Heather

Age at interview: 33
Outline:

Heather, age 33, has a strong family history of cancer and Lynch syndrome. She tested positive for Lynch syndrome at age 27 and stays on top of her annual screenings. She needs to advocate for herself when her insurance company routinely denies coverage for screening. Lynch syndrome put childbearing at the forefront for Heather and her husband. She lives life to the fullest—because you only live once!

 

Background:

Heather is a White woman who lives in a Western city with her husband.

Cancer-Related Experience: Elevated risk

Type of Inherited Risk: Lynch syndrome

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Heather’s story starts well before she “knew anything about hereditary cancers, or that cancer was genetic.” Her uncle was diagnosed with colon cancer when Heather was about five years old. Several years later, his cancer came back and genetic testing found he had Lynch syndrome. He died a few years later. When one of Heather’s parents also tested positive for Lynch syndrome, Heather was 26 and recalls thinking she didn’t need to worry “for 10-plus years.” But the decision to defer testing quickly pivoted when another close relative at age 30 was diagnosed with colon cancer and Lynch syndrome.

Assuming she would not have Lynch syndrome, Heather went by herself to the appointment with genetic counselor. Single and age 27, she was not prepared to hear “you've tested positive for Lynch syndrome.” She could not process the barrage of information about her heightened risk for “eight-plus cancers,” and describes the experience as “very scarring.” Genetic counselors, she says, ought to be aware that getting news of a positive cancer genetic marker changes what patients “know to be true about themselves.” She wishes that the counselor had asked, “How are you feeling? What do you want to talk about?” and then waited to deliver the technical information when Heather could absorb it.

Noting how much more complicated Lynch is for women than for men, Heather stays on top of her annual screenings. Insurance is another matter! As an educated, career women, she says, “staying on top of medical insurance has been the most challenging thing” she’s ever encountered. She coordinates her screenings by keeping spreadsheets, learning the billing codes, and continuously educating her insurer and benefits officer. Now married, Lynch syndrome put childbearing decisions are on the fast track. Given her heightened risk for gynecological cancers, the couple decided on in-vitro fertilization (IVF). Ethical dilemmas emerged in this process: How to deal with lingering social stigma? What are the ethics of testing embryos? Heather feels lucky to have found her “positive counterpart in life.” Talking to a psychologist and being part of focus groups to inform advocacy for cancer patients ease her journey.

Yes, Lynch syndrome makes for a more complex life! But Heather does not want to be viewed as someone who's sick. Rather, she is “perfectly healthy and happy,” but just needs “more annual medical screenings” than most people. And with that, Heather is building a successful career and fully enjoys her life, her family, her dog and her friends. Lynch, however, has prompted her to realize that life can be short. So, she embraces an attitude of “you only live once,” or YOLO. In that regard she is more likely to take that vacation now rather than later.

 

Heather wasn’t initially sure what to do about testing after learning about her mother’s Lynch syndrome diagnosis.

Heather wasn’t initially sure what to do about testing after learning about her mother’s Lynch syndrome diagnosis.

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My parents called us and said, we need to have a family meeting. And this would have been in 2011, so the fall of 2011. And so we showed up to this family meeting, and that is when my mom kind of explained all this to us, and that she had gotten tested and had just gotten her results, and she tested positive for Lynch syndrome. And it was this huge shock. She was very distraught about it, understandably. You know, but I think my brother and I approached this family meeting thinking someone was dying, because we'd never had a family meeting, and I must have been you know, 26 years old or something at this point. So it was very alarming. And so to us, it was a lot more like, “OK. So are you OK?” And her answer was like, “Well, yes, but I carry this thing, and there's this 50/50 chance-- because it is a genetically-inherited condition—that, that you guys might have it.” And we were kind of like, “OK, no big deal. So you're fine.” She was like, “Yeah, I'm OK.” OK. So at that time, we had a lot of conversations about whether we were going to opt to get tested. And it was a complicated situation because we didn't really know much about Lynch. We didn't really know what it meant. And at that time, all of the literature on it kind of said that you have these increased odds of developing hereditary cancers at an early onset age, which was kind of identified as like 40-ish for colon cancer, predominantly, which is what most of the literature was at that time. And here I'm sitting here at 26 …... And we were kind of like, well, gee, we don't really need to worry about this for 10-plus years. Maybe we just kind of sit on it and see what happens.

