Overcoming personal constraints

Take-home Message

Learn to deal with a young woman with a proactive psychological profile. When diagnosed with triple negative breast cancer, she seeks to rescue past mistakes using her natural skills of persistence and ability to foster bonds.

(Fictional narrative by the doctor)

James Fleck: Anticancerweb 27 (01), 2022

Lyla had just turned 27. Her first consultation was characterized by a free and spontaneous report. She revealed some acceptance of human imperfection and was proactive in seeking mature emotional balance. She expressed a lot of self-confidence. She was naturally coping with the cancer diagnosis and insisted on freely discussing decision-making in front of all family members. In fact, the disease was not new to the family. Her mother had breast cancer at age 55. The same had happened with two maternal aunts, but at earlier ages. There were strong signs of familial susceptibility. All were properly treated and showed no signs of recurrence at that particular time. They were in good health and were kept under periodic surveillance. Lyla expected the same outcome, but she was looking for a more comprehensive approach.

Lyla was diagnosed with breast cancer in a routine gynecological clinical examination. A subsequent mammogram was inconclusive. Lyla was very young and the dense breast tissue reduced the specificity of the exam. Sequentially, a breast magnetic resonance imaging (MRI) was strongly suggestive of malignancy. Lyla had undergone a core biopsy and the pathological diagnosis revealed breast carcinoma. Immunohistochemistry (IHC) had indicated a tumor with a high proliferative index and triple negative, that is, it did not express estrogen, progesterone or Her-2 receptors. This IHC indicated that Lyla had an aggressive tumor, which did not respond to hormone treatment or targeted therapy with trastuzumab, a monoclonal antibody directed against the Her-2 receptor. She had heard of genetic counseling that would assess family risk and wanted to be tested. The entire family, who had remained in the office throughout the anamnesis and physical examination, has been silent, just following Lyla's reasoning.

On physical examination, Lyla had a lump measuring approximately 2.0 cm, located in the middle of the outer quadrants of the left breast. There was no clinical evidence of axillary lymph node involvement. She was very young and, with the exception of a complicated abortion with uterine perforation and hysterectomy, had no other pre-existing conditions. All her clinical examination was normal. I explained that we would do some staging tests to exclude the presence of metastases, which would be essential for the best treatment recommendation. 

I had tried to start a sequential approach when Lyla abruptly interrupted me and asked what kind of treatment she would receive if all her tests were normal. I noticed that Lyla was actively seeking more information and the opportunity to discuss alternative directions. There was something greater in this young woman's goals, which had been previously agreed with her family and had not been clearly expressed. Lyla looked cautiously at her parents, her sister and finally making eye contact with me, she said: Doctor, I want to have a baby. 

Lyla explained that she had told her story in detail so I could understand the psychological importance of motherhood to her. She said that six months ago she had discussed this matter with her family. She felt that this was the only way to redeem herself from what she qualified as a mistake associated to immaturity. Her parents would support her and her sister would lend her the womb. 

There was an unshakable determination to Lyla's goals.

Her family explained that she has always been very positive. Her self-esteem had been temporarily shaken by the induced abortion. However, Lyla's plan would alleviate her guilt, leading her to a full and healthy family life. Lyla explained that her past actions have hurt a lot of people. Therese felt responsible for misdirection and connivance in previous thoughtless acts. The parents felt incompetent for not realizing the extent of their daughter's suffering or for having inadvertently planted the idea of ​​rigid morals. Lyla knew that the lost child was irreplaceable, but that her future was heavily tied to motherhood. She said she was confident that she would beat cancer and have a healthy, desired child.

I had already been through difficult professional situations, but this one was very peculiar. Lyla had a proactive psychological profile. She was focused not just on beating cancer, but on trying to redeem a past mistake. Technically it would be possible, but it would require some precautions. In parallel with cancer treatment, Lyla and her sister would undergo genetic, psychological and assisted reproduction counseling.

In the past, whenever I have encountered a proactive psychological profile, it has been characterized by persistence and the ability to foster bonding. In this particular moment, the feeling was comforting and reassuring. In Lyla's case, I had the same feeling, but it came with a bigger challenge. I would be involved in planning a new life, and I needed to make sure it didn't result in a decrease in Lyla's cancer treatment performance. I had no experience dealing with this double problem and sought a multidisciplinary assessment. I shared with Lyla and her family my concerns and possible referrals. 

That family got caught up in Lyla's ideas. Her parents thought her reasoning was correct. Therese was flattered to lend her uterus. It seemed that the child was a subjective guarantee that Lyla would be cured of her cancer. Not accepting this decision was to oppose her main reason for living. All family members were in favor of motherhood, regardless of the difficulties they had to face. It was a very close and harmonious family.

Lyla and her family had already contacted competent professionals in all required areas and I had confirmed the need to consult them. I explained that everything could run in parallel, but that the main focus was Lyla's life and her cancer treatment would take priority. She should perform the requested exams as soon as possible and return to my office for reassessment.


To be continued in PLOT 3 (conflict) …

* Attention: The story 9 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 9 from the beginning, just click in the numbered links located at the bottom of the homepage. 

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James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2022