GETTING A SECOND OPINION
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MORE PATIENTS REJECT RECONSTRUCTION
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Returning to work after
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A matter of survival Advances in chemotherapy are making breast cancer treatable, not terminal “Chemotherapy is certainly not something someone would choose dvancements in medito put themselves through, but cine and technology once someone understands that mean breast cancer it is necessary to prevent canpatients are living cer recurrence or to stop cancer longer, and many cancers are growth, the ultimate goal makes now treated as chronic illnesses the idea more bearable,” Cline said. rather than terminal diseases. Supportive measures now Life expectancy, even for mulmake some side effects of tiple stage 4 cancers, has risen. cancer treatment much less “It’s not a stretch to tell a impactful than before. woman newly diagnosed with “We’ve seen a sea change in stage 4 breast cancer that her management of nausea and vomsurvival will be measured in iting. It used to be one of the years and not months,” Dr. Mika scariest side effects,” Cline said. Cline, medical oncologist at Previously after chemotherapy Texas Oncology in Austin. “It’s a patient may have been severely not unusual for patients to be nauseated for days and there was treated for stage 4 cancer while nothing to do except bear it. planning their children’s wed“Now, though it is still a pleasdings, graduations, traveling and ant surprise for me to hear that even continuing to work. That’s a patient had no nausea with his not true for everyone, of course, or her treatment, it is becombut we see these scenarios much ing more common. It’s not true more frequently than we used to. for enough patients yet, but it’s “Given that, patients, caregivgetting there,” Cline said. ers and their oncology teams can Another innovation is immunofocus on the impact of treatment therapy, which “involves boosting and side effects on quality of life, a patient’s immune system to fight not just life expectancy,” she said. off the cancer,” Cline said. “For decades, a great deal of our pracReduced side effects tice was in managing side effects of chemotherapy, especially the Because of new medications with immunosuppressive side effects. reduced side effects, chemotherapy We’ve had to get comfortable is now delivered in an outpatient with therapies that may actusetting rather than a hospital. ally cause side effects as a result “The benefits are plentiful. of immune stimulation or from a Patients miss less work and sleep now overactive immune system.” in their own beds. There’s less risk of infection, a higher level Less effect on fertility of function and more interaction with family, friends and coworkers While chemotherapy can who can help support the patient affect a woman’s chances of through treatment,” Cline said. becoming pregnant, innovaChemotherapy sounds scary, tions are improving the chances but once a patient understands of preserving fertility. what to expect, most gear up and “Fertility preservation gives are motivated to get through it. patients peace of mind that they
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aren’t giving up on their views of their future if it includes children because they got this cancer diagnosis and are facing systemic therapy,” Cline said. “When contemplating cancer treatment, it helps to remember that it’s a marathon and not a sprint. You, your loved ones and your oncology team all have the same goal, which is successful treatment with side effects impacting your life as minimally as possible. That said, cancer and its treatment are going to impact your life, so be patient with yourself and take it one day at a time,” Cline said.
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By Melissa Erickson
“The benefits are plentiful. Patients miss less work and sleep in their own beds. There’s less risk of infection, a higher level of function and more interaction with family, friends and coworkers who can help support the patient through treatment.” Dr. Mika Cline, medical oncologist at Texas Oncology in Austin
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Latest screening recommendations By Melissa Erickson More Content Now
After decades of controversy there still is no national consensus about when women should start having mammograms and how frequently they should undergo screening. But now another medical society has concurred with the recommendations of the American Cancer Society, the American Society of Breast Surgeons and the U.S. Preventative Services Task Force. The American College of Physicians recommends that average-risk women between ages 50 and 74 should undergo breast cancer screening with mammography every other year, instead of every year. The American College of Radiation disagrees and recommends annual mammography screening starting at 40 for women of average risk of developing breast cancer.
