What happened next: skin cancer

Posted on 11 April 2019

A married mom of two shares how being diagnosed with advanced skin cancer during both her pregnancies taught her to view challenges as opportunities to grow

When An Bakkes talks about her children, it is with the confidence and pride of someone watching a plan unfold. It wasn’t always this way. An was 21 weeks pregnant with her first child when she was diagnosed with stage four metastatic melanoma for the first time. This means she had advanced skin cancer, and by the time it was picked up, it had spread deep within her body. “The frames of my glasses irritated a mole behind my left ear. So I went to see my GP, to ask if there was anything he could do about it,” she says. Her doctor’s eyes widened. “He said, I’m sending you to the best plastic surgeon I know. Today.”

Looking back, An says although the mole was in a place that made it difficult for her to examine, she now knows the signs were all there: the mole had darkened, its borders had become irregular and it had grown significantly. All of these are red flags that the cancer was growing, and fast. “When you’re pregnant, traditional cancer treatment becomes dangerous,” she says. “The tests and scans can have an unpredictable impact on your body.” Her stage of pregnancy, with her stage of cancer, was a high-risk combination. “When the doctors sat us down to give us our options, they looked at my husband, Tiaan, and said, ‘There is a chance here that you might have to raise this baby on your own. Are you up for that?’”

THE SCIENCE BEHIND THE DIAGNOSIS

Skin cancer occurs when skin cells become damaged at a molecular level, triggering mutations that lead to uncontrolled growth, says Dr Georgina McAdam, An’s oncologist, who helps run a melanoma clinic at Mediclinic Constantiaberg. As these cells multiply, they form malignant tumours under the skin. Sometimes, those abnormal cells can break away from tumours and travel to other organs, such as the heart, lungs or brain, causing secondary malignant sites. This is known as metastasis.

“This is considered stage four melanoma,” says Dr McAdam. “It can also spread to the lymph nodes, and at that stage, it is very serious. Those patients do not have a good prognosis.” Doctors will decide on an appropriate course of melanoma treatment depending on the stage of its development and its location in the body. An’s cancer started in her neck, just behind her left ear – and had spread to her lymph nodes. Treatment for stage four melanoma, under usual circumstances, is limited to surgery and chemotherapy. Hormone therapy is not used for melanoma, and radiation therapy plays a role only in local pain management, Dr McAdam explains. “Chemotherapy is also not very effective, as it is not curative. In fact, most patients with metastatic melanoma have a high chance of dying from the disease.”

An’s stage of pregnancy made her case even riskier. “With pregnant patients, we would not usually recommend chemotherapy, as it could cause major foetal abnormalities or hinder the baby’s growth. There is also a chance the mom could miscarry, and infection is another danger.” With other cancer treatments off the table, An was left with a single hope: that extensive surgery would remove the affected nodes and prevent the melanoma from spreading further.

Dr Deon van der Westhuizen, a plastic and reconstructive surgeon formerly affiliated with Mediclinic Cape Town, set about removing the moles on An’s body, behind her ear, on her face and on her belly. At that stage, An was climbing the corporate ladder, managing mergers on behalf of various blue-chip corporations. “The doctors told us, stress doesn’t help the treatment. The higher your stress, the higher your chance of the cancer spreading,” she recalls.

Just six weeks after being diagnosed with stage four melanoma, An confronted another source of anxiety when she gave birth to her first child, 13 weeks early. While recovering from cancer surgery, An’s own needs had to take a back seat in the face of the new challenge. “My son, Luca, weighed a single kilogram and spent 11 weeks in intensive care. I remember sitting in hospital, trying to feed this little boy, one millilitre of milk at a time. Sometimes his heart would stop, randomly, and we would have to fight to get it going again.”

STARTING AGAIN

For two years after giving birth to her son, An was cancer-free. But as a high-risk patient, she continued to go for regular positron emission tomography (PET) scans, which use small amounts of radioactive material to pick up new cancerous nodes in the body. Because cancer cells are more active than other cells, they rapidly absorb this material, and show up as highlights on a scan. Of particular interest were the lymph nodes in her neck that had been purposefully left behind to detect any signs of the cancer recurring.

During that time, An fell pregnant again. About 30 weeks into her pregnancy with Emma, the nodes started glowing again. “We don’t know the reason why this happened,” An says. “It is a very rare occurrence. There is a theory that maybe we didn’t get all of it the first time, there is a theory that I may be cancer-prone and the hormonal changes of my pregnancy brought it back … but there is no definitive medical answer to explain it.” Dr McAdam concurs: “There is no link between this cancer and pregnancy, or premature birth. We know that moles can look different when they become problematic, but there is no link between being pregnant and developing melanoma, or of melanoma spreading into the body and giving birth early. An was very, very unlucky.”

