A Few Things I've Learned About Cancer
Alternate title: F*ck Cancer.
A lot can change in a short period of time.
Just a few months ago, I was a proud dog and cat mom, thinking about the coming fall, and watching the first few leaves drift down from the trees. I was wondering if the otter would come back to our pond and drift belly-up, fish-nibbler that he is.
I’ve named him Ollie, of course. It seems a good name for a North American river otter. I regularly make mental notes to get a new pair of binoculars.
It’s February now, and I still don’t have those binoculars.
In fact, I don’t have a cat anymore, or a dog, (they both died unexpectedly, a month apart), or the rotted tooth that erupted in pain right before Christmas…or the black mole on my back they told me was cancer.
That’s a lot of excision to process.
Before you Harrumph at Skin Cancer
A mole being cancer doesn’t sound all that scary. That’s hardly a “cancer battle.” It’s just skin cancer—all things I might have said last year. And all things you might say until it’s your phone call from the dermatologist, who apologizes over and over again as he explains the pathology report.
Pathology report—that’s also something new in my life.
Something stirs beneath the surface.
This is the way of water, I know.
It is also the way of men.
—The Ways of WaterI had no idea how cryptic those words were when I wrote them. Looking back on that moment, I wonder if the cancer had already begun.
A Few Things About Melanoma
Yes, melanoma is considered the deadliest of the skin cancers. Partly because it can grow very quickly and spread (metastasize) in as few as 8 weeks. And because melanoma is notorious for coming back for repeat rounds of what I have coined “Whack a Mole.” I joined a melanoma support group for women on Facebook two weeks ago. There are close to 2K members. Since I joined, several have lost their fight.
There seems to be a trend:
It begins when a person has a weird spot or mole and tries to ignore it at first. Finally goes to a dermatologist.
The spot/mole/tumor thing is looked at with a magnifying thingy, and then the dermatologist makes the call of what to do. In cases where it looks suspicious, it is excised via an in-office biopsy. Then sent to a lab for diagnosis.
The SHOCKING pathology report—this is where many of the group members show up to get support. The waiting, the intense fear, the worry—and then that report with numbers and words and scary things on it. Many share images of their moles, pathology reports, or ask what one word or another means (I’ll share some of this in a minute.)
If pathology confirms any type of cancer a route of treatment is decided. Since melanoma was my diagnosis, that’s where I’ve done my research.
What comes next, almost always, is what’s called a Wide Local Excision surgery, accompanied by a Sentinel Lymph Node excision.
Mapping: Prior to the surgery, dye is injected into the cancer site to “map” where the lymph pathways are. Often, whichever nodes are at the ends of those pathways are removed, as this is the only way to determine if the cancer has spread past the original site.
Wide Local Excision surgery: This is done based on Breslow depth (I’ll cover what that is in a moment). Larger Breslow depths (like mine) require a 2cm radius.
How’s it done? So they draw a 2cm circle all the way around where the biopsy was done (mine is currently about the size of a cigar burn, and is located on the top left of my mid-back) and then they draw triangular “wings” out from each side. It looks like a giant eye shape. And, it’s shockingly big for what usually starts as a mole or small spot. All of that skin & underlying tissue are removed, and then corner to corner it is pulled together and stitched into a straight line. The skin has to be pulled tight over a sunken area so typically the scar is wide and gnarly.
Sentinel Lymph Node excision: Melanoma follows a pathway (usually, but they can pop up anywhere) from the cancer site, through the lymph node pathways to the lymph nodes, and then on to the bloodstream, liver, lungs, brain. By all reports I’ve read in the group, it’s the removal of lymph nodes under the arm that causes the most ongoing pain, even when the other surgical site is much larger.
Melanoma Staging
Melanoma staging works similarly to other cancers. Stages 1-4, with some a,b,c’s in there to further categorize. The staging is based on two main parameters: Breslow depth, and presence of cancer cells other than the main site. (Evidence the cancer has spread.)
My particular melanoma is stage 2b (currently) and the staging will change if they find any cancer cells in my lymph nodes (at which point it would be a stage 3(a, b, or c), and if elsewhere (like liver or breasts, etc) then it would be a stage 4 melanoma.
