English version | A rose to the chest

In Portugal, one in every eight women has breast cancer. One in every eight women, in a normal day like any other, is confronted with that news that no one is ever expecting to hear. But it doesn’t have to be perceived as a death sentence. Confirming it we have specialist doctors, scientists, and the hopeful voice of women that went through that calvary and that today consider themselves better human beings, more appreciative. Above all, more grateful for being alive.

“Life changes fast. / Life changes in the instant. / You sit down to dinner and life as you know it ends.”, Joan Didion wrote, in The Year of Magical Thinking (2005). It was in an instant – in a moment, in a split second, in between breathing in and out -, that the North American author saw herself forced to accept the end of her husband’s, John, existence. He was sitting at dinner and, in a split second, puff!, he ceased to be – he was there, just not breathing anymore. Life changes in an instant. Everything is ok and then it’s not. No one is ever waiting for one of these instants to happen to them, where everything is perfectly normal and then, suddenly, it isn’t anymore. The lives of the women that follow were all apparently “ok”. They were “fine”. Until breast cancer paid them a little visit and settled itself on their lives, turning everything upside down. Joana de Sousa Cardoso, architect, today a 39-year-old, was only 24 when she noticed a little nodule on her breast. She went to see a gynecologist that examined her boob and told her it was nothing. Her sixth sense made her question if it wasn’t best to get a mammography. He laughed: “You can think about it when you’re 40.” At 26 years old, around the time she started taking birth control, that little nodule had grown, in the space of a month, to a big nodule, too palpable, around the size of a golf ball. Concerned, she booked a doctor’s appointment. From there to the biopsy, and to the diagnosis that it was, indeed, breast cancer (in an advanced state), it only took a second. Life-changing in the instant. So young, and without the thought of what would happen even “crossing her mind”, the situation was the same for Filipa Ricciardi, investor relations. She was 33 years old. “I was pregnant and was just getting an ultrasound” – the same ultrasound that eventually took another course, way beyond pregnancy: “Although I didn’t know the diagnosis on that same day, because I had to wait for the autopsy results, I was sure something was wrong by the doctor’s reaction. Out of the whole process, I would say that was the most difficult day: I would rather have a bad certainty than just uncertainty.” The stylist from Porto, Tânia Dioespirro, was 33 – “too young of an age to have breast cancer” -, and was getting a routine breast scan, since she had two or three benign nodules that she kept an eye on just to be safe: “In 2019, I felt like one of the nodules was more preeminent. When I went in to do my checkup, I asked to do an ultrasound. The moment they placed the echograph on me, the technician had an odd look on his face: ‘Tânia, this is not one of your benign nodules’. Then they did an emergency biopsy.” Life changed quickly for these three women, just like it did for the 6000 women that, annually, are faced with breast cancer, in Portugal. One in every eight women. And an approximate figure of 1500 deaths provoked by this type of cancer, according to data from the DGS. Despite the indecorous numbers, it is not with this kind of weight that a doctor delivers the news to a woman. Because there is hope. “It is a moment of intense emotion and anxiety, when one has to deliver such news”, Pedro Gouveia, Breast Surgeon and Investigator in the Champalimaud Foundation Breast Unit, affirms. “We always prefer that the first consultation of these patients is accompanied by relatives in order for them to give some support, because along the way these women just stop listening”. Joana de Sousa Cardoso corroborates: “I walked into the office with my ex-husband. The doctor says: ‘I know that in life there are certain things we wish we didn’t have. Joana, you have breast cancer.’ From then on I didn’t listen to a single word. There was just this uninterrupted buzz. And in the middle of that buzz, I heard something like ‘this is going to be a year and a half of your life that will be thrown away, but it will be alright. We’re going to do the best we can’. I only reacted when he said: ‘You’ll need to go through chemotherapy, you’re going to lose your hair’ and then it seemed like I woke up. I started crying. The initial state of my cancer was aggressive. It was big. My reaction was one of total apathy”. That is why, as this specialist underlined, after the diagnosis, it is so important to explain to the patient what it means to have breast cancer. “I usually always refer that having breast cancer is not a death sentence. Most women survive it. Then we explain to the patient the type of disease they have”. Despite everything… “Digesting the news is the toughest part. It’s indescribable. I was not expecting it. The days that followed were terrible. Until I realized what my general condition actually was, what my chances of recovering were. Telling friends and family. And then everything that follows. For example, being told that: ‘We’re going to have to start chemotherapy as soon as possible’ – because it was a stage III cancer – ‘but you’re in your fertile years, and chemotherapy can cause infertility, so you need to decide right away if you want to do fertility treatment as well, if you want to freeze your eggs.’ It was a lot to digest. It was a very intense phase”, Tânia Dioespirro recalls. On the other hand, for Filipa Ricciardi, her baby on the way and her two-year-old son were her (possible) lifeline: “This maternal instinct just arose in me. I assumed I wasn’t going to let anything threaten or question the happiness of my children. They would become my superpowers and in spite of the fear, I tried to put my ‘wrong’ emotions aside, choosing only the ‘right’ ones. Those that would give me the courage to face the challenge.” The same happened with Joana de Sousa Cardoso: “The only thing on my mind was getting to Lisbon to hug my son, Afonso, who was five at the time. I started chemo. I remember one day being at a bakery asking for something when a hand of hair just fell on the counter. I was so embarrassed. I went out to meet some friends and they shaved my head. I told my son I had lost a bet with dad and that, therefore, I had shaved my head. He left the room and I started crying my eyes out. He saw me crying. I tried to cover it up and thought: ‘I can’t be sad all the time, I have to turn this around. And if I’m doing this, I’m going to do it right.’ Because that’s who I am. If I’m doing something, I’m going to do it right.”