In some respects, An says, the second diagnosis was worse than the first. “When you’re diagnosed with cancer for the first time, you don’t know what’s coming. That is scary. But when it comes back, you have a picture of the mountain you need to climb, and you have to ask, am I strong enough to do this again?” This time, the cancer had spread far enough that An required even more aggressive surgery.

Professor Johannes Fagan, an ear, nose and throat surgeon who was based at Mediclinic Constantiaberg at the time, performed an urgent neck dissection. This procedure is designed to remove the lymph nodes in the neck area and carries significant risks. “The surgeons started just behind my ear. They took out a large part of my neck muscle and about half of my shoulder muscle,” An explains. “The danger is removing these muscles while avoiding the nerves – if something goes wrong, you could end up paralysed on one side of the face.”

Operating on a pregnant patient adds an emotional burden, Dr McAdam adds. “This is a risky surgery. But now there are two lives at risk.” The series of surgeries was a success: the first removed the cancerous nodes, and a further five restored full nerve function in the area. Two weeks after An’s second diagnosis, she gave birth to her daughter, Emma, eight weeks early. “We were lucky with Emma,” An believes. “She spent only two weeks in the neonatal intensive care unit.”

While both Luca and Emma are free of many of the disabilities and disorders that commonly affect premature babies, one thing they had in common with other preterm infants was that they got sick – often. “In the first two or three years, it seemed at least one of them was always ill,” An says. Caring for two premature babies, while trying to avoid stress and recovering from extensive cancer surgery is a superhuman feat.

“There are times when I think it wasn’t that bad,” she laughs. “And other times I think, actually, it did get pretty bad. But what can you do? You do your best.”

APPRECIATING THE NOW

Today, An is a mother to two energetic, inquisitive children. She has full feeling in most of her face and her scar, running from behind her ear to below her left shoulder, is a reminder to appreciate each and every moment.

“Honestly, there was a time when I thought cancer had broken me,” she says. “The adrenaline of reacting to bad news, the effort of coping, of trying to be positive – it all just became exhausting. But when I look at my husband and my children, I have physical proof of what I went through. I know it was all worth it.”

Being alive, and being present for her family, is not something An takes for granted. “Before cancer, before my kids, I saw life very differently,” she says. “For a long time, I allowed my work to define me. Now, my priority is to be emotionally available to my family.” Two cancer diagnoses and two premature births have encouraged An to double down on who she is.

“These are serious challenges, but we have never hid away from them.” An says through all her tests and scans and surgeries, she has always looked forward. “Tiaan and I asked ourselves, how do we survive this? Our kids are the answer. They have given us this deep joy. We get just as frustrated as any other parents. But we also know, every day, what a privilege it is to watch these little people grow up.” It has been seven years since An last had cancer. “This morning, I woke up, and I could hear Luca and Emma, still in their beds, singing ‘The Sound of Music’ at the top of their lungs. That is happiness. Lying there, listening to them: this is living.”

Stages of skin cancer

Melanomas are classified according to how thick they are, how deep they have penetrated into the skin, and how far they have spread. Staging them helps doctors determine the most appropriate course of treatment.

STAGE 0 Localised Non-invasive

STAGE 1 Small Has penetrated outer level of the skin Usually show no signs of metastasising

STAGE 2 Larger: 1mm or thicker High risk of spreading

STAGE 3 OR 4 Advanced Has already spread to other organs

How Melanoma spreads

Melanoma develops on the epidermis, the outer layer of your skin. If it is not found early and surgically removed, it will continue to grow downwards and penetrate the dermis below. Once there, it has the potential to spread to lymph vessels through subcutaneous tissue. From there, it can move into many different parts of the body. This is because these vessels transport lymph, a fluid that carries white blood cells to wherever it is needed in the body.

The nodes act as a filter, removing bacteria from the fluid. Through this system, melanoma cells can travel deep into the body and latch onto the nodes they meet. While surgery is usually the recommended course of treatment for patients with early stage melanoma, it is also an effective way to remove lymph nodes that have been affected by metastasising cancerous cells.

It is important to note that surgery does not usually cure cancer – but it can slow the growth of the disease and alleviate symptoms. Speak to your doctor about how to spot early warning signs of skin cancer.

 

WORDS THOMAS OKES

PHOTOGRAPHS JAN RAS

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