 

Heather got the news in a way she describes as “scarring.”

Heather got the news in a way she describes as “scarring.”

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So a couple days later, I go to get my test results. And they had me come in in person, which they said we were going to do this regardless. You're going to come in either way. So I went in kind of believing that I was going to be told it was negative. And I went alone. I went wholly unprepared for any type of news. And you know, it was just me and a genetic counselor one on one, sitting in a room. And he came in and handed me a piece of paper and said, you know, “I'm sorry to inform you, but you've tested positive for Lynch syndrome.” And then proceeded to spend an hour, you know, diagramming what genetics are, and what this means, and where my mutation lives, and all the cancers that I'm now at risk for, which was like eight-plus cancers. Not just colon, which is what I'd previously known it to be-- colon and stomach. And it was a massive blur. I, I took almost nothing away from it. I sat in shock. You know, I was choked up. I thought, I'm alone. No one's here with me. I'm now getting all this information. He's telling me the screenings that I need to do in order to stay on top of my health care. And I walked out of there-- I couldn't have repeated probably anything that he said to me. And so it was a very overwhelming experience. And I think that was kind of the first thing for me about being diagnosed with a hereditary cancer gene, that was like, this isn't right. Like this isn't being handled properly. The way in which that news is to be delivered should be different than this.

 

Heather says that cancer screening is harder for her than it would be for men because women have more affected organs.

Heather says that cancer screening is harder for her than it would be for men because women have more affected organs.

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Cause it is not a guarantee that I am going to get cancer. It's not a guarantee I'm going to develop one of these, but I kind of take it to be that way. It's going to happen. The goal here is to find it faster than otherwise, giving me better chances to treat it, to fight it. You know.
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Just the volume of more screenings that it means for me as a female, you know, spilling over into ovarian, endometrial, some bladder. All of this stuff kind of connected in the reproductive system. Those screenings are-- I don't want to say more difficult than colon and stomach, but not as certain in the outcomes of them. And still can be pretty uncomfortable and difficult. And so it adds a bigger list of things for me to tackle.

 

Heather, who has Lynch syndrome, undergoes at least half a dozen different screening tests each year.

Heather, who has Lynch syndrome, undergoes at least half a dozen different screening tests each year.

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You know, I walked out of there with a sheet of paper that listed, here's your seven annual screenings that you need to have done. And so it was a colonoscopy and an endoscopy to check colon and stomach. It was having a urine analysis done to check for bladder cancer. I get a endometrial biopsy every year of the endometrium lining, which is super painful and uncomfortable-- the worst screening I do by far. I get ultrasounds done that are looking at both you know the endometrium and my ovaries. I do a CA 125 blood test partnered with the ultrasound to hopefully detect a change with my ovaries, because ovarian cancer still remains one of the hardest to diagnose. And the biggest goal there was to create some kind of baseline, and be monitoring the ultrasound and bloodwork so that, should there be any change with my ovaries, hopefully, it will be picked up between one of those two. And then there's a recommend to do an annual dermatology appointment to kind of check out any spots. I started out also doing an MRI of my brain as someone with a history of migraines. And my mom's father, so my maternal grandfather, who is, I'm certain, the lineage in which this passed down. He died when she was five from brain cancer. And much later in life-- in fact, not that many years ago-- found his death certificate to-- the autopsy report actually listed colon cancer, which was not something we knew of prior. So they believe that it was actually colon cancer that metastasized to his brain, as opposed to vice versa. They had been treating the brain cancer, but because there's any amount of brain cancer and my history of migraines, they wanted to do a baseline MRI. So I did that the first year. And you know, there's some kind of perimeter things that kind of come and go. Maybe a little pancreas, maybe a little liver? But not really much screening development there yet, and not yet recommended to me as part of my Lynch screening schedule.


So I know that there's some work on maybe a pancreatic one that's being developed, and they kind of said it might be something that we explore and add on in a three- to five-year interim as opposed to annual screening with the rest of my stuff. But those, you know-- so six, I think, annually. The seventh one that I did was the MRI of my head. And so I now do all of them every year except the endoscopy, I do every other year with my colonoscopy. So they go into the stomach every other year, but my colon is every year. And I have basically assembled my team of doctors to do all this.

 

Despite her certainty one day the news will be bad, Heather finds screening to be empowering.

