Breast Cancer Scenario

JoNightshade · Jan 10, 2011

My new WIP involves the protagonist's wife dealing with breast cancer. I'm really just at the outline stage here, trying to figure out how best to pull my plot together. I'd love to have input from anyone with experience in this area - namely, whether the progression is reasonable and if I've missed anything important. Also, if anyone could give me a sense of how much time would pass between each step, that would be SUPER. (I know each person's treatment is different, but I don't want to accidentally have something take, say, a week, that should realistically be more like months.)

1. Routine mammogram has an irregular result.

2. A more thorough mammogram confirms that there is a mass in her breast.

3. A biopsy is taken, and several days later the doctor calls to confirm that it's cancerous.

4. Consultation to discuss treatment options. Doctor and patient agree to proceed with lumpectomy to remove the mass.

[Note: After this point is where things get a bit fuzzy for me.]

5. Some time (?) after the lumpectomy, a lymph node biopsy is performed. The results are not positive. (Would one say that the lymph node is cancerous? Or indicative in some other way?)

6. A mastectomy is performed, but the cancer has metastasized.

7. Chemotherapy for a period of time leads to eventual remission.

Okay does that sound reasonable? Basically I want it to seem not THAT serious at the beginning - okay, just a lump, we'll get it removed - but then by the end it's truly life threatening and scary. However I do want to be able to say at the end that she's in remission. I'm a big proponent of keeping the "action" of a story within the shortest timeframe possible, so I'm hoping this could take no more than 1-2 years after the original diagnosis. Yes/no?

Thanks in advance for any and all help.

Storyteller5 · Jan 10, 2011

My mother had breast cancer, but didn't have the lumpectomy. She was diagnosed June 11 and had surgery on July 08th. (We're in Canada; I don't know how wait times are elsewhere.) She had the mastectomy on one side at which time they also tested the lymph nodes. (She can't have an IV in that arm now because the nodes in her armpit were removed.) She had both chemo and radiation afterwards. Her chemo started in January and ended in April; I believe chemo was once a week. (Radiation was once every 3 weeks.) Thankfully, she beat the cancer. My family refers to it as the cancer year.

I don't have an experience with cancer metastacizing so I don't know how that affects things. Sadly, I'm sure someone here knows someone who has. Good luck with your piece.

JoNightshade · Jan 10, 2011

Thanks for your experience, Storyteller! Actually, from what you've said, maybe I don't have to have the cancer metastasize. I sort of assumed I needed it to if I wanted her to have chemo. Anyone know what the policy is on this? And what the "seriousness" level is of non- vs. metastasized?

PinkAmy · Jan 11, 2011

I'm a breast cancer survivor. Here was the way it went for me....

1) Found a lump
2) Went to the DR
3) got a mammogram (it didn't show up on the mammogram because younger women often have lumpier breasts and I was 37 at the time)
4) got an ultrasound (because it didn't show up on the mammogram)
5) saw the breast surgeon- he told me it was nothing but I wanted it out ASAP
6) had a lumpectomy/biopsy- he told me it was non cancerous
7) 3 days later he calls and says OOPS, you have cancer.
8) saw the surgeon and decided to go for bilateral mastectomy
9) waited for the scars to heal.
10) chemo for about 6 months
11) cancer scare 6 months later, surgery but it was a false positive.
12) cancer free so far.

Linda Adams · Jan 11, 2011

My mother died of breast cancer. I was not present for the earlier stages, so I don't know the timeline (also a while ago). Once it metastasized, she had about ten days.

PinkAmy · Jan 11, 2011

Storyteller5 said:
My mother had breast cancer, but didn't have the lumpectomy. She was diagnosed June 11 and had surgery on July 08th. (We're in Canada; I don't know how wait times are elsewhere.) She had the mastectomy on one side at which time they also tested the lymph nodes. (She can't have an IV in that arm now because the nodes in her armpit were removed.) She had both chemo and radiation afterwards. Her chemo started in January and ended in April; I believe chemo was once a week. (Radiation was once every 3 weeks.) Thankfully, she beat the cancer. My family refers to it as the cancer year.

