstrual history. Because estrogen levels peak during the years a woman is menstruating, starting early (experiencing the first period before the age of 12) or ending late (having menopause after 55) makes one more susceptible to the disease.
Hormone-replacement therapy. Estrogen, progesterone or both hormones given to postmenopausal women to combat hot flashes and diseases like osteoporosis increase the chances for breast cancer.
Radiation therapy. Long-term or high-dose radiation exposure, especially to the chest, before age 30 is a risk factor for breast cancer.
Being overweight or obese. Postmenopausal women who tip the scales beyond their ideal weight are more likely to get breast cancer.
Seven ways to lower the risk
Studies have identified the following preventive measures against the development of breast cancer:
Exercise. Getting enough physical activity, about four or more hours a week, can help decrease the body's estrogen levels. Its breast-cancer risk-reducing effect is most notable in younger women with normal weight.
Breast-feed. Experts discovered that breast-feeding can keep estrogen levels low.
Limit alcohol intake. Some studies suggest that increased alcohol consumption can elevate the risk of breast cancer.
Pharmacological intervention. Selective estrogen-receptor modulators (SERMs) have an estrogen-like effect on certain tissues of the body, while blocking the endogenous hormone's effect on other tissues. Two such drugs are known to reduce the risk of breast cancer-tamoxifen and raloxifene. Because the probability of developing side effects from tamoxifen-stroke, cataracts, blood clots in lungs and legs, and endometrial cancer-increases with age, those who would benefit the most from the drug are women with a high-risk for breast cancer and are no older than 50.
Raloxifene, used to treat osteoporosis in postmenopausal women, also carries the threat of blood clot development; but it has been shown to lower breast-cancer risk in both high- and low-risk groups. It still remains to be seen if raloxifene has the same effect when administered to women without osteoporosis.
Aromatase inhibitors, on the other hand, work by blocking the aromatase enzyme that triggers the production of estrogen in different parts of the body, from ovaries, to brain, fat tissues, and skin. Potential side effects include osteoporosis and aberrations in brain functions, such as memory and learning.
Prophylactic mastectomy. Having both breasts removed to prevent breast cancer may seem to be too extreme an option. But for a small percentage belonging to the high-risk group, including one woman whose father had died of breast cancer, it was the best decision they could make after undergoing a thorough risk assessment with their physicians.
Prophylactic oophorectomy. Another preventive measure is the removal of ovaries, the primary source of estrogen, although the procedure can cause early menopause or symptoms of menopause. Some breast-cancer patients have also elected to have oophorectomy to guard against cancer recurrence.
A healthy diet. Some experts believe that having a diet low in fat and high in fruits and vegetables can help protect against breast cancer. But according to NCI, there is not enough evidence yet to prove that diet is a significant risk factor.
Detecting the Big C
Early detection saves lives. The Philippine Cancer Society says that 38 percent of all cases of breast, cervical, colorectal, oral, thyroid, and prostate cancer are successfully treated, provided these are diagnosed in the early stages.
The mainstay for screening breast cancer is mammogram, an X-ray that spots for lumps even before they can be felt and microcalcifications-calcium specks-which can be precancerous cells. Mammogram testing should be part of a woman's annual or twice-a-year health checkup once she is in her 40s. Some abnormalities-lumps, altered breast shape and texture, nipple discharge, and inward nipple-can be detected through routine breast self-exam and clinical breast exam, one performed by a health professional.
If tests reveal an abnormality, ultrasound may be prescribed. The sound waves emitted by the machine create a detailed picture that can show whether the lump is a cyst, a fluid-filled sac that is harmless, or a solid mass, which can be malignant. The more sensitive magnetic resonance imaging (MRI) may be used, especially for women with a high genetic risk for breast cancer.
Once a lump is detected, diagnosis can be made by a pathologist through a biopsy. Depending on the size of the suspicious tissue and other factors, the physician may recommend an excisional biopsy, where the entire lump is removed; an incisional biopsy, where a part of the lump is taken; core-needle biospy, where a wide needle is employed to extract a sample tissue; and needle biopsy, where fluids or tissue is removed using a fine needle.
Treatment options
Primarily determined by the stage of the cancer, the choice of treatment can be localized (surgery and radiation) or systemic (chemotherapy or hormone therapy). Most patients undergo both surgery and adjuvant therapy, a postoperative treatment in the form of radiation therapy, chemotherapy, or hormone therapy to increase the chances of cure.
Breast-conserving surgery can be a lumpectomy, where the tumor and a small amount of the surrounding tissue is removed; or a partial mastectomy, where a larger segment of the breast is excised. Some of the lymph nodes under the arms are usually included in the procedure to minimize the possibility of a recurrence. On the opposite end, mastectomy involves taking the entire breast. When it is also accompanied by the removal of the lining over the chest muscles, possibly a section of the chest wall muscles, and many lymph nodes under the arm, it is called modified radical mastectomy. In more advanced stages, radical mastectomy is required, where the whole breast, all the lymph nodes under the arm, plus the chest-wall muscles beneath the breast is removed. Breast reconstruction done immediately after the mastectomy or in the future can be performed using the patient's nonbreast tissue, such as the abdominal tissue, or synthetic implants filled with saline or silicon gel.
Radiation therapy can be external, relying on a machine, or internal, an inpatient procedure that entails inserting an implant containing a radioactive substance into the cancer tissue or near it and leaving it in for several days.