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Despite her certainty one day the news will be bad, Heather finds screening to be empowering.

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And you know, luckily have continued doing all of my annual screenings ever since, and have remained clean and clear. And it has become something that I-- there is a sentiment of knowledge is power, staying out in front of it, knowing that I just have to do all these screens every year so that the hopes are we find something. And that's really, I guess, the way I view it, is I want to find it before it's a major problem. But I wholly anticipate and expect finding it. Which is interesting, right? Because it is not a guarantee that I am going to get cancer. It's not a guarantee I'm going to develop one of these, but I kind of take it to be that way. It's going to happen. The goal here is to find it faster than otherwise, giving me better chances to treat it, to fight it. You know.

 

Heather calls the way she learned she has Lynch syndrome “scarring.”

Heather calls the way she learned she has Lynch syndrome “scarring.”

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Delivering news about somebody's health that is going to affect them from here on out-- it changes what they know to be true about themselves and their identity and their future has now been altered...I really wish that that news had been delivered and there had been some kind of, I don't know, a care coordinator, or just counselor, like therapist counselor, to then be there to say, “How are you feeling? What do you want to talk about?” Because I was reeling about what that meant for me and my life, and I was not thinking about, “OK, logistically, what are the next steps I need to take?”

 

Heather says bad news should be delivered in a better way; it was scarring for her to learn she has Lynch syndrome so suddenly and without support.

Heather says bad news should be delivered in a better way; it was scarring for her to learn she has Lynch syndrome so suddenly and without support.

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So a couple days later, I go to get my test results. And they had me come in in person, which they said we were going to do this regardless. You're going to come in either way. So I went in kind of believing that I was going to be told it was negative. And I went alone. I went wholly unprepared for any type of news. And you know, it was just me and a genetic counselor one on one, sitting in a room. And he came in and handed me a piece of paper and said, you know, “I'm sorry to inform you, but you've tested positive for Lynch syndrome.” And then proceeded to spend an hour, you know, diagramming what genetics are, and what this means, and where my mutation lives, and all the cancers that I'm now at risk for, which was like eight-plus cancers. Not just colon, which is what I'd previously known it to be-- colon and stomach. And it was a massive blur. I, I took almost nothing away from it. I sat in shock. You know, I was choked up. I thought, I'm alone. No one's here with me. I'm now getting all this information. He's telling me the screenings that I need to do in order to stay on top of my health care. And I walked out of there-- I couldn't have repeated probably anything that he said to me. And so it was a very overwhelming experience. And I think that was kind of the first thing for me about being diagnosed with a hereditary cancer gene, that was like, this isn't right. Like this isn't being handled properly. The way in which that news is to be delivered should be different than this.
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You know, my experience in getting the news that I had Lynch syndrome, it was very scarring. And I, and I think, on some level, I want to be aware of it just being a scarring experience in general, and I don't want to blame this poor genetic counselor for all of it. But on the other hand, I do think that there is so much that could have been done in this process. Delivering news about somebody's health that is going to affect them from here on out. It changes what they know to be true about themselves and their identity and their future has now been altered. And you just delivered that news. I really wish that that news had been delivered and there had been some kind of, I don't know, a care coordinator, or, or just counselor, like therapist counselor, to then be there to say, “How are you feeling? What do you want to talk about?” Because I was reeling about what that meant for me and my life, and I was not thinking about, ‘OK, logistically, what are the next steps I need to take?’ And then I wish that that meeting with that genetic counselor would have been some period later. I don't know, come back in two weeks and we'll then go over all this information. Because I think there was a huge amount of information to be learned in him teaching me how genetics work and how my specific mutation-- the location of it, and how, what it means, and how having this deletion results In this activity. Because I walked out of there with just little like pieces that may be missing context. And you know, I walked out of there with a sheet of paper that listed, here's your seven annual screenings that you need to have done.

 

Heather envies people who can just have children without having to worry about genetic risk.

Heather envies people who can just have children without having to worry about genetic risk.

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And it’s then a whole other layer of added responsibility and decision-making that you come to that I just think the average person isn't aware of. And that's a struggle, right? I watched my friends get married and have kids, and none of them are having to think about, gee, should I be spending $50,000 to do this IVF with this PGD testing to avoid passing on this gene to my offspring that they would have a 50/50 chance of inheriting that could lead to them some day developing a cancer?

