Breast Cancer and Herceptin (Trastuzumab)

During my treatment for breast cancer, I was part of a medical trial in relation to the effecacy of the drug Herceotin (Trastuzumab). Herceptin is a drug that belongs to the group of drug treatments called targetted or biological therapies. It stops specific ways that breat cancer cells divide and grow. I was treated with Herceptin because my cancer cells were found to have a higher than normal level of the protein Human Epidermal growth factor receptor 2 (HER2) on their surfaces. That stimulates the cancer cells to breast-cancer-s10-photo-of-her-2-genegrow. Herceptin works by attaching itself to the HER2 receptors so that the cancer cells no longer grow. it also stimulates the body’s immune system to fight the cancer cells.

I am one of the 20% of breast cancer patients to benefit from Herceptin as my tumours were the fast growing ones that are HER2 positive. I was given the Herceptin along with chemotherapy after my surgery in order to reduce the chance of the tumours spreading or returning. If your breast cancer is not HER2 positive or, indeed, HER2 negative, Herceptin will not be effective to you.

The Herceptin treatment I was given for my breast cancer was given to me intravenously through my Hickman line on the same days as my other chemotherapy. I was treated every three weeks as an out patient. However, the days were long, as the Herceptin was given over 90 minutes with additional time taken to give me saline solutions and my chemotherapy. I had to stay in hospital for several hours in case I was allergic to the treatment. Luckily I was not. However, like all drugs, Herceptin has side effects.

The common side effects of Herceptin include: feeling like you have flu, nausea and diarrhoea. I had all of these. I felt pain in my muscles and joints and often felt breast-cancer-s2-breast-cancer-illustrationlike I had a temperature so I swung between feeling hot and cold. I also had to have treatment with anit-sickness drugs for the servere nausea I suffered. I also got medecine from the hospital to counter the diarrhoea that I suffered.

The trial I was part of was looking into reducing the period of time that women are treated with herceptin, to see if it makes a difference to the efficacy. The usual period for getting Herceptin is about a year. I was treated with it for 9 weeks. I found the hospital visits and the side effects very draining, so, although I had initially felt diappointed that I was only receiving the treatment for a shorter period, in the end I was quite glad to get to the end of the course of Herceptin.

Valerie Penny

 

 

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Risk of Recurrence of Breast Cancer

herceptin_drugMy body has endured surgery, chemotherapy and radiotherapy. As a result of this I have lost my hair and my energy. Still, that tumour the size of a baked bean is perceived as a threat. Its return must be further discouraged. My oncologist therefore insists on mammograms every six months and prescribes Letrozole. I must take one 2.5mg tablet each day for 5 years.

Breast cancer is often discussed as a general condition, but there are several different types that require different treatments. One way to distinguish breast cancer cells is through your genes. When you are diagnosed with breast cancer, your doctor will test the cancerous cells to determine their genetic makeup. My tumour had more of the HER2 protein in it than it should have had. HER2 is a protein that stimulates the growth of breast cancer cells. It can be found in your blood and urine. Sometimes it is referred to as a tumour marker. Tumor markers like HER2 cannot be used for cancer diagnosis, but they can provide other important information and the presence of HER2 helps the doctor predict how likely the breast cancer is to respond to treatment.

It is estimated that about 20 percent of breast cancers are HER2-positive. Younger women are more likely to be her_2_geneHER2-positive than older women. HER2-positive breast cancer tends to be more aggressive and to spread more quickly than other cancers. That is why it is important to find out if the cancer cells in your body contain this protein. If your breast cancer is HER2-positive, you have a much better chance of successful treatment with methods that target the HER2 protein specifically. Results show that those who tested positive for HER2 at an early stage of the condition (with tumours 1 centimeter or smaller) had a higher risk of recurrence. Researchers have also found that HER2-positive patients had a 77.1 percent five-year survival rate, with no recurrence. However, they also are
around five times more likely to suffer recurrence than those who were HER-2 negative and have close to three times the risk of recurrence of those who tested negative for HER2. So I am absolutely sure I want to discourage recurrence.