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“The conflicting guidelines do lead to a lot of confusion among women, as well as a lot of worry,” said Dr. Deanna Attai, assistant clinical professor in the department of surgery at David Geffen School of Medicine at University of California, Los Angeles. “There is no question that the regular use of screening mammography has resulted in improved survival from breast cancer, but ‘early detection saves lives’ does not apply to every case — there is much more nuance to all of this.
“Currently, there should be a discussion of the potential benefits as well as harms from mammography, as well as consideration of the patient’s perspective in terms of risk tolerance and cancer worry. It should also be stressed again that these guidelines do not apply to high-risk patients,” Attai said. In March the Food and Drug Administration announced the first policy changes in mammogram recommendations to modernize breast cancer screenings and provide patients with more information to make betterinformed decisions. Mammogram providers should now alert patients if they have dense breasts, which is associated with an increased risk of breast cancer and makes it more difficult to spot a tumor with a mammogram. It is advised women with dense breasts should get further testing, such as an MRI or ultrasound.
How, and why, to get a second opinion By Melissa Erickson More Content Now
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etting a second opinion after a breast cancer diagnosis is always a good idea. That’s how a person makes sense of something: Through comparison. When diagnosed with breast cancer a person often feels a sense of urgency to start treatment immediately, but a better course of action is to do some research and assure the diagnosis is correct and the course of treatment a good fit, said independent health advocate R. Ruth Linden, president of Tree of Life Health Advocates in San Francisco. “When a biopsy reveals a breast cancer diagnosis, it’s rarely an emergency. It’s important to act, but it’s not something that has to be taken care of by the end of the business day,” Linden said. Ongoing advancements in treatment and diagnosis have led to better medicines and more minimally invasive procedures, but breast cancer always has surprises. “Getting two or three opinions is important because a cancer diagnosis
“Getting two or three opinions is important because a cancer diagnosis is not always clear-cut. There is an element of subjectivity.” R. Ruth Linden, president of Tree of Life Health Advocates in San Francisco
is not always clear-cut. There is an element of subjectivity,” she said. Proven benefits Getting an additional medical opinion will add time and stress, but it’s worth it for the assurance it will bring. “The confidence we get from a second opinion buoys us as we go into surgery or other treatment. That increase in confidence in turn can positively affect the outcome,” Linden said. For many people a second opinion is a valuable tool. A small study done by researchers at the Medical University of South Carolina found that more than 40% of the people in the study who asked for a second opinion had a change in diagnosis. “Seeking a second opinion doesn’t mean you don’t trust your doctor. It means, ‘I respect my body and want to confirm,’” Linden said. Among doctors there is a virtual
consensus that a second opinion is not a luxury. It’s good medicine, Linden said. If your doctor is unwilling or hesitant, consider that a red flag. “No responsible physician will discourage a second opinion,” Linden said. What it entails A second opinion is a consultation where another breast cancer specialist will review and interpret your medical records and test results. Be sure to have a copy of your mammogram on disc and your medical report, Linden said. Seeing a new doctor is an opportunity to ask questions you previously may not have considered. “They may have new resources the other doctor didn’t know about. You might find out about new developments or clinical trials,” Linden said. Additionally, a different doctor may take a different approach when faced with the same information, she said.
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To keep insurance costs down, stay in network if possible. “If only one breast surgeon is available within your network, take it up with insurance. That’s not acceptable. Make an appeal,” Linden said. Where to find a second opinion • Ask friends and family for a breast cancer specialist whom they like and trust. • Ask your doctor whom he or she would see or send their wife, mother, sister or daughter to. • Ask others within your social network. • If those fail, turn to a patient advocate. Ask your insurer about resources or seek out a nonprofit like the Patient Advocate Foundation, patientadvocate.org. You may have to travel for a second opinion, but it’s worth it, Linden said. You can use the internet, but don’t find a doctor on Yelp, she said: “Triangulate what you find with other sources.” Take a trusted friend with you to take notes, ask questions and help prompt you.
