Neapolitan Cancer

A couple weeks ago, I enjoyed lunch with two remarkable women – who both happen to be breast cancer survivors. We each have different cancers. We each are at different places in our treatment. We have each had a different journey to reach the places at which we find ourselves.

Every cancer is unique. Having breast cancer, or, in fact, the same subtype of breast cancer, does not mean people are going to have the same, or even a similar, experience – much like the person who orders vanilla ice cream does not have the same treat as one who orders fudge peanut butter ripple.

In our case, Kim is Miss Chocolate – known as triple negative. Her cancer is the rarest and doesn’t possess any of the three primary characteristics the medical world uses to select treatments to target specific cancer cells. She does have a mean mutation of the PALB2 gene that makes her cancer particularly aggressive, so lets say her cancer is chocolate peanut butter cup. This means Kim was blasted with every general cancer killing device available. She had old-school chemo, a tool that kills all fast-growing cells in the body but is not capable of differentiating a cancer cell from a hair or stomach lining cell. She had radiation, which destroys everything in its path. And she had surgery to remove known cancer sites.

Nicky is vanilla. Her cancer is “hormone positive, HER2 negative.” While Nicky’s flavor of cancer is the most common, representing 80% of breast cancers, she also possesses a mutation that makes her cancer unique – in Nicky’s case, on the NF1 gene. Not only does Nicky have an NF1 mutation, this is her second breast cancer battle and her cancer has moved beyond the breast and adjacent lymph nodes and found other homes in her body, particularly the lungs. This means Nicky’s doctors know her cancer is no longer stored in lumpy tumors but there are individual cancer cells elsewhere in her body. So, let’s call Nicky’s cancer hazelnut caramel swirl crunch.

Being Estrogen or “ER” and Progesterone or “PR” positive means these hormones support the growth of Nicky’s cancer. On top the “normal” chemo, surgery, and radiation, ER+ and PR+ cancers can be treated in a variety of additional ways, both with drugs and surgically, that limit the presence of these hormones in the body and the ability of those hormones to act upon cells. People with ER+ and PR+ cancers are likely to be on targeted medication for anywhere from 5 to 10 years after initial treatment to prevent the breast cancer from reoccurring.

It seems like a long time. But this is a good thing! Yes, a lot of people don’t enjoy certain unpleasant side effects of these drugs, but they are nowhere near as toxic to the body as traditional chemo – and they directly impact one of the specific factors contributing to the cancer instead of gratuitously attacking the whole person in hopes of hitting the cancer.

Miss Hazelnut Caramel Swirl Crunch is being treated not only for the cancer doctors can see, but for any little swirls of cancer that might be floating around undetected. This means she will have more monitoring than most breast cancer patients and she will not “ring the bell,” a ritual that signifies the end of treatment. There are many treatment options for patients like Nicky who have breast cancer that has moved beyond the initial location. She, and others like her, can live long lives and do a lot of fun things, but they will never get to say they are done with treatment and will continue to undergo extremely regular testing.

And then there is me. Miss Strawberry Ice Cream. My flavor of cancer is known as “triple positive.” It means my cancer cells are ER+ and PR+, just like Nicky’s – but they also over express (have too many of) a protein named HER2 that is a factor in cell replication. I don’t have any particular genetic mutations, and my cancer hasn’t spread beyond the lymph nodes leading from my breasts, so I’m just plain old Strawberry – no nuts, peanut butter cups, or swirls of caramel.

Being HER2+ means that in addition to all of the treatments available to Kim and Nicky, I received monoclonal antibodies, which target the HER2 receptors on my cells and shut them down. These treatments do not ambush the whole cell the way traditional chemo does – they target a precise characteristic of the cell that is causing the cancer.

HER2+ patients tend to spend far more time in the infusion center than many other breast cancer patients, but that is because there is a treatment specific to them that is highly effective.

So, when you hear that one person had surgery and moved on from their cancer diagnosis, another had chemo and became very sick, and yet another is in lifetime treatment – remember that there are as many breast cancers as there are flavors of ice cream. Each individual has a medical team helping to make the right decisions for them based on the primary flavor and “fun” add-ins present in their own individual breast cancer.