I don't have an experience with cancer metastacizing so I don't know how that affects things. Sadly, I'm sure someone here knows someone who has. Good luck with your piece.

My initial wait time was 3 weeks to see the surgeon and 3 weeks for surgery because he was sure I didn't have cancer.

They do a procedure call sentinel node biopsy to see if lymph nodes are involved. They inject the patient with dye at the site of the cancer and the dye travels to what would be the first (sentinel) lymph node that would be effected. When I was dx in 2001, it was a new procedure so even though the sentinel node was clear my surgeon took the first layer of lymph nodes (there are about 3 layers). Not having a good portion of the lymph nodes leaves me (and your mom) at risk for lymphodema, which is swelling of the arm. It's quite painful. The arm can blow up to 3 times it's normal size. I can't have any procedures on my right arm, including blood pressure, blood draw, IV etc. I lifting over 15 lbs with that arm is not recommended. Fortunately, I'm a lefty. I was a bad breast cancer survivor and got a tattoo on my wrist from that side. I knew it was a risk but I wanted one and the other side was full.

Technically, if breast cancer has spread to even 1 lymph node, it's considered metasticized. Most of the time people stage 2 -4 need chemo. Radiation depends on the location of the tumor or calcifications and the type of surgery. If the patient opts for lumpectomy, radiation is more likely because they want to be sure the margins are clean (the area near the tumor). Some patients have chemo/rads before surgery, particularly if they want to save their breasts through lumpectomy. Me...I wanted the sucker out ASAP. I didn't want to be ~~fucking~~ playing around with cancer inside my body. The reason for chemo and/or rads beforehand is to shrink the tumor. Also, because cancer travels through the lymph node and blood stream, chemo can start attacking any loose cells. With surgery you have to be reasonably healed before starting treatment. That's because chemo changes blood counts and effects clotting and thus healing.

PinkAmy · Jan 11, 2011

Linda Adams said:
My mother died of breast cancer. I was not present for the earlier stages, so I don't know the timeline (also a while ago). Once it metastasized, she had about ten days.

10 days, yikes! I'm so sorry for your loss and that you didn't have more time to prepare. More and more often, oncologists are looking at metastisized cancer as a chronic, rather than terminal illness. I have known people living with mets (that's what we call it METS) for over five years. I have also known people who did not survive. A lot depends on the aggressiveness of the cancer, the age of the patient, and type of breast cancer. There are dozens of types of breast cancer. You find this out with the pathology report. I was fortunate to only be stage 1b Grade 3 (there is stage 0 also called DCIS meaning the cancer hasn't spread outside the tumor. Stage 1 and 2 are considered early stage. 1a is for tumors under 2cm 1b is over 2vm but not more than 5cm. Stage 2 is either a large tumor with no lymph node involvement or less than 2 lymph nodes. Stage 3 means the cancer has spread outside the general area but not to the organs- usually to the bones Stage 4 is organ involvement) I was ER/PR negative (estrogen, progesterone, meaning that my tumor wasn't fueled by hormones. There are more treatment options for ER+/PR+ folks. Negative folks usually have more aggressive cancers, but they respond better to chemo), HER2Nu + 3 (HER2Nu is a substance in the cancer. If you're positive +1, +2 or +3, can take the chemo drug herceptin. While this gives another tx option, it usually means more aggressive cancer)

PinkAmy · Jan 11, 2011

5. Some time (?) after the lumpectomy, a lymph node biopsy is performed. The results are not positive. (Would one say that the lymph node is cancerous? Or indicative in some other way?)
The results are considered positve if cancer is present. I know that flies in the face of common sense, because it's a negative/bad that the cancer is there. We would say there are X nodes involved or that X nodes had cancer (the number). The results are known from a pathology report. The surgeon can do a frozen section, (meaning testing it on the spot, but the results aren't 100% accurate) during the surgery. Usually the pathology report takes a few days to a week .