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There’s all kinds of factors as well with the risks I have for ovarian and endometrial. The recommendation is for me to have all of that, you know, surgically removed by the time I'm 40
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And that also puts a timeline on having family. Right? It makes you go, gee, I don't know that I would normally say, yes, I'm ready for children today. But if we want them, we should probably do it now, like get on top of it. So for my husband and I getting married at-- I was 32 and he was 34 when we got married. And it, I mean, it was right after our wedding became, all right, we need to now figure this out. What are we going to do? We need to do it soon.

 

Heather explains how complex the process is and the ethical dilemmas that go along with it.

Heather explains how complex the process is and the ethical dilemmas that go along with it.

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We ultimately made the decision of, “Hey, if we're going to this length to do IVF, we might as well do PGD and we'll make decisions as they come. We will work through this.” So we are basically in the middle of it now. We've done one cycle of an egg retrieval. And, you know, it's a huge kind of emotional roller coaster, and takes a huge toll. We, you know, ultimately ended up with six embryos that were viable to be biopsied. And of those six, two of them were chromosomally abnormal and wouldn't have resulted in a successful live birth, was basically the way they put it. And then we had four left that were chromosomally super healthy, highly-graded embryos. And of the four, three of them tested positive for Lynch. That was a huge blow for me. I think I struggled with that a lot more than I expected. I thought, I'm going to be good with whatever. And you know to end up with one that didn't carry it, and these three that did, I ended up in this world of, “Well, if we started with the one that doesn't, and that either it takes and we have our first kid without, it means our second kid, we're, we’re giving them Lynch. It's no longer a 50/50. It's, we're having a kid that we know to carry this gene.” And you know, struggling with, oh, your sister doesn't have to worry about this, but you do. You know it’s, there was a big dilemma for me there. And then again, I really came back to this. I now feel like there's these embryos, and they're half my husband and they're half me, and they could make these people that are our family. And how can I let this gene that we have all managed to screen for and live with happily and healthily up to this point, all of us, prevent me from having that kid? So, you know, it’s been really a very, kind of just-- it's posed a lot more questions than I even ever anticipated.
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But if I had the opportunity to select away from Lynch, and my mom's mom could have done that, she wouldn't be here. And then my brother and I wouldn't be here if my mother had the choice to select away from it. And there's an even greater dilemma for me, really, when it gets into some of those decisions. And it can be really overwhelming.

 

Heather thinks about the potential financial burden on a child who inherits her condition.

Heather thinks about the potential financial burden on a child who inherits her condition.

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I look at the money that I've spent on my screenings just in the last six or seven years that I've been doing them. And I feel like a huge financial burden for my child, that I'm setting them up to enter a medical system where, sure, it may look different 18 or 20 years from now, but by the time they're in their mid 20s, they, I mean, you start paying for these screenings. And by the time you finish paying them off for one year, it's time to book them for the next year. Gosh, if I could spend the money now and avoid passing that on, that seems like a great option.

 

Heather says she sees herself as perfectly healthy.

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Heather says she sees herself as perfectly healthy.

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And you know something that we all felt very strongly as a family about from the beginning was, I don't want to be viewed with pity. I don't want to be viewed as someone who's sick, or there's something wrong with me. I'm not. I'm perfectly healthy, happy. I just have to get more annual medical screenings done than you do.

 

Heather says she started making it a priority to do what matters to her most, and live life well.

Heather says she started making it a priority to do what matters to her most, and live life well.

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And so my mom and I know, you know-- we kind of joke. It’s a canned saying, but we often say, ‘life is too short to drink cheap wine.’ If we open a bottle that doesn't taste good, well, pour it out! Who gives a shit? Like, who cares? Life is short. And, you know, splurge. Pay the extra money. Take the trip now. It has really been really impressed upon all of us to not wait and not put things off. You know, and I attribute it hugely to my uncle. But, my dad also has had his very best friend passed unexpectedly in a very tragic way. And, he was the kind of guy who had spent his life working and saving for retirement. That retirement never came for him. These things have all just kind of led to this, this motto in our family. You know we joke about it for my mom. We make fun of her a lot, actually. We buy her anything that says "YOLO" anywhere. We buy it for her. You know, this, "you only live once." But it's really become our mantra....
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You know, I've traveled more because of it. I am quicker to make decisions. It’s, I used to agonize about being indecisive. And now, I just think I come to decisions a lot faster. You know, we look at a house to buy and I'm like, yep, this will work. Let's do it. Like, where's the dotted line? I think I used to just weigh things a lot more heavily, concerned about making the right decision. And now I'm kind of like, let's just go for it. You know, if we mess up on something, we'll fix it. I'd rather do that than sit here not moving for any amount of time because I'm concerned with picking the right decision. And I think that has 100% been attributed to feeling like I'm aware of time now, and I don't want to waste any of it with inaction. You know, I'd rather go to bed later and be tired during the day if it meant spending that extra hour with our friends over dinner laughing and telling stories. You know, it's those types of decisions, it's easy for me to come to them now.