Tumours that are HER2-positive are more often associated with factors that increase recurrence rates. For example, HER2 tumours are more likely to occur in younger women and have higher nuclear grade. Generally, the higher the nuclear grade, the more aggressive the tumour. HER2 tumours are also more likely to show positive margins during breast surgery. Positive margins occur when cancer cells extend beyond the edge of tissue that is removed. HER2 tumours also have a higher likelihood of residual disease being found when additional tissue is removed. Up to 70 percent of patients with HER2-positive breast cancer respond to treatment. However, total remission for the condition occurs only in around 7 to 8 percent of patients. Targeted treatments (medicines that target the HER2 protein, like the Herceptin I was treated with) have improved the prognosis for HER2-positive patients. Remissions can also be lengthy, offering another bright spot in prognosis and reports show that remission can last more than 15 years for some patients.

tabletI was diagnosed HER2-positive and this brings special challenges in my recovery from breast cancer. The HER2 protein can make the breast cancer more aggressive. It can also make it harder to treat with hormone treatments used for other types of breast cancer. However, drugs like trastuzumab (Herceptin) target HER2 directly and effectively. This drug, when used in combination with other drugs, shows some very promising results for improving prognosis and survival rates for patients with HER2 cancer. However, there is a small but real risk of heart damage and possible lung damage. Scientists are still studying how long women should take Herceptin for the greatest benefit. I am not ashamed to tell you that I hope their studies are successfully concluded soonest. I have a vested interest in this, as my tumour was HER-2 positive.

All in all, having made the decision to stay alive long enough to thoroughly embarrass my children, when the oncologist tells me that I must take one 2.5mg tablet of Letrozole each day for the next five years, I will do just that. Letrozole has side effects but I have decided that whatever they are, they have to be better than allowing the tumour to return.

Valerie Penny

The Longest Day of Chemotherapy

It was Tuesday, 5th June, Jubilee Day. Most of the UK was celebrating the 60 years of the reign of Queen Elizabeth II with an extra public holiday.   I marked the day with my first day of chemotherapy.   It was certainly memorable!

I met with the oncologist at 9.30 am.   She told me my blood results and scans from the previous week were satisfactory as a result of this,  I could go ahead with chemotherapy today as planned. This was both a relief and a challenge.  A relief because, due to my depression, I am not good at dealing with changes in plan.  A challenge, of course, because this meant, again,  it was made real to me that I had breast cancer a condition that required lengthy and invasive treatment.  Reality struck again.

Fortunately my husband was with me.  His very presence keeps me calm.  It was during this appointment that my breast cancer nurse, Angela Wallace, began to explain some of the side effects of the chemotherapy that I might expect. These were difficult to hear. The cancer had been caught so early that I had not recognised any symptoms of the disease in myself.  I felt quite resentful to hear of the side effects I might suffer from the cure.

She explained to me that I would be entitled to a wig, in case I suffered from hair loss.  She also told me that the hair loss would be likely to be from all over my body and that I could expect, among other things, to suffer from a dripping nose. It all sounded distressing and disgusting.

I told Angela that I did not think I would bother with a wig.  I thought it would be too hot during the summer. However, she explained to me that it can sometimes be easier for other people if I wear a wig, especially my mother and my children.   She also drew to my attention that my treatment would last well into October and therefore it would be the end of the year, a much colder time of year, before my hair would begin to grow back.  This was another reality check.

Chemotherapy is a treatment which uses anti-cancer drugs to destroy cancer cells. The drugs work by attacking the cancer cells and disrupting their growth. Unfortunately, they can also affect the normal cells in the body, including the cells of the hair follicles. This causes hair loss, also known as alopecia. Unlike cancer cells, however, the normal cells quickly recover, so if you lose your hair due to chemotherapy it will almost always grow back when your treatment is over.  Before you start chemotherapy, your doctor or chemotherapy nurse will discuss the possibility of hair loss and other side effects with you.