Flat-out
fabulous More women are sharing why they delayed or rejected reconstruction By Melissa Erickson More Content Now
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iagnosed with breast cancer in 2009, health journalist Catherine Guthrie felt prepared. She knew her options. Her choice was a lumpectomy. But as a small-breasted woman Guthrie was told she was not a good candidate for lumpectomy. Instead, her surgeon suggested a single mastectomy along with a plan for reconstruction that seemed shocking to Guthrie but turned out to be quite
common: Her breast would be reconstructed by severing the largest muscle of the back, wrapping it around and laying it over a breast implant. “Is this for real?,” Guthrie remembers thinking. While not a hard-core athlete, Guthrie felt it was an invasive surgery that would affect her body’s ability to function. She would no longer be able to do handstands, which always gave her a sense of strength. With mastectomies, women have choices, and more of them are choosing to go flat.
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When faced with breast reconstruction, women are asked to choose between the artifice of looking like man’s idea of a woman or the feeling of strength and power in their own bodies, Guthrie said. Guthrie chose to go flat and shared her story in a memoir, “Flat: Reclaiming My Body from Breast Cancer.” Going flat is a form of radical honesty, Guthrie said. It’s about body positivity, about coming out of the shadows. “I can still be a woman, be sexy and empowered, strong and confident,” she said. The No. 1 reason women choose to go flat is for their health, said Dr. M. Michele Blackwood, chief of breast surgery at Rutgers Cancer Institute of New Jersey. Recovering from a mastectomy without reconstruction is easier because it’s a less complicated surgery. There’s less chance of infection or other complications. Recovery is quicker. Some don’t want a foreign implant or feel strongly that their breasts don’t define who they are, said Barbara Kriss, founder of BreastFree.org, a website for women with breast cancer who opt not to have reconstruction after mastectomy surgery. “Others do want to preserve their natural shape in clothes but prefer to use external breast forms as opposed to internal ones,” Kriss said. Cost can also be an issue, Blackwood said. Today surgeons are required by law to discuss the myriad choices women have, from same-day reconstruction surgery to going flat, she said. “Know that you are your own best advocate. Do your homework. Know that you have multiple options and that reconstruction is always an option even years later,” Guthrie said. Things to consider According to a 2014 study published in the Journal of Clinical Oncology 25% of double mastectomy and 50% of single mastectomy patients chose to go flat. The stress of cancer coupled with major surgery “can put women in paralysis mode,” but the decision can be put off, Blackwood
said. In delayed reconstruction — whether for six months or 10 years — a tissue expander is inserted as a placeholder, she said. “Many more women are opting to not get reconstruction after their mastectomies, and now there is a growing trend toward women getting explant surgery many years later and opting to go flat,” said Nanette Labastida, an Austin, Texas, residential real estate professional. “My surgery is scheduled for October, nine years after mastectomy with implants.” For aesthetics and comfort, a mastectomy should be as cosmetically pleasing as possible, leaving the patient with a smooth, flat chest, no extra skin and symmetrical incisions (for a bilateral mastectomy), Kriss said. Going flat is an easier option for thin, smaller breasted women with lower body fat, Blackwood said. For women who are big breasted and/or overweight, sometimes extra, non-breast tissue is left after a mastectomy, particularly under the arms, Kriss said. Commonly known as “dog ears,” this can be uncomfortable and unsightly but can be removed by a plastic surgeon as a minor outpatient procedure, which may or may not be covered by insurance. How going flat has evolved Previously “going flat” generally referred to women who chose not to have reconstruction and opted not to wear breast forms after a mastectomy, said Kriss. “In the years since, the term has evolved to encompass all women who opt not to have reconstruction, even though many of those women may wish to wear breast forms,” she said. The distinction has been lost. Women considering not having reconstruction may hear the term “going flat” and may not realize that being flat doesn’t mean they can’t have the shape of natural breasts in clothes if they wish, Kriss said.