6. A mastectomy is performed, but the cancer has metastasized.

Depending on the type of lump, a needle biopsy can dx the cancer and only 1 surgery is needed. Mine was a hard mass, like a marble, so they couldn't get fluid from it, which is why I needed the lumpectomy (also called excisional breast biopsy). If I had chosen to get a lumpectomy rather than a mastectomy, I would have needed a second one to get wider margins to make sure the cancer hasn't spread to those cells.
Your character would likely know from tests before the mastectomy whether the cancer has metastisized- I was sent for a chest x-ray and bone scan right after I was dx, before I met with the surgeon to decide on the bilateral mastectomy)
7. Chemotherapy for a period of time leads to eventual remissio
most people in early stage cancer are considered cancer free after a mastectomy. If the cancer has spread to bones/organs, it would be after the chemo or rads. IF and only if there is no sign of the cancer. Breast cancer isn't called remission, because it can come back at any time, even 25 years later. It's called NED (no evidence of disease) because they can't be sure the cancer is really gone. The longer time without mets, the better, but there are no guarantees. Also, a new breast cancer can form, even after mastectomy. This is uncommon, but can happen because there are often stray breast cells left after a mastectomy. They're microscopic in size so the surgeon can never really tell.

Is your character getting reconstruction? I chose not to- I'm even, just flat . If your character chooses reconstruction, most do so at the time of the mastectomy. It makes for a longer and more uncomfortable recovery though, and having to put off chemo a few weeks longer. The two most common types of reconstruction are implants (saline or silicon) and tram flap (tram flap takes skin from another part of the body, often the butt. it's a harder surgery than implants, but more natural looking and feeling)

PM me if you want more info- I'm an info junky-- knowledge is power!

Debbie V · Jan 11, 2011

I have done some research on this for another book. I've spoken with two oncology nurses at different woman's health centers associated with hospitals. Both were very helpful, and one was from a cold call to the facility and met with me in person the first time.

I got different answers from both women - because one considered more of the specific patient aspects and the other gave me hospital protocol. For metastasis, the type of breast cancer, area it moves to, speed of discovery and other factors effect the survivability. My char. has it in the brain where treatment is radiation. She dies about a month after treatment ceases - they won't irradiate the brain for a second series.

I have not had cancer, but I've had questionable mammograms followed by sonos and stereotactic biopsies - an x-ray is used to guide needle placement to drill out offending cells. A titanium clip is always left at a biopsy site so the site won't be rebiopsied the following year. I've had needle biopsies as well. Five clips and counting.

JoNightshade · Jan 11, 2011

Thank you SO MUCH everyone, and wow, PinkAmy, expect some PMs from me in the near future.

I literally got about 3 hours of sleep last night (lovely screaming sick baby) so I don't have the mental capacity to think about this right now, but after what you said I was thinking about my character...

And I think she's the sort of person who did what you did - just do the double and get it over with. She wouldn't get reconstructive surgery either. So I need to adjust my outline a little bit.

PinkAmy · Jan 11, 2011

JoNightshade said:
And I think she's the sort of person who did what you did - just do the double and get it over with. She wouldn't get reconstructive surgery either. So I need to adjust my outline a little bit.

My surgeon asked me to convince him why this was the best road for me to go down. I told him that I had done my research and I knew that long term survival at my stage was virtually the same for lumpectomy and mastectomy. BUT... I knew myself. I would have never been happy with just a lumpectomy because I am an obsessive type person. I'd be giving myself self-exams several times a day. I knew I would have a better life with the bilateral.
He originally suggested getting the bad one removed and then after chemo having the good one removed (I think he just said that because he's paid more for 2 operations). I said NO WAY. I'm not having 2 surgeries when I just need 1. He asked if he should leave come skin incase I decide on reconstruction at a later date. I had seen picture of with and w/o extra skin and I just wanted to go for flat. I told him I didn't need breasts to define me as a woman. Lots of women go through an emotional trauma at the loss of their breasts, but I didn't have any of those issues.
When the visiting nurse came out the day after I got home to check the wound and drains, she expected me to be upset. "It's ok to cry." she kept saying.
I had the biggest smile on my face because I looked soo much better than I expected. She thought I was nuts.

HopeWelsh · Jan 16, 2011

If you're going to write a story where the mastectomy and all was rather quick--you might consider those that are prophylactic. There is a genetic marker for a certain type of cancer--and women often choose mastectomy over the high risk of cancer

Breast Cancer Scenario

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