By Beverly A. Caley

Jill Cohen is enjoying Seattle mornings, walking her dog and appreciating the support of family and friends.

In 1999, when Cohen was 39 years old, she found a lump in her left breast. She was diagnosed with early-stage breast cancer. The tumor was so small and she responded so well to treatment, it seemed everything was fine. But approximately 30 percent of newly diagnosed patients with solid tumors already have metastases, and 90 percent of cancer deaths result from metastatic tumors.

During the summer of 2002, Cohen was bothered by a persistent cough and pain in her left thigh, which she had injured during a Pilates class. “There’s this graceful thing you do in Pilates where you sink down to the floor. I’ve been a dancer all my life, so it shouldn’t have bothered me, and it did,” she remembers.

When time and physical therapy didn’t heal the pain in her thigh, she consulted an orthopedist, and X-rays showed metastases in her hips. An MRI (magnetic resonance imaging) scan taken later the same day confirmed widespread metastasis from her skull to her knees. Sent home on crutches from the orthopedist’s office and not fully understanding how fragile her bones were, Cohen lost her balance while doing housework and ended up with a shattered femur.

The Metastatic Journey

Cancer cells can spread by invading neighboring tissues and starting new tumors directly in the nearby tissue. When invading cancer cells travel through the blood vessels or lymphatic system and grow in a new location, the process is called metastasis (see illustration). But it’s important to understand that even if a tumor, such as a breast tumor, spreads to the lung, bone or brain, it is still considered breast cancer.

Isaiah Fidler, PhD, of M. D. Anderson Cancer Center in Houston, explains that most tumor cells don’t have the ability to metastasize, and those that do must complete a series of difficult tasks in order to establish a tumor in a new location. First, the cells have to become motile (self-propelled). Cells usually don’t move from the place they originate because they cannot move through the body’s barrier membranes. However, some tumor cells are able to produce enzymes that eat away at the membranes, softening them enough that the cells break through.

To get oxygen, tumor cells need to stay close to a red blood cell—“less than a tenth of a hair’s width” away, according to Dr. Fidler. In order to grow and spread, a tumor must create new blood vessels, a process known as angiogenesis. Once the new vessels are in place, cells can break off the primary tumor and move to distant locations. The direction of blood flow and the size of the cancer cells cause most cells to come to rest in the first capillary bed they encounter. Cells that invade the lymph system may be trapped in the first lymph node they enter (known as the draining or sentinel lymph node). However, the cells may also escape to nearby (regional) nodes or grow in distant nodes, a process called skip metastasis.

If one million cancer cells enter the circulation or lymph system, perhaps one will survive. “One in a million sounds like very little, but in the lifetime of the cancer, a billion cells can enter the circulation. So, one in a million is not rare enough,” Dr. Fidler notes.

Those that do survive are the most vicious, aggressive cells. But surviving the rigorous journey is not enough; the cells must find a hospitable place to grow. Certain types of cancer tend to spread to fairly predictable locations, because the environments of those organs are more compatible with the arriving cell. For example, around 80 percent of bone metastases grow from cells originating in breast, lung or prostate tumors, and more than half of all people with these types of tumors end up with bone metastases.

Cancer as a Chronic Disease

Metastatic cancer is considered by many physicians and researchers to be a chronic and incurable disease. However, many patients with cancer live for a long time, continuing to lead functional, fulfilling lives. Newer treatments for meta-static disease can relieve pain and treat the problems caused by the cancer as well as potential future spread of cancer.

Cohen has a rod in her left hip to repair the fracture and a matching rod in her right hip to prevent fracturing. From August 2002 until early 2005, she was stable on Femara® (letrozole), an aromatase inhibitor, along with a monthly infusion of Zometa® (zoledronic acid), a drug that helps prevent skeletal complications caused by bone metastases. In February 2005 she was treated with radiation for a small tumor in her right hip. Post-radiation scans showed additional active tumors, so her medication was changed to Faslodex® (fulvestrant), a medication that blocks the effects of estrogen. Cohen has great confidence in her team of healthcare providers, which includes a psychiatrist and a naturopath.

While in the hospital recovering from the fracture, Cohen had a long and emotional talk with her oncologist. “I was convinced I would die right then and there,” she explains. “I had to ask what my odds were, and I’ve already outlived them. The thing I couldn’t realize when I was three months out from my recurrence was that I could be the person living a long time with metastatic disease. Every month I would see my oncologist and he would say, ‘Bones heal slowly. You’re going to be fine.’ While I was in pain from the disease, I didn’t take it in. But later I appreciated how consistent he was about what he was telling me.”

One of the first things Cohen did was seek support. The Association of Online Cancer Resources (www.acor.org) provides access to e-mail support groups. Cohen received help and encouragement from the list of around 200 women and caregivers in the metastatic breast cancer group. In addition, she continues to attend local support groups, where she has learned coping techniques from other survivors. She recently attended the 5th Annual Conference for Young Women Affected by Breast Cancer, sponsored by Living Beyond Breast Cancer and the Young Survival Coalition, a convention for breast cancer survivors diagnosed before age 40.

Living Each Day

Cohen credits her service dog, Pumpkin, for much of her quality of life and mobility. Prescribed by her psychiatrist, Pumpkin goes with her just about everywhere, and the fact that he needs to go for a walk twice a day helps her keep up with her daily exercise. “Plus he loves me unconditionally, which boosts my mood,” Cohen says. “He is without doubt the most effective therapy I have.”

For Cohen, the biggest challenge is not knowing whether the cancer is stable or progressing, what she calls “living in the gray areas.” However, long talks with friends from her online and face-to-face support groups have helped her cope with the recent progression. She observes that although living with metastatic cancer is difficult, she is still glad to be alive.

“It’s not the life I thought I would get. But it’s the life I have, so I am going to live every day the best that I can.”