When a door closes, open a window … but what about when you run out of windows?

In this clumsy metaphor, the doors and windows are treatment options for Stage IV Metastatic Breast Cancer (MBC) and so many of us only have a finite number of treatments before this terminal diagnosis completes its trajectory and ends its own existence and the host. Reaching the end of a treatment option and contemplating the shorter and shorter list of what could be next has occupied my thoughts and triggered a deluge of new and familiar angst in the last few months.

But let me take two steps back and mention a new wrinkle in the cancer experience for me — a new primary cancer. I have also been diagnosed with melanoma and am still trying to wrap my head around how to learn and incorporate yet another cancer into the whole picture of my cancer care. The area on my leg that was biopsied in 2025 is depicted below and, yes, the wide excision surgery did affect my water dragon.

But, how did this happen??

About 3 months ago, when applying lotion to my leg, I noticed that a birthmark I’d had since birth was raised instead of flat. Years ago, a work colleague had come from a dermatology office and she taught all of us the ABCs to watch for:

“ABCs” of skin cancer refers to a mnemonic for identifying suspicious moles that could be melanoma. It stands for Asymmetry (one half doesn’t match the other), Border irregularity (ragged, notched, or blurred edges), Color variations (uneven color with shades of brown, black, or even white, red, or blue), Diameter (larger than 6mm, about the size of a pencil eraser, though they can be smaller), and Evolution (any change in size, shape, color, or other characteristics).  

I’m thankful that I absorbed her instructions and once I felt the difference in height of my birthmark while applying lotion, sought out medical care. Despite my family history (father and paternal grandmother), I’d not begun regular skin checks with a dermatologist and I have no excuse for not doing so. We live in Florida and there’s those family risk factors to consider in addition to my germline mutation at ATM, which is a repair gene. I have been tested for genetic mutations that would lead to melanoma and do not have a mutation associated with melanoma (or maybe we just don’t know of all the genetic risk factors) but still, should have had that as part of my regular checkups. Don’t be like me—be sure to have someone who is paying attention to skin changes!

After the biopsy was done and surgery was clearly needed, I didn’t feel comfortable with the mostly cosmetic practice where I’d gotten the biopsy. I was so sure it was nothing that I didn’t do much research in selecting the practice for that initial visit (won’t make that mistake again). After a lot of phone calls and visits locally, feeling more and more uncomfortable, I trusted my gut and scheduled the surgery at the Mayo Clinic with a surgical oncologist. Likely a bit of overkill since the melanoma was determined to be only Stage I and the surgery was likely curative since the sentinel node they removed was negative for cancer (any cancer), but I needed the extra care in other ways.

Here’s what my water dragon looks like now with the healing incision from the surgery. While it wasn’t the priority, the surgeon did his best to follow the black lines outlining my dragon and did a great job in both taking sufficient tissue to get clear margins and also ensuring that my dragon wasn’t too mangled — I really thought it would be worse and I’m thankful it was a good experience with a good outcome (anyone who has surgery should ask for the heated gowns, which were AMAZING!).

I’m thankful that the surgery was considered curative and that I’ll be under some close surveillance to ensure that nothing else pops up without us knowing about, but it was a very sobering experience and reminded me how much I need to be thinking about more than just breast cancer.

Here’s some interesting things I’ve learned along the way:

• It isn’t abnormal for lymph nodes close to a tattoo to be permanently stained by the ink. The sentinel node removed from my groin was extremely colorful, which apparently caused a brief bit of consternation in the procedure room. Thankfully my surgeon was ready and undeterred.
• Melanoma is one of the only cancer types where a full body PET scan will be covered by insurance. Not sure my breast oncologist was ready for that message from me! But I am determined to find and take advantage of any silver linings possible.
• Natera, the company that I get regular tests of circulating tumor DNA (ctDNA), will only sequence the DNA of one cancer per person at present. The dermatology oncologist who will be following me now utilizes regular ctDNA testing for what he calls “enhanced surveillance” in addition to regular skin checks, but since I’m already following ctDNA for the breast cancer, we’re having to use a different company and adding that to all the things has been quite a bit of work. Hoping this will change in the figure but since the only tissue I have has likely been consumed by the testing, I’m probably stuck with this scenario.
• A secondary primary cancer diagnosis is often an exclusionary factor for clinical trials, so this melanoma diagnosis has consequences beyond the effect on my water dragon tattoo. Consequences that could prove quite complicated as I run out of treatment options. Yet another reason patients should be involved in the design of clinical trials, to bring up from the beginning these form over substance exclusionary factors.

I suppose all of that simply leaves me in the same position — watching for more treatment options, now for two different cancers, and always always always looking for the silver linings where I can. I am starting off 2026 with a slightly different set of priorities and hopes that have changed and morphed to fit a rather different set of circumstances. Looking for more doors and more windows to open.