Not all chemotherapy drugs make your hair fall out, and sometimes the loss is so small it is hardly noticeable. However, some people will have temporary, partial or complete baldness.  Some chemotherapy drugs make other body hair fall out, such as eyebrows, eyelashes, nasal hair, beard, moustache, chest, underarm, leg and pubic hair. The amount of hair that falls out depends on the drug or combination of drugs used, the doses given and the way that your body reacts to the drug.

If your hair is going to fall out, it usually starts within two to three weeks of starting chemotherapy, although very occasionally it can start within a few days. The first thing you may notice is that your hair starts to come out more when you brush, comb or wash it. You may also find hair on your pillow in the morning.

Hair may just thin and become dry, fragile and break easily. For other people their hair may carry on falling out over a few weeks so that they become completely bald. Sometimes the hair comes out very quickly over 1-2 days, which can be very upsetting. Some people find that their scalp feels tender.

It was all so much to take in.

Angela explained to me about a method of trying to prevent or reduce hair loss. By cooling the scalp.  It is sometimes possible to reduce the amount of chemotherapy drugs that reach the hair follicles on your scalp. This reduces, and in some cases prevents, the hair from falling out. It is done by using a ‘cold cap’ or a machine that cools the scalp.  I decided to try that.  I was to go to the ward for my chemotherapy by 11am, so my husband and I had time for coffee in the hospital canteen before we went up, but life is never that simple! It is Jubilee Day. The canteen was closed for the public holiday – so we settled for coffee from a machine. Yugh!

  When we went to the ward, I was reminded of all my friend, Margaret Boe, had told me. She had been given the all clear after her breast cancer last October. She said that the ward was a surprisingly happy place. She told me every body, staff and patients alike were very friendly. She said everybody was happy there, but her husband, Billy, said he had not been happy and he found the whole experience of being present at Margaret’s treatment terribly difficult no matter how pleasant the surroundings were. In any event, I was glad to have my husband’s company and support. While this was a long day for me, at least I was the centre of attention. It was an even longer day for him. I was nervous and anxious. It was so important to me to have him there.

I was shown into the treatment room. There were 12 treatment chairs and I was shown to one that accommodated the use of a cool cap too. In the corner of the room a TV high up on the wall ran the Jubilee Day celebrations all day. In our neck of the woods the weather was beautiful but we watched the Royal Family enduring the downpour in London, England for  hours as they stood waving to the crowd. While I sat on the chair waiting for my treatment to start I was anxious. I was pleased to be starting my treatment, anxious about what it held for me and even more pleased that I was not in London getting drenched watching the Flotilla on the River Thames.   

The first struggle for the nursing staff was to get a cannula fitted into a vein in my left hand. That proved to be more of a struggle than expected so the staff began talking about getting a Hickman Line inserted into my chest.  This was to make taking blood and inserting chemotherapy easier in the future.  I was put more at ease when a woman came round and offered us all a cup of tea or coffee and a biscuit. Even the visitors got offered one. My husband was pleased!

In the meantime my treatment today began with a saline solution being inserted into my vein before two different antihistamines were added to the cocktail.  Antihistamines are a type of medicine often used to treat a number of allergic health conditions. Antihistamines work by blocking the effects of a protein called histamine.

Histamine is a protein that the immune system uses to help protect the body’s cells against infection. The immune system is the body’s natural defence against illness and infection.  If the immune system detects a harmful foreign object, such as bacteria or a virus, it will release histamine into nearby cells. The histamine causes small blood vessels to expand and the surrounding skin to swell. This is known as inflammation.  

The expansion of the blood vessels allows an increased number of infection-fighting white blood cells to be sent to the site of the infection. The swelling of the surrounding skin also makes it harder for an infection to spread to other parts of the body.

