Beans, Beans, the Magical Fruit...

About six weeks ago, the Monday of All Surgeries, I had blood drawn for genetic testing.  Genetic testing isn't routinely ordered for those diagnosed with breast cancer except in certain circumstances (young age, multiple diagnoses, or where a genetic mutation is suspected).  Surprisingly, only about 5% - 10% of breast cancer is caused by genetic mutations; the rest of us have either a genetic component not yet discovered, or we've been dealt a shitty hand in the poker game of life.  Breast cancer is not directly attributable to lifestyle choices (such as smoking) although there are known risk factors (the first and most prevalent being a woman), and I hesitate to call it "bad luck" as there are likely reasons we don't yet know about, and quite possibly can't control.  It just is what it is.

With a second incidence of cancer in such a short timeframe, the question becomes whether there's a genetic mutation involved.  Those with a BRCA-1 mutation are at higher risk for, and higher incidence of, Triple Negative breast cancer.  Having a BRCA-1 or BRCA-2 mutation also puts one at higher risk for recurrence (typically contralateral, or in the opposite breast).  Genetic testing would give us more information about my cancer, including additional risk factors for ovarian cancer, as well as information to share with my family members to assess their risks.

We received happy news at our last chemo appointment - my genetic test results came back negative.  No BRCA-1 or BRCA-2 mutations, no other genetic mutations, not even a hint of an "unknown variant."

So I fall into the Shitty Poker Hand family.  I'm not unhappy about this news, however, as it means my family members are not at higher risk for breast cancer or ovarian cancer.  It's the only gift out of this mess that I can give them.

The only reason I had held out hope for a genetic mutation was as an explanation for this new cancer.  My concern (and that of my doctors, as I'm learning in our conversations), is that a non-mutation "poker hand" recurrence means we're dealing with something different and probably aggressive, and that's Shitty, too.

Because there's no reason for it now.

So since this new diagnosis, the Big Question has been this:

Is this a new primary cancer, or a recurrence of my previous breast cancer?

The answer is unequivocally no.  And yes.  

During our visit with UofM a few weeks ago, the oncologist shares their explanation of how this cancer both is, and is not, the same as before.  As often happens to me when I am overloaded with stimuli and information (or in a staff meeting), my mind starts to wander.  I hear her words and understand what she's saying, but because I am an exceptionally visual person my brain is furiously reaching for examples of this explanation, tangible things I can see and touch to make this more understandable to my BusyBrain.  I see apples and oranges, catepillars and butterflies, Yin and Yang, and finally...

Jelly Beans.  My cancer looks like an Easter basket filled with jelly beans.

Seriously - my mouth starts to water (mmmm, popcorn-flavored...) as I envision a bowl of brightly colored jelly beans.  Pinks!  Blues!  Greens!  Oranges!  All the flavors of the rainbow jumbled together, representing the various estrogen and progesterone receptors in my cancer.  As the oncologist continues her explanation, the bowl of beans changes colors and size, shifting proportions and dimension, moving from old-cancer to new-cancer.

Of course.

Let's pause for a little science-y stuff...

Each breast cancer cell has two hormone receptors: estrogen and progesterone.  These receptors determine whether the cancer is "fed" by these important, naturally-occuring hormones.  While estrogen plays a vital role in women's bodies - protecting our bones from breaking and our hearts from disease - if it's fueling our cancer it becomes dangerous.  There are medications (like Tamoxifen) to selectively inhibit estrogen, thereby diminishing that fuel for the cancer (and throwing us into instant, hit-a-brick-wall, unpleasant menopause).  Progesterone (PR) is the red-headed step-child of the hormone-receptor status of cancer cells.  Important, yes, but not considered quite as important as the Big ER.  Like ER, PR can be either positive (PR+) or negative (PR-).