 

Heather and her husband faced tough decisions, together, about having children.

Heather and her husband faced tough decisions, together, about having children.

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His, you know, immediate reaction when I started getting very emotional talking about, if we were to have kids, here's what this would mean. And I'm scared of going through like getting pregnant and being off birth control because I’ve kind of for so long been told that birth control's been a very healthy thing for me to suppress my hormones, which ultimately helps diminish, you know, the odds of some of the ovarian and endometrial cancers to develop. So I was scared of, what if it takes a year? And during that time, I've now increased these odds that I'm already at an increased percentage of. And they go up even more. And I have this kid, and then I, you know develop one of these cancers, and I can't be here to raise this kid. And I had gone to this place of like, I'm going to leave you a widower, and you're going to be a single dad. And all these things, I just went so far out into what this could all mean. And I think I've been very lucky to have found someone who was just so, like, it's all going to be good. We're going to be good. You're healthy, your mom's healthy, your brother's healthy. You guys have all lived with this. You just got to do your screenings. And he was very like, you know, your health first. So let's go meet with doctors and see what the impact is to your health. But beyond that, let's just have our kids and who cares?

 

Heather believes that being open about hereditary cancer is constructive.

Heather believes that being open about hereditary cancer is constructive.

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It's really about just not being ashamed or shy about things. I think the more we talk about them, the more good it's going to do. I spent a couple years being really hesitant to talk about Lynch syndrome. And I ultimately came to this place of, I've had some conversations where I really raised awareness about it. And any way that I can contribute to that, it's going to be a ripple effect ultimately, hopefully lead to more interest, more funding, more research, and then more knowledge.

 

Heather had concerns about having to disclose her condition and losing her insurance.

Heather had concerns about having to disclose her condition and losing her insurance.

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The first couple years-- the first probably two to three years after learning that I had Lynch syndrome-- I was really scared of leaving my job, because I thought it would mean going somewhere new, needing to get new health insurance. I also thought about my life insurance policies. Right? All these things that are through my employer as my benefits package with my employer. Well, starting now, when I went somewhere new, now I have a preexisting condition. That is what this is classified as-- a genetic mutation is a preexisting condition. And now that becomes something I have to disclose. And how is that going to affect my health insurance benefits, or my life insurance benefits?

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There’s been, there was this real fear for me around, man, I guess I better like this job because I'm going to have to stay here for a long time. You know and at first, I ultimately felt like I had to go to my benefits manager because I needed somebody's help in trying to navigate the insurance side of it. But I otherwise didn't tell a soul.

 

Heather says the number one thing is to stay up on recommended screenings, because though they can be a hassle they pay off.

Heather says the number one thing is to stay up on recommended screenings, because though they can be a hassle they pay off.

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But my, my number one thing is just get the screenings. I know some people shy away from the doctor. I know some people don't want to know the results or the outcome. They don't want to face it if something is there. Get the screening, get the screening, get the screening, get the screening. I know money can be a burden, and I know not having access to it and access to health insurance, I know these are all factors. But they can be figured out. You know, it’s get that screening and stay in front of your health, because as long as we're able to do that, we are at an advantage. Right? I met with a genetic doctor at [location] last year to check in on my screenings. Am I still doing the right thing? The last time I talked to somebody was six years ago, and it was this genetic counselor in this moment when I was diagnosed. So here's what I'm doing. Is this still right? And I had a follow-up with her. And one of the things she said to me that resonated so much is that, at this point, what I am doing, it takes my risk of colon cancer potentially down to almost 1%.
Wow.
Due to the frequency of my screenings and my now history of clean screenings. It was like, I’m now a little bit below the general population's risk of colon cancer, and I carry Lynch syndrome. And like that's crazy. But that's just from getting my screenings done. So.