Note: Melanomas are notorious for spreading rapidly, invading other organs, and popping up in whole new places once you think it’s gone and you are cured. Melanoma can spread anywhere in the body, at which point it doesn’t morph into lung cancer, brain cancer, etc. It is a “melanoma of the lungs” or “melanoma in the brain”. Stage 4s are beatable, but obviously very serious and sometimes terminal.Another note: Get any weird mole checked. Just go.
Breslow Depth
Breslow depth measures the depth of the melanoma into the skin. It’s in millimeters, so usually a very low number. My Breslow depth was 2.8 (significantly deep) putting my cancer in this T3 category below, and with “ulcerated” as a further diagnostic that means it was “split” on the surface. Both of these indicate rapidly growing cancer, aggressive, and quite possibly already spread.
Note: My mole went from flat to a protruding, ugly black thing in a matter of 3 months.
Figure description: “Different patterns of skin invasion by melanoma cells. Skin melanoma staging is based on the TNM (tumor, node, metastasis) characterization. The tumor category T is determined based on Breslow tumor thickness and the presence or absence of ulceration. The stage of the skin lesion is dependent on the tumor thickness, with T1, T2, T3, and T4 lesions presenting a thickness smaller than 1 mm, between 1 and 2 mm, between 2 and 4 mm, and larger than 4 mm, respectively. Melanomas with a Breslow thickness lower than 0.8 mm have an excellent prognostic. Thicker the melanomas, higher the risk of migration of melanoma cells to lymph nodes (N) and higher the risk of distant metastases (M)”—Springer article
Mitotic Rate
Mitotic rate is a number given to show how aggressive the cancer is, and how fast it is spreading. It’s defined as: the number of actively dividing cancer cells (mitoses) per square millimeter of tumor tissue.
A mitotic rate of less than 1 mit/mm² is generally considered low risk.
A mitotic rate of 1-3 mit/mm² is considered intermediate risk.
A mitotic rate of greater than 3 mit/mm² is considered high risk.
My mitotic rate was greater than 10 mitoses/mm2. (Very aggressive, rapidly growing).
Brisk vs Non-Brisk
Brisk melanoma is characterized by a diffuse infiltration of tumor-infiltrating lymphocytes (TILs) throughout the tumor, while non-brisk melanoma is characterized by TILs in one or more distinct foci. Brisk melanoma is associated with a better prognosis than non-brisk melanoma.
What the heck that means: My non-brisk categorization denotes that my body did not recognize the cancer cells and made no effort to fight them. (Produced no TILs).
I think of all the numbers/scary words—that non-brisk scares me the most. My body didn’t even recognize the cancer cells were dangerous. My immune system didn’t respond.
Clear Margins & What That Means
There was only one good thing on my pathology report that gives me and my surgeon some hope; “Clear Margins.”
Those two words are everything in melanoma cancer. This means they “scooped” around and under the cancer enough in the biopsy to have a perimeter clear of cancer cells. This is indicative that the cancer has not spread to the lymph nodes but not certain.
While my report said “clear margins” with the biopsy, it also said “Lymphatic/perineural/angio/invasion: lymphovascular invasion identified” meaning that the lymph “pathways” which are like little blood vessels going to lymph nodes that carry lymphatic fluid, were determined to have “involvement”. Cancer cells were in the lymphatic pathways already at the time of my biopsy (first week of January).
The Good News About Melanoma
➡️ Caught early, it is beatable.
➡️ It’s somewhat preventable.
What causes melanoma? Melanoma is caused by two things: genetics, and the sun. While you can’t do a damned thing about your genetic coding, you can wear sunscreen to protect your skin.
What’s Next for My Cancer?
On Monday, February 10, I go for mapping and my wide local excision & sentinel lymph node biopsy surgeries. I’ll be under anesthesia. The surgery will take approximately an hour and a half.
They plan to take one lymph node under my arm, but there may be more removed based on the results of the mapping procedure.
Then, I wait for pathology results to determine two things:
Clear margins. If pathology does not determine clear margins, the wide excision surgery will be repeated.
Whether the cancer is detected in the lymph nodes. If it is determined the cancer has spread to the lymph nodes, then the staging of my cancer will be raised to a higher level.