Each cancer cell also has a receptor for a protein called Human Epidural Growth Factor 2, or what we fondly call Her2.  If a cancer cell has a gene mutation which makes an excess of the Her2 protein (which fuels cancer growth) it is considered positive, or Her2+.  There are targeted therapies such as Herceptin and Perjeta for Her2+ cancer.  Only about 20% of breast cancer is Her2+; the remainder is Her2-, or cancer that does not overexpress the Her2 protein.

Receptor status drives treatment, so samples are stained and examined by a pathologist to determine the percentage of cells that are estrogen-receptor positive (ER+) and progesterone-receptor positive (PR+).  Either of those receptors can range in positivity from 100% to 0% (for instance, 95% of cells could be ER+, meaning the remaining 5% would be ER-).  Because ER+ breast cancer has more treatment options, the standard theory is that any positivity means the breast cancer is considered ER+.  Breast cancer is considered ER- when 0% of cells stain positive for estrogen receptors.  Her2 is not stained for percentage, but tested for overall positivity or negativity.

These three receptors occur in every breast cancer cell, and can occur in a variety of configurations, including:

• ER+/PR+, Her2- (the most common form of breast cancer)
• ER+/PR+, Her2+ (Triple Positive, about 10-20% of breast cancer)
• ER-/PR-, Her2+ (Her2+, about 5-15% of breast cancer)
• ER-/PR-, Her2- (Triple Negative, about 10-20% of breast cancer)

To complicate matters even more, breast cancer is a hetergenous disease, with a variety of different cancer cell configurations within each tumor.  Not every cell in a tumor will test exactly the same.  The important information to know is the ER status and Her2 status because these determine risk and treatment. 

So...all this science-y stuff is the conversation we're having with the oncologist at Uof M about how my cancer is, and is not, the same as before.  Science-y break over.  Back to our beans...

Four years ago my initial pathology sample report noted my breast cancer had both estrogen and progesterone receptors.  In my case 50% of the cancer cells expressed estrogen receptors, and only 10% expressed progesterone receptors.  Two tests confirmed that my cancer did not over-express Her2, so I was negative:

After that initial pathology, the Oncotype DX test was completed using a larger sample from my lumpectomy.  The results of that test indicated that I had fewer estrogen receptors than found on my initial pathology report, and that no cancer cells (or very, very few) had any progesterone receptors, and so my hormone status changed:

Fast forward four years:  This time around, both initial and repeat pathology testing revealed that none of my cancer cells had any hormone receptors, so my cancer is much more tropical and exotic than before:

The oncologist explains:  My original cancer was 50% ER positive, but also 50% ER negative.  It was 10% PR positive, but also 90% ER negative.  So in my mind, I'm thinking - this is what my original cancer must have looked like:  50% of the cells are ER+ (Very Cherry) and 50% are ER- (Orange Soda).  90% are PR+ (Sour Apple), and 10% are PR- (Berry Blue).  All of them are Her2- (Cream Soda):

After initialy surgery a few stray cells must have been left behind.  It happens.  So again, I visualize - this is what might have been left after surgery:

This is one of the reasons we do chemotherapy - to systemically destroy any remaining rogue cancer cells.  Maybe now what's left looks something like this:

Then we do radiation, hopefully eradicating any last remaining local cancer cells - but probably leaving something behind that now looks like this:

So we've destroyed almost all of the cancer cells that were left behind.  But those that remained were tough, and strong, and determined.  Like fucking Cancer Cockroaches they survived toxic poisons and photon radiation.  And eventually, they woke up and started to thrive again, growing and replicating and becoming the TNBC I now have:

So this is how my cancer is, and is not, the same as before.  I have a new cancer because it's different than what I had before.  But it's quite likely that this grew out of some left-over Cancer Cockroaches.  We'll never know for certain, we can only surmise.  But in a mouth-watering way, it all makes sense.  And so we embrace this new information that helps us understand the "how", if not the "why", of this second Dance.  

If only I could rid myself of this cancer as easily (and tastily) as I did those yummy visual representations...