Why is this happening to me?

Hereditary breast cancer accounts for between 5 to 10% of the cases of the most common cancer amongst women. EVITA is an association that helps to support families who have been affected by syndromes of hereditary cancer. Tamara Hussong Milagre, the president of this association, explains that: “it is important to look out for the hereditary factor, especially amongst women who have suffered from breast cancer at a young age or bilateral, or from a breast cancer subtype called ‘triple negative’.” And she brings attention to the fact that even those women with a family history of various cancer diagnosis at early age should seek genetic counseling: “At least, knowing about the mutation and not wanting to go through with radical surgeries, one enters a state of vigilance that is more specific from the age of 25 onwards, thus avoiding surprising diagnosis later on”, she states. The reality is that most breast cancer cases are sporadic, without an identifiable cause for their appearance. It is known that there are risk factors for breast cancer and that its incidence is increasing. “Generally speaking, healthy lifestyles promote health. Anything that isn’t a healthy lifestyle will promote disease: smoking, obesity, unhealthy diet, stress… All this contributes to in a cumulative to the appearance of cancer”, Pedro Gouveia reinforces. Maria do Carmo-Fonseca, College Professor at the Medical School of Lisbon and Founder of the Institute of Molecular Medicine, clarifies: “The origin of breast cancer, just like the origin of cancers in general, results from a failure, from the lack of functioning of a series of mechanisms our cells require in order to maintain their regular social behavior. The cell exists to maintain the society of other cells that compose our organism, meaning, that a cell can’t behave selfishly, it can’t divide whenever it feels like, but only when it is necessary for the organism that it does so. Cancer is a form of rebellion of cells that become individualists and selfish, ignoring society and thinking only of themselves. The cancer cell is one that only reproduces itself, ignoring completely the society to which every other cell of the organism corresponds to. A cell with normal physiological behavior is one that is willing to sacrifice itself, one that will ultimately commit suicide if that is what it takes for the organism to survive, for its well-being.” I question her about healthy habits, as protective agents against future cancer. “Scientists base themselves in evidence, in experimenting and interpreting the results. And the great problem of this field, which is making someone feel good, happy, not stressed, is also what remains very hard to experiment on while controlling those variables. How can we control the effects of someone who feels happy versus one that feels stressed? And it is due to the lack of well-controlled results that scientists prefer not to speak out about these effects, which doesn’t mean that science is skeptical about the influence of well-being or its contrary on our health. It is becoming more and more obvious that it does; as of now, we’re still in a phase where science and scientists need to find more controlled ways of conducting those experiments, so that results can be more objective and reliable. It’s a field that is drawing in more and more scientific interest, because day-to-day observations start to pile up and it is becoming evident that a balanced person, who is happy, is less prone to a handful of diseases than someone with a tone of problems. But I would underline once more that there are a lot of factors pitching into this, because, for example, someone who is depressed or anxious will have a certain lifestyle that promotes bad health habits; and then we can’t tell if the effect produced was due to the depression or the lifestyle that person adopted because they felt depressed”, the scientist concludes.