Histamine is usually a useful protein, but if you’re having an allergic reaction it’s sometimes necessary to block its effects. Allergic reactions occur when your immune system mistakes a harmless substance, such as pollen, as a threat.  The release of histamine causes the process of inflammation to begin and leads to nearby tissue becoming red and swollen. It can also affect the nerves in the skin, making the skin feel itchy.

I had been in the cancer treatment ward for over 2 hours and the chemotherapy itself had not started.  The next excitement was that the woman who had come round with the tea earlier came back. This time with bowls of soup and a choice of sandwiches for all the patients and the visitors. By this point she was my favourite member of staff!

Another nurse set me up for more saline drip: another half hour passed. It was only then the chemotherapy began and I got hooked up for my course of herceptin. The time lapse was this was to be another hour and a half. My husband took an opportunity to go for a walk and buy a magazine and a paper at the hospital shop. This opened in the afternoon notwithstanding the public holiday. He needed to stretch his legs and move around a bit. I really didn’t blame him for that.  By now it was almost 2pm and we had left the house more than 5 hours previously, it was clear it was going to be a long day: a very long day.

While the herceptin dripped into my vein I sat and flicked through another magazine left by someone in the ward. Herceptin is a cancer medication.   It interferes with the growth of cancer cells and slows their growth and spread in your body.  Herceptin is used to treat breast cancer that has progressed after treatment with other chemotherapy.

I was glad when my husband got back. I know the day was boring for him, but I was happy to have his company and support. I am not sure I ever told him that. I just expected him to know. When he did come back I did the puzzles in the magazine. It was something new to look at and think about apart from the unceasing coverage of the Queen and the Duke of Edinburgh endlessly waving to the crowds in the rain.  

The afternoon rumbled on and my favourite staff member came round again, this time with another cup of tea or coffee for the patients and family members with them. This woman secured her place in my heart!

After the dose of herceptin had completed, I was given another dose of saline and then the cool cap was switched on so that it would be ready for me to wear by the time I was ready for my dose of docetaxyl. Time continued to pass.  My favourite nurse was the person who put the cool cap on for me. It had to go on a full half hour before I started taking the docetaxyl at 4.50pm.

My husband was getting bored again. Who can blame him for that? He left the ward to go down to the car park. It was emptying fast as staff came to the end of their day and clinics ended, yet evening visiting had not yet started in the wards. He took the chance to move our car closer to the hospital so that I would not have so far to walk when we, eventually were able to make our way home. That time still seemed so far away to me.

Almost all the chairs in the ward had been used during the day. Now there was only one other patient, no great surprise really, most of the staff in the ward finished their shift at 5pm. This really was a marathon session.

The other patient in the room was a woman who was further into her treatment than me. Her daughter and two grandchildren were with her. The grand daughter was asking about the cool cap I was wearing. It did look a bit like a cycle cap and felt a bit like it does when you are standing in New York City, New York, USA in January waiting for a taxi. The only difference is there is no wind in the cool cap!

It was quite re-assuring to notice how accepting the family were of the woman’s hair loss and treatment. I am not looking forward to the prospect of losing my hair. My hair has been thin for some years due to an under-active thyroid, but the thought of losing it all together makes me very self-conscious.

So another hour passed while I sat with the docetaxyl dripping into me. By 6pm even the woman with the grandchildren had left and my husband and I were alone in the ward waiting for a nurse to come and unhook my drip. Even then the day was not over. When, eventually, the last nurse on duty in the ward came back in she told us the cool cap needed to stay on for another 20 minutes.  The nurse’s shift ended and she left. My husband and I were alone in the ward. He had been given instructions by the nurse as to how to turn off the cool cap and remove it from my head. It felt strange to be leaving from a completely empty ward.

