The term “breast cancer” is a big umbrella, with the outcome for individual patients ranging widely due to a vast spectrum of factors. And for patients with triple-negative breast cancer, one of the disease’s most serious and life-threatening forms, those factors can drastically change their treatment plan.
That was news to Jana Cox, 35, a Vancouver woman diagnosed with triple-negative breast cancer in April. A product developer at Nike, Cox is an avid runner and traveler with no family history of cancer.
Coming to terms with the fact that she’d been diagnosed with such an aggressive and fast-moving cancer was a shock, she said.
“I thought there was one kind of breast cancer. I had no idea,” Cox said in a Sept. 24 interview with The Columbian. “There are so many steps in breast cancer that have been made so people, myself included, didn’t really understand how unfortunate my diagnosis is.”
Fortunately, she caught it early. She also had a plan, and a doctor who understands how important a plan of action can be in helping a patient move past that first point of diagnosis — Dr. Cory Donovan, an oncology surgeon at Legacy Salmon Creek Medical Center with a focus on breast health, and three years out from her own diagnosis of triple-negative breast cancer.
“As soon as you have a plan, you can put one foot in front of the other,” Donovan said.
‘Big, bad and scary’
“It turns out that not all breast cancers are created equal. It’s a vast, heterogenous mass of different kinds of diseases that are all lumped into one heading,” Donovan said.
Triple-negative accounts for between 10 percent and 20 percent of breast cancer cases. It moves fast and is hard to treat. Triple-negative cancer cells, Donovan said, are “big, bad and scary.”
“It requires all the guns,” she added.
Triple-negative breast cancer differs from more common types of the disease in that hormones are ineffective as a treatment option. Researchers are unsure how to starve cancerous cells by any method other than chemotherapy and radiation.
Most cells have receptors within the cytoplasm that they use to identify signals that stimulate cell division. Hormonal cancer treatment hijacks this system, halting the spread of the cancerous cells.
“They (receptors) are basically like little antennae that are waiting for signals from the body,” Donovan said. “Like an outstretched hand, waiting for the ball to come and hit it. And they come in three types.”
Most cancer cells have receptors for estrogen, progesterone or human epidermal growth factor receptor 2, called HER2.
Hormonal treatments such as tamoxifen can be used to block estrogen receptors, stopping the cancer in its tracks. Breast cancers caused by an excess of HER2 receptors, which are on the surface of most breast cells, can be treated by blocking the receptors that send out signals to grow and divide. HER2 receptors make it easier to identify and isolate cancerous cells.
“If you have none of these receptors — no HER2 receptors, no progesterone receptors, no estrogen receptors, then you get to be called-triple negative,” Donovan said.
“The only thing we have to deal with these cancers is chemotherapy. Luckily, it saves lives.”
Outside of surgery, radiation and chemotherapy, there are few options by way of treatment. Since hormones are not supporting the cancer’s growth, it is unlikely to respond to hormonal therapies. Studies have also shown that triple-negative breast cancer is more likely to spread outside of the breast tissue and more likely to recur after treatment.
Short-term survival rates are less than for other types of breast cancer. A 2007 study encompassing more than 50,000 women with all stages of breast cancer found that 77 percent of patients with triple-negative breast cancer survived at least five years, compared with 93 percent of women with other types of breast cancer.
Triple-negative cancers “spread faster, are usually more aggressive, usually faster dividing. They’re the kind of cancers where a women went in for her mammogram six months ago or a year ago and there was nothing there, and this year there’s a big mass,” Donovan said.
In younger women
In Cox’s case, the diagnosis was even more abrupt. She’d had a cyst on her breast aspirated, but it returned, so she underwent surgery to have it removed. A few days later, she found out that it wasn’t a cyst at all, but a mass of extremely aggressive cancerous cells.
“The first thing that came to my mind was, ‘How do I tell my mom?’ ” Cox said. “Then, the really bizarre side: ‘I’m going to be late for work.’ ”
Triple-negative breast cancer is far more common in women younger than 40 than hormone-based cancers. For some young women, many of the existing resources and support groups for breast cancer patients can feel a bit alienating.
“When people think of an image with someone with breast cancer, often they think of somebody who’s retired, or somebody who’s older. And they face different challenges,” said Donovan, who was 34 years old when she started her own cancer battle. “But I think as a young woman, the implications of the diagnosis in terms of your work and your financial situation are pretty significant.”
Cox said she’s not into wearing pink, and feels that many of the breast cancer causes sprouted by brands are just a marketing ploy. She finds solidarity in blogs of women in her age group undergoing the same fight, she said.
It also felt good to take control. After her diagnosis, Cox bleached her hair bright blonde and cut it short. She had her eyebrows microbladed, then shaved her head as soon as her hair started to fall out.
“I just didn’t want to look sick,” Cox said. “When you don’t have eyebrows and you have patchy hair, you look very ill.”
She spoke with The Columbian between treatments — in the month previously, she’d undergone her eighth and final round of chemotherapy, and she was scheduled to start radiation.
During the intermittent month, she underwent “doctor-ordered fun,” Cox said.
She’d come to the interview from the airport, after spending the night prior at a Bachata concert in California. The week before, she’d gone on a road trip with her mother to Mount Rushmore.
“My job, I had a lot of control. It’s what I did for a living. I was a planner, I planned things. I worked in factories, we had tight deadlines. With this — no,” Cox said. “There’s so many gifts that have happened with this cancer. I have to just sit back and let things happen. I can’t control it. … I’ve become impressively chill.”
The good news
The good news is that the aggressive, fast-multiplying nature of triple-negative breast cancer cells also means that they respond better to chemotherapy than other types of cancerous cells.
Or, in other words, the treatment arsenal shrinks for triple-negative breast cancer, but the weapons in that arsenal are more powerful.
“Chemotherapy is just a nonspecific bomb, kind of, which is why people hate it and why it’s not an enjoyable experience,” said Donovan. She underwent aggressive chemotherapy over the course of five months in 2016.
“It targets cells that are dividing faster than other cells. And the goal is, that if the cancer cells are dividing faster than all the rest of the cells, they get killed first.”
Cancer cells are easier to distinguish from healthy cells, and therefore easier to zap.
“Patients who respond best to chemotherapy are often conversely the patients who have the fastest-dividing tumors,” Donovan said. “It’s easily targeted — you kill them off before you get a lot of toxicity.”
The other good news is that while triple-negative breast cancer tends to recur early, it’s rare for it to recur late.
A 2017 study followed 873 women with triple-negative breast cancer and found that survival rates after five years were no worse than for other types of breast cancer. After 10 years, there was a low probability of recurrence.
“If you get two or three years out with no evidence of disease, you’re out of the woods,” said Donovan, who gave birth to a healthy baby girl earlier this year.
Watching Donovan and Cox interact, it’s clear that their relationship extends beyond a typical doctor and patient. They text photos back and forth. They commiserate about all the unsolicited advice they’ve received from strangers. They cry and they laugh.
Donovan said she sees a lot of herself in Cox.
“When I had to tell her about her diagnosis, all I could think of was how I felt when I looked at that ultrasound and I knew I had a bad cancer. And all I could think was, I’m going to take her world and make it come crashing down. And I didn’t know how to do that. So I thought what I would have wanted, and what would have helped me,” Donovan said.
The feeling is mutual.
“I feel so lucky that it was you that had to tell me,” Cox said. “I know that doctors care, but I really felt cared for.”