Well, if happiness and well-being are not everything when it comes to causing breast cancer (or any other cancer), can they be a part of its treatment? “My doctor, to whom I owe and love so much, told me at the beginning of the process: ‘Joana, this is how it’s going to go: 50% depends on medicine; the other 50% it’s you’. And I hold onto that so tightly that my 50% were worth 90%. I was really determined that was not going to be the end of the road. I wanted to live. Life was too good. I was 26 and still had an infinite roll of things I wanted to do. It was a year and a half of treatments and I learned to live with it. Human beings really are something, we will adapt to anything. I was going out at night, have a few drinks, have fun and had presented my Master’s thesis in architecture to a cheering crowd. That was one of the most beautiful moments of my life. I got emotional and thought: ‘Joana, if you managed to do that, then you can do everything else.’ Because I didn’t want to stay home, I didn’t want to stay focused on the disease”, the architect shared. The stylist from Porto recalls how the strangest thing during the stage of getting used to all of this was that “you wake up in the morning and during those first five seconds you think: ‘Ah, good morning, all is well?’, and then you get hit by the realization that: ‘No, everything is not well.’” But he confesses that she ended up changing her mindset: “I thought: ‘I’m going to have to go through this, so I’m going to try and do it the most optimistic way possible.’ I decided that I was going to take care of myself the best way I knew how. I continued to work out three times a week. I would go on to the treadmill and walk to start draining and make my body react. I tried to eat as cleanly as possible – I bought a book [Healing Recipes During Cancer Treatment] that became my bible. I know it doesn’t depend on one’s will and drive alone – these are things you can’t control. But I tried to focus in doing all the right things, on thinking positively. Although it’s a slippery slope: I don’t believe the mind can cure the physical to that extent. I know of many cases where people had all the strength and optimism in this world and things didn’t go so well. To assume that the mind has that power is almost the same as holding these people accountable for not being lucky enough. Sure, I think optimism helps, even if only to give us strength and predisposition to deal with being sick, but I don’t think it can heal completely. It made the process easier.” Filipa Ricciardi brought up an important subject, were we not speaking of a type of cancer that affects women – women and their beautiful attributes: “Treatment by chemotherapy is a poison that grows stronger with time. The body changes a lot: hair falls off, eyelashes, brows, you’re bloated… Despite how futile it might be, at a certain point we can barely look at ourselves in the mirror because those are still very important symbols of a woman. And suddenly, that femininity is ‘stolen’ from us. More than physical discomfort, to be able to preserve my self-esteem was the real challenge here. Curiously enough, after going through all of it, I feel much more confidant as a woman today.” She adds that it was paramount that she felt loved, and that everyone around her wanted to help. She ensures that without it she wouldn’t have come this far: “I always had a very present notion on my mind that I needed to stick around for the sake of my kids, especially when I had a baby on the way.” The importance of friends and family that is, in fact, a premise that encapsulates these three breast cancer survivors. “During that year and a half, I learned a great deal about myself, about others, and realized that we can be much stronger than what we ever believed we could. If someone were to tell me ‘look, you’re going to have to go through this’, I would have said, ‘you do it! And then tell me how it went’. We need each other. We’re designed to live in society. We’re happier this way. My friends and family were the main reason why I am standing here today”, Joana de Sousa Cardoso states. Tânia Dioespirro contemplates the unconditional support she got: “I have a partner that makes me feel beautiful every day, and my friends and family were tireless. Sure, there were some tense moments where I had to deliver the news and also console that person. I used to joke around: ‘Look now, it’s me who has it, it’s fine’ (laughs)”. Within this context, we go back to the words of the Breast Unit’s surgeon at the Champalimaud Foundation: “To have breast cancer, though it isn’t a death sentence, is a problem one has to manage, in order to solve and treat it. And the goal of the treatment is to return to the patient the life they had before the diagnosis. Mathematics and statistics side with hope, which is living a very long life after the diagnosis of breast cancer and becoming a survivor of breast cancer. We never focus on the tragedy side, but rather on treatment and on hope.” But what happens when breast cancer actually is a death sentence?

Checkups: solution or distraction?

