The chemistry behind cancer

As I am starting the next phase of chemo treatments and have new biopsy reports back it is a great time to clarify some of the logic behind this crazy cancer care.

When I was diagnosed with breast cancer originally back in 2006 I was very young, only 30 years old.  I had 3 children, the first was born before I turned 26 and I breastfed all 3 children – so, in spite of having children and breastfeeding (two factors that decrease likelihood of breast cancer) I still got it, and very young.

While doctors can get a pretty good idea of whether you have cancer or not, positive confirmation is done through analysis of cells.  So, the biopsy is the definitive determination of whether you have cancer and what type of cancer you have.  Additionally, they test breast cancer cells to understand which elements may be feeding the cancer growth.  Three key elements are tested.  The first 2 test the amount of hormones, estrogen and progesterone, present in the cancer.  The outcome is referred to as being estrogen or progesterone positive or negative.  Positive = the cancer feeds off of that hormone.  The third element test for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells.  Again, positive means that the cancer feeds on this protein. About 1 of every 5 breast cancers has a gene mutation that makes an excess of the HER2 protein. HER2-positive breast cancers tend to be more aggressive than other types of breast cancer. (mayoclinic.org)

So, you may hear about a breast cancer that is triple positive, triple negative, hormone negative and Her 2 positive or hormone positive and HER2 negative.  My cancer was triple positive – estrogen, progesterone and HER2 all assisted in the growth of my cancer.  This is a very aggressive form of breast cancer and, until targeted HER2 therapies were developed, was very deadly.  With the discovery of Herceptin in 2006 for non-metastatic breast cancer and now Perjeta which was FDA approved in Nov. 2014, the prognosis is significantly better.

Wanna geek out? See the Herceptin timeline here. See the timeline of other Genentech drugs, including Perjeta here.

In 2011 when I was diagnosed with metastatic breast cancer the cancer had spread to my spine and sternum.  A biopsy was done, which confirmed that the cancer cells originated from breast cancer.  So, while the cancer was making a home on the bones, it is still breast cancer.  This is true of any metastatic cancer.  It is still the cancer of the original site, whether breast, skin, colon, lung etc.  But, it has spread to a distant site, which is what makes it metastatic. 

The 2011 biopsy of my spine showed the tumor to be hormone positive by HER2 negative.  So, the treatment I had previously for the HER2 protein was effective. 

In 2014 I had a lymph node in my stomach with cancer activity.  That biopsy revealed the cancer was again triple positive, so we added the Herceptin and Perjeta back into the regimen.

My most recent new cancer growth, a lesion on the liver, has been biopsied and shows to be hormone positive and the first test (a stain) showed it as HER2 negative.  A stain test is very subjective because a lab employee is comparing the amount of staining in the specimen to a known positive cell. What one diagnostician may say is a 2+ another may call a 3+.  Therefore, another sample is sent to a central lab for a FISH test.  The FISH test is objective because the diagnostician counts the number of HER2 receptors on the cell.  The FISH test came back saying the tumor is triple positive.

So what does all of that mean?  Well, we know the chemo I have been taking – taxol – is no longer effectively controlling the cancer because tumors have started to grown in the liver.  We also know that the HER2 treatments are ineffective because that protein has not been suppressed in this new growth. 

Last Thursday I began a treatment called Kadcyla/DM1.  Kadcyla was approved in March 2013 for use in metastatic breast cancer treatment. See press release here.

In my opinion, it is good that the liver lesion presented.  The liver lesion gave us soft tissue for a biopsy which tells us about the chemical make of the new tumors in my body.  This makes the choice of drugs based in science, not a best guess.   With the tissue sample we are also hoping to get genomic testing of the tumor done. What is genomic testing? Well, it is looking at the DNA of the cancer cells and determining which part of the DNA is damaged.  It answers questions such as which chemo agents will work best on a subtype of cancer, other therapies that could be effective, etc.  Hopefully over time these tests will become more advanced and will provide even more information.

All of life is a series of chemical and biological reactions.  Cancer is just one of these reactions that went wrong and then reproduced incorrectly out of control and creating a mass of damaged cells in someone’s body.  Understanding the science of cancer is the first step in choosing smart treatments.  I am hoping other chemical reactions will help me to control/master the cancer in my body.  I believe that complimentary medicine, treatment offered along with the western medicine I receive, could help my body fight the cancer growth.  At least, it will make me feel good about what I am doing for myself.  So, one complimentary treatment I am choosing to add is nutrition. 

Kadcyla has the side effect of losing your appetite and this is all the more reason to be thoughtful about what I am putting into my body.  One change is buying organic produce according to the Dirty Dozen, Clean Fifteen theory.  Also, I am realizing how hard it is to get adequate protien – again the lack of appetite. (Guidelines on protein consumption) But, one thing that I have started, and enjoy a lot, is juicing.  Did you know you can juice cabbage?  Did you know broccoli juice is bitter?  I am increasing my fruits and veggies and like what I feel like when drinking fresh juices. 