If an estrogen- and progesterone-receptor test shows that the cancer cells have a significant amount of receptors for these hormones, which help the cells grow, hormone therapy is integrated into the treatment. Tamoxifen blocks the action of estrogen, making it effective during the early stages and during metastasis. For postmenopausal women whose tumor growth is dependent on the hormone, aromatase inhibitor is recommended.
Of all the treatments, chemotherapy is probably the one most dreaded by cancer patients. It effectively kills malignant cells or stops them from dividing and spreading, but the systemic approach means even healthy cells on its destructive path are destroyed. Side effects may include nausea, vomiting, loss of appetite, hair loss and, for some, even depression.
The importance of support
Being diagnosed with cancer is a life-altering moment, and fighting off the disease is both physically and emotionally exhausting. A cancer patient needs all the help she can get from her doctor, her family, and a cancer-support group.
Her foremost concern is to keep her strength up, despite the appetite-suppressing effect of chemotherapy. Many nutritionists working with cancer patients advise adopting a diet low in fats and high in fruits and vegetables. It should have enough calories to keep her energy up, and enough proteins to help her tissues heal and rebuild. Eating healthily will make the treatment and recovery process easier to bear.
The same goes with getting adequate physical activity. In fact, the doctor or the physical therapist will prescribe the patient to perform specific exercises daily, such as lifting the arm next to the operated breast that was operated on by doing a slow crawl up a wall to restore muscle strength.
Follow-up care after surgery is crucial. The patient should update her doctor on any changes in the treated breast, and other suspicious symptoms such as vaginal bleeding or blurred vision. These may indicate a recurrence of cancer, serious side effects from the drugs, or other health problems.
On the emotional front, a few hospitals provide their own cancer-support groups where patients have access to a counselor, psychologist, or psychiatrist. Some hold group sessions for cancer survivors to share their experiences and insights, and to gain strength through common ground. But perhaps the most influential support group a patient can have is her own family. The family can learn how they can best help their loved one cope with the treatment by talking with the doctor, who can refer them to an expert, or with a cancer-support group.
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Chemo drug may only benefit a few
CHICAGO
A widely prescribed chemotherapy drug does not work for many of the women with breast cancer for whom it is prescribed, according to a recent study.
Taxol is typically given to women with stage-II breast cancer as part of a cocktail of drugs designed to prevent a recurrence of the malignancy. But US researchers say the drug may only be effective in women with a type of tumor known as HER2, which occurs in about 20 percent of breast-cancer cases.
Writing in the New England Journal of Medicine, researchers report that women with the more common estrogen-receptor-positive breast cancer do not appear to benefit from Taxol based on their analysis of previous clinical data. The researchers say the findings are preliminary and it would be premature for doctors to withhold the drug from patients at this point.
However, if further studies confirm their observations, a simple molecular test could identify the women that would benefit from the medication, sparing others the unpleasant and possibly harmful side effects of unnecessary courses of toxic chemotherapy.
"In general, chemotherapy for breast cancer has been a one-size-fits-all approach," said Daniel Hayes, clinical director of the breast-oncology program at the University of Michigan Comprehensive Cancer Center in Ann Arbor. "Our decision to recommend it is based on whether a woman is at high risk of the breast cancer recurring, without any idea of whether she would benefit from the additional therapy. With these data, we hope we will be able to focus chemotherapy on patients whom it's most likely to help," he added.
Hayes based his findings on an analysis of the results of a clinical trial from the 1990s, in which women with breast cancer that had spread to the lymph nodes (stage II) were treated with two chemotherapy regimens. Half of the women got four courses of the chemo drugs Adriamycin and Cytoxan. The other half got four courses of so-called AC chemotherapy, plus a further four cycles of Taxol, which is a protocol used by many oncologists.
The women with HER2-positive tumors were 40-percent less likely to experience a recurrence of their cancer if they were treated with Taxol. The drug did not appear to benefit the women with estrogen-driven tumors.
In addition to suppressing the immune system, and leaving a patient vulnerable to infection, Taxol can also cause a woman's hair to fall out, or prevent it growing back if it has already gone. It has also been associated with temporary and in some cases long-lasting nerve damage.
Still, Hayes cautioned doctors and patients against dropping the drug just yet, saying that they should stick with the current chemotherapy protocols until his findings could be duplicated in other trials. "The stakes are too high," he said. But if future studies confirm the findings, "we can really start tailoring treatments to individual patients."
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Foundation fosters linkages
Pearl Imperial is cofounder and president of the Breast Friends Support Group that meets every Monday at the Breast Care Center in East Avenue Medical Center (EAMC), Quezon City. "A lot of patients come here to consult," she says. Many of them including survivors sit in to share their concerns, their victories, and support each other emotionally and spiritually. Clinical psychologist Elizabeth Pineda and a pastor provide counseling.
The Philippine Foundation for Breast Care (PFBC), established in 2001, is a nonstock, not-for-profit, grassroots, volunteer-based organization committed fighting breast cancer by fostering collaborations and linkages for "Breast care, Research, Empowerment, Advocacy, Support, and Treatment." The organization, where Imperial is treasurer, partners with the EAMC Breast Care Center and Breast Friends. It holds lay forums, employee and student action programs regarding breast cancer prevention and the benefits of early detection.
For the past few years, PFBC and Wacoal have been spreading public awareness and providing free screening every October, Breast Cancer Awareness Month. The foundation is also running an adopt-a-patient program, where anyone can sponsor a patient's chemotherapy. After setting up a breast-care center in Bacolod, PFBC hopes to build more facilities like it in provinces around the country.
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