There are two possible scenarios when talking about breast cancer: metastatic breast cancer, when there is treatment and the patient can still live a few years, but there is no cure. And that where the patient shows no spreading of cancer and treatment is conducted towards healing completely. “The odds of a patient having the first type of diagnosis of breast cancer and it being metastatic is under 6%”, Pedro Gouveia enlightens. But what if it is? For many cases of cancer, detecting it early is paramount. The same doesn’t apply to breast cancer. When Lynne Archibald, Laço’s ex-president, created the organization, the idea was to take breast cancer off the shelf and put it out there in the open, while also raising funds for the tracking program. “When we started [Laço] in 2000, 2001, we felt it was still a very incipient field in Portugal, that needed more resource allocation. It was a program that was aligned with the idea of bringing awareness. Thus, we thought: ‘One can do the checkups, catch it early and there you go, the mortality rate will go down’. Except it wasn’t that simple. In 2010 or 2011 I was at a symposium, and a doctor – the current director of the IPO back then -, referred back to a study that questioned the benefits of tracking breast cancer, specifically. I was revolted”, she shares with Vogue. And she continued: “The assumption was that the fight against breast cancer also worked with tracking. That study was a huge slap across the face. I was very disturbed. It was the first moment of doubt when it came to the checkup program. We continued [Laço], in good faith, for four or five more years. More studies questioning the tracking started to come out.” She explains that the basic problem with checkups is that breast cancer is not susceptible to being caught in the same way that other cancers are. “Every woman that dies from breast cancer, dies from metastatic breast cancer. And no one talks about metastatic breast cancer. Women with this type of cancer live up to two, three, ten years, knowing they are going to die. Their only hope is that science will find a cure or a halt to stop the cancer from spreading. Metastatic breast cancer always returns though, even after the physical tumor is removed, hence the problem. Women with this type of cancer do everything right: the early diagnosis, treatment, everything they should have done, and cancer still comes back and kills. There is a misconception about the woman who suffered from breast cancer, which spread and led to her death. As if it had been some sort of carelessness on her part.” She recalls that, in Laço, the word prevention was not used: “Checkups are not prevention. They’re not a vaccine. To track cancer just means you’ll catch it sooner. If anything, it would prevent the cancer from spreading, but after all it doesn’t even do that. […] Tracking sounds great, but no one is looking at how the number of women who die every year from breast cancer is increasing. There are small fluctuations, but… In the last 20 years of checking up and tracking – which cost a fortune – we have the same number of casualties. There is something that isn’t adding up. In Laço, we reached the conclusion that tracking shouldn’t be where we invest our money. It should be put into investigation, into science. Because if we don’t have the solution for metastatic breast cancer, which is the one that kills every woman who is dying from breast cancer, then we’re never going to be able to control that number!”. And so Laço was closed down, transposing the scholarship project to the IMM (Instituto de Meedicina Molecular): “We didn’t have the scientific capacity at Laço.” The ball was then passed on to IMM who, since 2015, is now called Fund iMM-Laço, whose only purpose is to investigate and search for a cure for breast cancer. “Checkups are sold to women as if they were a solution but they’re not. They’re a distraction from the main issue, which is that there is still no cure for metastatic breast cancer. If the tracking of breast cancer was the equivalent of eating an apple every day – it’s good for you and it doesn’t cost a lot of money – fine. However, checking up is not only extremely expensive financially, as it also is the kind of exam that can produce negative effects. It should be done when necessary, as it is not something that is good for women. It’s radiation. It has secondary effects”, Lynne Archibald concludes.

Surviving breast cancer, because they exist – those great survivors -, forces us into the old and famous cliché that assures us that a walk in the darkness can also lead to fruition. Never meaning with that that going through pain suffering should be necessary in order to open our eyes for life. It only draws attention to those who are alive and in good health: ladies and gentlemen, thank God (the angels, spirits, the universe, whatever), because you are alive and well – another old cliché, the “health is the most important”. “I’ve always been someone more scientific and skeptical. After this, I became a more spiritual person. I began to believe that it was too demeaning to believe we are only this little dot in the universe. I started thinking in a more profound way: how did we get here, what are we doing? I understood that positive energy attracts positive energy. That positive thoughts attract positive thoughts. When I was going through cancer, I would repeat every morning: ‘Today is going to be a good day. It is up to me to make this a good day’. I still do it today. Because if you really think about it, it is largely up to us. The biggest lesson I took away from it is that we are not eternal. Things don’t just happen to other people. It’s pointless to take things for granted. Thus, it’s pointless to waste time, strength and energy getting mad about it. Now, I try to pass onto my children that we should always respect other people, be thankful, because it can all change in a split second. So, we should be kind, nice people, with a good heart. I am a very grateful person today and I believe I am a better person too. This changed my way of being. We are the product of our experiences”, the 39-year-old architect manifests. Filipa Ricciardi and Tânia Dioespirro, without knowing it, share more or less the same views. “This sickness changed a lot my way of facing life. I have always been a very intense person. And I believe this made me learn how to put things in perspective. Of course, there are situations when one gets a little but more anxious, but if we’re healthy, why does it matter? I began to be more optimistic and serene. There’s this one day when I go to the gas station near my house, I had been diagnosed just two or three days prior, and the men working there are always very nice. And I left the place feeling like ‘well, I was a total bitch today’. Because I couldn’t just be nice. On that day I realized that one never realizes what other people are going through. From that moment on, I started to reflect on this: we never know other people’s pains. I believe we should all try to be kinder to one another”, Tânia shared. For Filipa, however, cancer made her more confidant and capable of putting things in perspective. It allowed her, “most of all, to be proud of myself. Many times, I would define my own personal success through my career. Now that I’ve been really been put ‘under the gun’, the biggest challenge I ever had to face, I feel like I outdid myself – not because I conquered the disease, but mostly because I didn’t lose my mind along the way. And that makes me feel somewhat proud.”

Translated from the original on the "Pink Issue", from may 2021.Full credits and story on the print version.