My goodness I was tired by the end of all that. Not just because it had been such a long day, but also because everything was new and strange and stressful. The shops were shut when we were driving home by the time we got there we had been away from the house for over 11 hours. It was as long a day and as stressful day as I could remember. We were both too tired to cook, so we decided to pick up a meal from our local Chinese takeaway restaurant. This was a welcome end to the longest day.

Valerie Penny

Hard Truths about Cancer

Over the next few days I had an appointment about my breast cancer with my consultant, Mr Osman. He explained to me that the  tumour he had removed was slightly bigger than anticipated. It was about 8mm long. He had expected it to be about 5mm. It still did not sound big to me, but I knew bigger, in this case, did not equate to better.

Mr Osman also explained to me in some detail that the tumour was HER2 positive and that I would benefit from treatment with the drug Herceptin. HER2 is a receptor found on the surface of certain cancer cells.  It is made by a specific gene called the HER2/neu gene. HER2 is a receptor for a particular growth factor called human epidermal growth factor, which occurs naturally in the body. When human epidermal growth factor attaches itself to HER2 receptors on breast cancer cells, it can stimulate the cells to divide and grow.

He told me that some breast cancer cells have a lot more HER2 receptors than others. In my case, the tumour is described as being HER2-positive and that it is thought that about 1 in 5 women with breast cancer will have HER2-positive tumours.  HER2 is a gene that sends control signals to the cells, telling them to grow, divide, and make repairs. A healthy breast cell has 2 copies of the HER2 gene. Some kinds of breast cancer get started when a breast cell has more than 2 copies of that gene, and those copies start over-producing the HER2 protein. As a result, the affected cells grow and divide much too quickly.

This genetic problem is not inherited from your parents. The most likely cause of this problem is aging, and wear and tear on the body. It is not yet known if environmental factors (pollution, smoke, fumes) are part of the cause of this problem.  If your breast cancer is tested for HER2 status, the results will be graded as positive or negative. As my results were graded as HER2 positive that meant that my HER2 genes were over-producing the HER2 protein, and that those cells are growing rapidly and creating the cancer. Mr Osman thought that he had removed all the cancer from my body with the surgery but in order to be sure of this and to minimise the risk of return, he recommended that the oncologist discuss with me the benefit chemotherapy would offer me.  

The oncologist, Dr Lumsden, recommended that I should have three lots of three weekly cycles of chemotherapy. The first 3 would be Herceptin and then docetaxel in a liquid that I would get through a drip (infusion) into a vein (intravenously). Each infusion of herceptin takes about 90 minutes, the docetaxyl takes about an hour and I would have one treatent every 3 weeks for 9 weeks. He recommended that I would then have chemotherapy as a course of 3 cycles of FEC (fluorouracil, epirubicin and cyclophosphamide) for a further 9 weeks.

Docetaxel can cause an allergic reaction. To try to prevent this, Mr Lumsden explained I would be given steroid tablets to take, usually for 3 days, starting the day before each treatment. He went on to tell me that FEC treatment would be given to me as a day patient. Before I started treatment, I would need to have a blood test a day beforehand. He also told me that I would be seen by a doctor or specialist nurse. If the results of my blood test were normal, the pharmacy would prepare my chemotherapy drugs. All of this might take 2-3 hours.

A nurse would insert a thin, flexible tube (cannula) into a vein in my hand. Dr Lumsden told me also that some people need to have their chemotherapy given through a thin, plastic tube that is inserted under the skin and into a vein near the collarbone (hickman line). He did not know if this would be necessary for me. I was also to be given some anti-sickness drugs as tablets, or more usually by injection through the cannula, which is often connected to a drip.

The chemotherapy drugs are then given separately after this.

It was so much to take in. The disease had been found so early that I had had no symptoms that I was aware of. Looking back, the extreme tiredness and exhaustion caused by any degree of physical effort, so typical of cancer, had already started to show. I just did not know to consider it. Still, it sounded like the cure was going to be worse than the disease. All of a sudden it was emphasised to me that my condition was serious and needed to be fully eradicated.  I was forced to face some hard truths that, until then, I had preferred to try to ignore.