 

Heather says she wants her fears acknowledged rather than “bulldozed” by people close to her who may be struggling to face the reality of her cancer risk.

Heather says she wants her fears acknowledged rather than “bulldozed” by people close to her who may be struggling to face the reality of her cancer risk.

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I went through this with my husband. That first year that we were dating and I was heading into my screenings, he was that person who kind of blindly said, “You're going to be fine. You're not going to get cancer. You don't have cancer. It's going to be fine.” And it was the most anxiety-ridden screening round that I've had in all of them. And so after that one, we had to really hammer through it. And it was tough. Like we had some, some tension around it, and it was hard for me to properly express it. But ultimately, going into the second year then, what I was able to finally verbalize to him was, I know that for you, like he needs, he needs me to be OK. He needs to believe I'm never going to get cancer, and I’m not, I don't have it, and I'm going be fine. But I need you to acknowledge that that may not be the case. I need you to acknowledge that I may come out of one of these screenings and we may be told, we found something. I need that to just be validated. You can still believe that I'm going to be OK. And you can still tell me, no matter what, we're going to be OK. We're going to figure it out. And we’re going to, you know, we're in it together. But you can't tell me I don't, you can’t tell me I don’t have cancer at any moment, and you can't tell me I'm not going to get it at moment, because you don't know. And saying that diminishes my fears. It tells me that I’m not valid in feeling that way. And I think the most important piece of advice I could give to anyone is, the receiver of this type of news, or the person supporting someone in this type of news, would be, let them feel however they feel. Tell them, it's totally fair for you to feel that way. That's a valid concern. That would be, yeah, I can see how that would be difficult, or something I'd be worried about. It's also OK to say, but the good news is you're being proactive. The positive thing in all of this is to say, you're getting your screenings done regularly. We're going to be out in front of it. Like those are the words of encouragement. Don't tell me I'm going to be fine. Don't tell me I'm not going to get cancer. Tell me, we're going to get out in front of it. You're doing these screenings. That's fantastic. How cool of you. Knowledge is power. Like those are the positive encouraging things. And then the validation of the, of the not-so-positive things. Let them be afraid. Let them be sad. Let them be worried about a screening. And let them know that, yeah, it's OK to be scared to go into your screening. It's an unknown. But hey, you're getting a screening done. And if there's something there, they're going to find it sooner than anything. And then we'll have a plan of attack. Like that's where the encouragement and support comes from. Less from kind of bulldozing someone's fears with your own need to not address it or deal with it.

 

Heather is grateful to have a friend who will listen curiously to her questions and fears without trying to minimize them.

Heather is grateful to have a friend who will listen curiously to her questions and fears without trying to minimize them.

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Sometimes it wasn’t, I didn't want the positive friends. The ones that always spin everything—“Oh, you'll be fine. Oh, you're not going to get cancer.” I didn't want that friend. I wanted the one who I went to and said, “I'm thinking about having kids, and that I could have a kid and die before that kid was old enough that I felt like I'd given them the tools they needed.” And the friend that would go, “Wow, yeah. That would be scary. How are you dealing with that?” You know, I would choose that friend. I needed to be able to share some of that morbid stuff, and I think that's a specific friend in your life. So it was finding, what are my needs? What are the conversations I need to have around it? It's not just about me informing all of my friends, “hey, I have this thing.” It was, what are the conversations I need to have about it? And then who, who of them are the right people to have those conversations?

 

Heather says she has a bigger list of Lynch-related things to tackle because she’s a woman.

Heather says she has a bigger list of Lynch-related things to tackle because she’s a woman.

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Cause it is not a guarantee that I am going to get cancer. It's not a guarantee I'm going to develop one of these, but I kind of take it to be that way. It's going to happen. The goal here is to find it faster than otherwise, giving me better chances to treat it, to fight it. You know.
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Just the volume of more screenings that it means for me as a female, you know, spilling over into ovarian, endometrial, some bladder. All of this stuff kind of connected in the reproductive system. Those screenings are-- I don't want to say more difficult than colon and stomach, but not as certain in the outcomes of them. And still can be pretty uncomfortable and difficult. And so it adds a bigger list of things for me to tackle.