It all started with an innocuous lump in her left breast. Knowing that it needed to be checked out, Madam Aggarwal, a 48 year old educator, saw a doctor, did a biopsy and received the news that she had breast cancer.

She was advised by the breast surgeon to undergo surgery but she decided to see me for a second opinion to discuss her treatment options.

After examining her and reviewing the biopsy reports, it was clear to me that the surgeon was correct – there was little doubt as to what needed to be done.

The lump was in the upper outer quadrant of the left breast and measured about 1.5cm in size.

The standard approach for any patient with early breast cancer was surgery first.
However, before the surgery, patients needed to undergo a staging work-up to establish whether the cancer had spread. In patients with a small breast tumour, the likelihood of finding cancer spread to other parts of the body is small, probably less than five percent.

Madam Aggarwal was sent for a computed tomogram (CT) of her chest and abdomen as well as a bone scan.

The next day, she came back to see me for review of the scans.

To my surprise, she had masses of lymph nodes lining both sides of the abdominal aorta. Based on the CT scans, it was very likely that the patient had a malignant lymphoma (primary cancer of the lymph nodes).

As I explained the findings, I felt a sense of disbelief. Being diagnosed with one cancer is often frightening enough. To be told that there were two cancer co-existing simultaneously, I would have thought was enough to throw anyone into a panic.

But Madam Aggarwal was calm. She took her time digesting the information as

I showed her the tumours on the CT scans.

A game plan was drawn up on how to go about confirming the diagnosis of lymphoma, followed by how the two cancers had to be treated effectively to try and achieve a cure.

Madam Aggarwal had a CT guided biopsy to the abdominal lymph nodes which confirmed that she had a malignant lymphoma. A bone marrow biopsy found that the lymphoma cells had already spread into the marrow – a Stage 4 lymphoma.

This was followed by breast surgery and clearance of the axillary lymph nodes. As there was also evidence that the breast cancer cells had spread to the lymph nodes in the armpit, she was deemed to have stage two breast cancer.

One week after her surgery, Madam Aggarwal started on her chemotherapy. She completed her six cycles of chemotherapy in January 2011.

She has remained well since.

I recently asked her how she managed to keep her cool through the whole ordeal.

“I had to. Otherwise, my husband and daughter wouldn’t have been able to handle it.”

It was, she explained, a brave front; deep down inside, she was actually very scared.

There was much furore over a recent report that up to two-thirds of cancers occurred because of “bad luck”.

The authors of the scientific paper, from Johns Hopkins University, Baltimore, Maryland, came to the conclusion that the majority of cancers arose from random mutations leading to the genesis of cancer cells. As there was no clear reason why these mutations occurred, they blamed it on “bad luck”

The term “bad luck” was possibly a heuristic. What I believe the authors wanted to highlight is that we often cannot find a good reason why some patients develop cancer. Indeed, I cannot come up with a good reason why Madam Aggarwal had not one but two cancers.

What I do know is that her breast cancer was detected early because of her vigilance in finding the lump when it was only 1.5cm in size.

I also know that thinking with a clear head, and not panic in face of having two cancers, allowed her to tackle the disease effectively.

And it was “good luck” that both her cancers were curable.

By Dr Ang Peng Tiam