Valerie Penny

Breast Cancer on Black Wednesday

Some days are better than others. Wednesday 25 April was a busy day. I spent the first half of it shuffling from one doctor to another. My first appointment was at my GP just for a regular check-up. It was then I was able to tell my GP that I had been recalled after my mammogram. He was quite cross that the hospital had not informed him. The GP also wanted to speak to me about the length of time I had been taking hormone replacement therapy (HRT). It was a long time, over 12 years. However, in light of the other appointment I had to attend later in the morning he decided not to make any changes at this point.

doctor's room

When I came back out of the surgery, I phoned my husband and he drove me on to my next medical appointment of the day. This, again was a regular appointment. It was my fortnightly visit to my psychologist. It is, perhaps, also ironic that I did not believe in depression until I was diagnosed with it over 10 years ago. Like many people, I thought it was not truly an illness, but a state of mind that could be surmounted simply by “pulling yourself together”. I cannot help but think a higher being was having a laugh when they got their own back and I have battled depression, without surmounting it, for so many years now.

However, when the psychologist asked how I felt about the possibility of a diagnosis of cancer, I still could not truly admit that it might, even now happen to me. So I put on my mask, as I so often do when faced with a problem too difficult to face, and told her that I did not know how to feel, until I knew what I had to face. It sounds sensible, but really, I simply could not release my emotions or inhibitions: not then, not yet.

When my husband and I walked from the psychology department of the hospital to the breast cancer care department we went quite slowly. Almost as if by not knowing the results of the biopsy and screening it would prevent the news from being bad.

We were not kept waiting long before I was called through to meet with the doctor and my husband came with me. None of the staff that I had seen the previous week were at the clinic that day. It was a little daunting to know I was to get the results from someone I had never met before.  However, the doctor introduced herself and the cancer nurse assigned to me was there and introduced herself too. She is Angela Watson.

It was explained to us that the biopsy had shown the tumour to be cancerous. It was explained to me that the disease had been found early and the tumour was about half the size of a baked bean. (I have always seen myself more as a “petit pois” kind of girl!) The doctor told me I would need to have surgery, a lumpectomy, (such an ugly word) to remove the tumour.  I was given an appointment to meet with the surgeon on Friday and that I would probably go for surgery in 2-3 weeks. What a lot of information.

Basic RGB

I was told the tumour was found to be HER-2 positive and that I should stop my HRT with immediate effect. HER2 is a protein found on the surface of certain cancer cells. Some breast cancers have a lot more HER2 receptors than others. In this case, the tumour is described as being HER2-positive. Tumours that are HER2-positive tend to grow more quickly than other types of breast cancer. Knowing if a cancer is HER2-positive can sometimes affect the choice of treatment. Women with HER2-positive breast cancer can benefit from a drug called trastuzumab (Herceptin). Herceptin only works in people who have high levels of the HER2 protein.

To understand HER2, it first helps to know a little about receptors and growth factors:

  • Receptors are particular proteins that are present within cells or on their surface. Other proteins or chemicals in the body can attach to these receptors to bring about change within a cell (for example, to make it reproduce or repair itself).
  • Growth factors are chemicals that attach to these receptors and stimulate cells to grow.

HER2 is a receptor found on the surface of certain cancer cells. It is made by a specific gene called the HER2/neu gene. HER2 is a receptor for a particular growth factor called human epidermal growth factor, which occurs naturally in the body. When human epidermal growth factor attaches itself to HER2 receptors on breast cancer cells, it can stimulate the cells to divide and grow.

Some breast cancer cells have a lot more HER2 receptors than others. In this case, the tumour is described as being HER2-positive. It is thought that about 1 in 5 women with breast cancer will have HER2 positive tumours. So roll on Friday and then I get to hear what the surgeon has to advise, but I am not ashamed to say, I have had better days.

Valerie Penny

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