So, that’s the long update.  

How I imagine cancer growth

I picture little cancer cells in my body as having a squiggly outline, messy hair and enormous mouths.  I imaging these little monsters hanging out wherever they hang out a in my lymph and blood system, which look like a lazy river.  Each time a source of cancer fertilizer floats by their oger-like mouths start chomping.

This week, with the results of my biopsy, it has been clarified that my cancer is indeed Her2 positive still.  When the cancer originally presented 8 years ago the biopsy came back showing triple positive.

What is triple positive?
It indicates that the my tumors grow in response to the hormones estrogen (as in as many as 75% of cases) and progesterone (as in as many as 65% of cases).  The third + comes from being HER2/nue positive (as in 20-25% of cases).  Her2/nue, often shortened to Her2, is a more aggressive type of cancer.  This was definately the case with me.  

When my cancer was discovered there was a very large and palpable mass.  My Ongologist figured it was probably 10cm.  Between my first and second chemo I could feel one or two additional lumps.  So, in the course of a very short time I believe new masts were growing.  Luckily it was also very responsive the the A/C, paclitaxel and Herceptin regimen I was given. I didn't have any heart health issues which are possible with these drugs other than HBP that was easily controlled and has since almost reversed completely.

When my cancer returned about 3 years ago it was found in my bones.  While a biopsy was performed and extensive testing was done across the country, the results did not indicate the tumor was HER2+ any longer.

So, how did it go from + to - to +?  Bone tumors are very difficult to biopsy - it's a solid matter versus soft tissue.  So, it was probably HER2 positive all along.  In fact, even the biopsy this week failed to indicate being HER2+ in the first test - an ImmunoHistoChemistry (IHC).  Protocol would be to trust the results of the IHC.  But, luckily Dr J requested that they move forward with the next test, a FISH test.  (I say luckily not because I was lucky, but because if she hadn't I would have been angry and insistent that we go back and get the test done. I mean lucky for her since she didn't have to hassle with me.)  It's a little funny to say, "Yeah, I had a FISH test." I feel like I could follow that up with, "they found out I am a mermaid."

Since I was probably always HER2+ and the treatment protocol is different when they aren't treating HER2 I did receive 3 years of treatments that weren't as custom tailored to my cancer as they could have been.  It is easy to ask the question, what was the price I paid for not getting the HER2+ treatment for the last 3 years?  And I will never know the answer.  I don't have to know, because the treatment I received did a great job of keeping the cancer pretty controlled.  I had results that far exceeded average experiences.  I also was able to exhaust a long list of medications.  Had I been treated with a HER2+ regimen for the last 3 years I would have already cycled through a number of chemo therapies that I am just starting now.   Additionally, the drugs I have taken in the last 3 years, while not without side effects, have had side effects that were manageable and allowed me to work and raise my kiddies. 

As I have gone through treatment it has often been my prayer that I would have peace when the choices about treatment I made were good choices that would offer me the best balance between being a druggy and a mommy.  I have had a lot of peace over the last 3 years about the medical choices I have made.  I have been so blessed to know the questions to ask and have felt guided in what I have done.  Another case in point, after visiting with Dr J Thursday I talked to her about adding the bone treatments back into my protocol.  Not that she would have forgotten or not done it, but I am so thankful to know what I need and be able to ensure that my medical team is giving the best of everything I need. 

from the Perjeta website homepage

Starting this week I am going from my 30 minutes of medication (which requires 2-3 hours at the doctor) to a 4-5 hour infusion.  I will go from pre-meds (the anti nausea meds) and a 5 minute injection to premeds, bone strengthener shot and 3 chemo treatments.  (technically 1 is a chemo and 2 are monoclonal antibodies, they are often referred to as chemo, side effects are more mild than many chemo drugs) I will go back on Herceptin, which I took before and had good results with.  I will add perjeta, which from the website looks like it may turn me into a cat. And, to round out the cocktail, taxol. Taxol is a chemo that stops the division of cells, thus making it impossible for those hairy little monsters to divide and grow.  And, because it stops the division of fast growing cells, all fast growing cells are going to get beat-up including hair, nails, gums and the mouth in general, GI track and blood cells, etc.

So I will probably become a hair-less cat. Yes, this is the 3rd time I am loosing my hair this year.  I lost it right about Halloween last year, I remember thinking I should be a pirate.   And, It will probably be gone before the first week of November ends again.  This year I am considering something permanent to decorate my perpetually bald head.  To keep from going on and on about how much I just want to grow long, dark, thick hair I am going to close now. 

Meow.