My Five-Year Breast Cancerversary

Five years ago today, I learned that I had breast cancer.

I didn’t find out in the usual way, an alarmingly ambiguous phone call and then a sit-down with my doctor. The radiologist knew I saw patients in the office for genetic counseling, so while I was getting dressed after my annual mammogram, she beckoned me to her nearby office.

“Take a look at the two screens, Ricki. The left one is last year’s image.”

It didn’t take training in radiology to see that something had happened since last year’s mammogram. On the right screen, a small mass blocked a narrow passageway, a milk duct.

When the radiologist enlarged the image, the clump of cells was not only blocking the duct, but pushing against one wall. I realized instantly that if I had skipped my mammogram that year, the next year’s scan would have shown invasive cancer.

The clump, growing as its cells divided faster than surrounding cells, would have eased itself between the flat-brick-like units forming the wall of the milk duct, oozing out. Perhaps, eventually, it would have entered a tiny blood vessel and gone who knows where, probably my bones.

A biopsy confirmed the mammogram’s findings. I had ductal carcinoma in situ, aka DCIS. Details are here at DNA Science, from 2018.

My mother had been diagnosed with breast cancer when she was my age. But I knew that most breast cancers are not inherited, that you inherit increased risk and not cancer directly, and that breast cancer is so common that it can strike more than one member of a family just by chance.

Only about five to ten percent of cases are familial. They arise from inheriting one risk allele (aka mutation or gene variant) that’s in every cell because it’s present from fertilization. Breast cancer can bloom when a mutation affects the second copy of that gene in a breast cell. But in the vast majority of cases, two mutations happen in breast cells only. They arise as a consequence of faulty DNA replication, as mutations do, or they’re triggered by an environmental factor. In this DNA Science post, I sought environmental explanations for why most of my small circle of friends from our high school in Brooklyn have recently developed breast cancer. Was it the knishes? Egg creams? Subway filth and noise? Pot? Pollution? It was more likely our shared Ashkenazi heritage, having inherited gene variants that predispose to developing breast cancer.

Back in November 2017, I was too upset to order my own genetic test, so I turned to a friend who specializes in cancer genetic counseling to help me wade through the options. I chose a company that offered tests for 108 genes. Besides the familiar BRCA1 and 2, there’s ATM, CHEK2, TP53, PTEN, BARD1, RAD51, and a whole bunch of others.

Mutations are in genes that control the cell cycle (rate of cell division) and DNA repair. The idea of “the” breast cancer gene, which unfortunately persists, paints an oversimplified portrait of how cancer arises. A series of mutations in different genes, unfolding over time, causes and drives cancers. The dance of carcinogenesis is perhaps best and longest studied for colon cancer.

After genetic testing (of blood) showed no inherited mutations, events unfolded quickly. It helped that I knew exactly what I would do, resisting the pressure for reconstructive surgery that came from physicians and the assumption of most of the people I shared my news with that of course I would rebuild my chest. I was grateful to a friend who related how a plastic surgeon had warned her that her new nipples might slide off, without warning, confirming my decision. I hate when body parts do that.

While pressure to launch into a series of painful and potentially disfiguring surgeries to rebuild the glands, for cosmetic reasons because they don’t feel or function, continues, it’s becoming more accepted to elect not to replace missing mammaries.

Women have sued physicians who left flaps of tissue in case life without boobs proves unlivable, and the women changed their minds when they came to their senses. See “Some women want flat chests after mastectomy. Some surgeons don’t go along” in WaPo or “These Cancer Patients Wanted to Get Rid of Their Breasts for Good. Their Doctors Had Other Ideas” in Cosmo. And finally breast surgeons are listening to patients who do not want the gross, wobbly flaps for future boobs. Annals of Surgical Oncology recently ran “Patients Who Go Flat After Mastectomy Deserve an Aesthetic Flat Closure,” the word “deserve” subtly telegraphing the perceived weirdness about the request to control what our bodies look like.

Facebook groups of survivors helped me the first two years of my breast cancer experience. Slowly there were days when I didn’t think about it. Now I only relive the angst in October, with the month-long “pink” messaging.

Since the end of 2017 when I had my surgery, I’m thankful every day that I had the off-kilter cells and their surroundings removed. I’m all for the genetic testing that can reveal the workings of the cells that go awry in cancer. But it’s important that I discovered mine from an IMAGE.

Mammography saves lives. Do it!