If the cancer has spread: Further scans will be done to determine where the cancer has spread to. Immunotherapy treatments are the likely outcome. These are done every other or every third week for one year. They are IV treatments with a lot of potential side effects. Some people are not able to tolerate the treatments, or the immune system begins attacking organs. If this happens, a different treatment plan is considered.
How Will I Miss Work?
The wide excision site will likely be a large scar—more than 6 inches across my back. Also, the lymph node removal leaves a scar under the arm and by all accounts is the most painful and long-healing portion of the surgery.
I have taken two full weeks off work for healing, but this is not nearly enough time. Returning to work will be difficult, and painful, but necessary as I have zero income while I am out of work, and cannot risk losing my existing clients.
I plan to take the time off to do several things:
Rest & sleep (and monitor my high blood pressure)
Read books
Take walks
Meditate
And rest my neck/arms (because I am in the middle of a flare-up of pain from the disc issues in my neck.)
My diagnosis means I will have to have (every 3-6 months) full skin screening…ongoing, to spot other melanomas early and excise them, possibly repeating treatment all over again. My first check is already scheduled.
It’s not easy putting a sole proprietorship on hold for two weeks. There’s a lot of prep, getting the word out to all clients (and potential ones who may pop up during those weeks), and the difficulty of (tons of) pre-surgical paperwork on top of my regular workload.
Who Will Care for Me?
My surgical team, dermatologist, and new primary doctor will be my care team. And, my boyfriend, Kevin. “Nurse Kevin” is ready to do for me, bring me what I need, and clean my wounds. At this time I do not have an oncologist, but likely will if the cancer has spread.
Why Am I Sharing This With You?
When I joined the Melanoma Warriors support group (for women) I learned that my intense stress, nightmares, lack of sleep, and obsessive rabbit-holing and Google searching are all normal reactions to getting this diagnosis. The fear is real. For many others with cancers in the depth and aggressiveness of mine, that year of immunotherapy is common and difficult. I’ve also seen that many people with cancers less severe than mine go through this therapy, and face subsequent battles when the cancer returns in different moles/spots, and often spreads rapidly. Many of them started at stage 1 and ended up with stage 3 and 4 battles down the line.
I am sharing this with you because some of you have moles that don’t look right.
You have fear in your heart and mind.
And you need to know that time is of the essence—you must see a dermatologist immediately. You’d rather have an all-clear, no-worries response than miss a malignancy.
I don’t want anyone to feel alone and afraid. One day, someone will read this post and go to the doctor—in time!—and it may save their life by catching it early.
Do I Need Anything?
People keep asking if I need anything. (Thank you.)What I need most is time to heal and to not worry so much about how the bills will get paid with me out of work. That’s the honest truth of it. Other than that—happy thoughts, positive energy, prayers, and the like.
How Am I Handling Everything?
Some moments I am strong, others I am tearful. I have taken lots of quiet moments to think or take a walk. I am trying not to burden other people with worry. Much of the time I have felt a sense of numbness.
I do not feel like a warrior. But ask me again in a few weeks. By then I’ll have a couple of big scars and hopefully the “all clear” from pathology.
Mentally speaking, I had no idea what people go through with a cancer diagnosis. NO. IDEA. There’s so much worry, uncertainty, fear, this weird “nothing matters” feeling, juxtaposed with “every moment counts! Don’t waste it!”…both in the same headspace. The mental “game” alone is enough for the “warrior” moniker.
It’s hard to sleep.
I can promise this—I am not one to give up on any battle that I face. That’s just not in my nature. (Sidenote—I desperately miss my dog, Josie. She was my emotional support in every way.) And lastly, I don’t know where this part fits into this newsletter but I feel it so deeply, that I want to share it:
I’ve learned that people who have had melanoma cannot be an organ donor. Ever.
And this news has caused more tears for me than the cancer diagnosis itself. I have always wanted my death to give life to others. I am proud to always have chosen to be an organ donor—and now that I cannot do this, I am grieving.
I know this post was long. I thank you if you’ve read it through and I am hopeful you have learned something important here that could save your life or the life of someone you love.
For those of you who want to “do something”: Leave Christina a ‘tip’ or a word of well-wishing. Donate to the American Cancer Society to help fund research.
Thank you.
Love & care,
Christina M Ward
Writer, editor
—and soon-to-be survivor.