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“Know that you are your own best advocate. Do your homework. Know that you have multiple options and that reconstruction is always an option even years later.” Catherine Guthrie, author of “Flat: Reclaiming My Body from Breast Cancer”
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Returning to work after treatment By Melissa Erickson More Content Now
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eturning to work after treatment for breast cancer can be a return to normalcy. “It’s a reminder that you are more than your cancer diagnosis,” said social worker Alida Rubinstein, coordinator of volunteers for the Adelphi NY Statewide Breast Cancer Hotline & Support Program. You’re a valued employee, boss or volunteer. But can also be stressful, exhausting and disheartening. Because 1 in 8 women are diagnosed with breast cancer in their lifetime, is likely that someone in the office may have faced a similar situation, Rubinstein said. When it comes to what to expect, think
about how they were treated. Were others sympathetic and welcoming or did they face insensitive questions and subtle discrimination? At home you feel like your cancer diagnosis, said hotline volunteer Myra Taylor, who was diagnosed with breast cancer in 2004 at age 59. After treatment, Taylor returned to her job in information technology with JP Morgan Chase in Manhattan. “It was good to go back and be with people again and not be cooped up at home being sick with nothing on my mind but cancer,” Taylor said. In addition to the camaraderie, work is a great distraction, Rubinstein said. That’s especially helpful because people are often continuing treatment as they return to work, she said.
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know you were covering for me. Can you fill me in? I want to get back to work.” You don’t want to be thought of as the person in the office who had cancer. When asked how you feel, admit it was tough but that you’re ready to get back to work, Rubinstein said. Expect that people will stare at your chest and possibly ask insensitive, intrusive questions, Taylor said. “It’s better to say nothing than to say something stupid,” she said. For example, after losing hair to cancer a person doesn’t want to hear something like, “Would you rather have hair or have cancer?”
How to prepare As time nears to return to work, it’s always advisable to speak with your doctor. If you’ve received short- or long-term disability coverage it’s mandatory to get a doctor’s permission, Rubinstein said. “Ask if you’re ready to go back, what accommodations you may need,” she said. For example, if you are still receiving chemotherapy your doctor may advise getting it on a Friday so you have the weekend to recover, Rubinstein said. It’s a personal decision about how much or how little you want to share with coworkers, but it’s a good idea to discuss your situation with your supervisor and the company’s human resources department. Ask whether a flexible work arrangement is possible, if needed. “At the beginning you probably won’t be able to do it all. You will feel tired, exhausted. Maybe you can’t stay late for an after-hours meeting, but stay positive. It’s temporary. You will get back to your full potential,” Rubinstein said. Try to turn hostile comments or questions about your ability around. “Coworkers can be resentful, especially if they’ve been picking up the slack,” Rubinstein said. Redirect them with comments such as “I
Know your rights
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It’s a personal decision about how much or how little you want to share with coworkers, but it’s a good idea to discuss your situation with your supervisor and the company’s human resources department.
If you feel like you’re being discriminated against, passed over for a promotion or not getting the same work back, know your rights and what you’re entitled to, Rubinstein said. “Put everything in writing. Keep a paper trail,” she said. Workers’ rights vary state to state, and sometimes state laws offer more protection than federal laws, she said. For helpful resources, expert advice and useful tools, visit cancerandcareers.org.
How to improve quality of life during cancer treatment
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ighting cancer is the biggest priority for people when they have been diagnosed with the disease. After the initial shock of diagnosis has worn off, patients can then take their first steps towards recovery. Powerful chemotherapy drugs and radiation treatments can kill cancer cells and prevent them from spreading. Individuals may also need other medications to help mitigate the side effects of these treatments. At the end of the day, treating cancer can become a full-time job and one that can have a significant impact on the quality of life of the patient and his or her loved ones. According to the Mayo Clinic, stress, pain and fatigue can severely diminish quality of life during and after cancer treatment. What’s more, family members caring for cancer patients also may
experience diminished quality of life. Incorporating some strategies during and after treatment can help cancer patients and their caregivers maintain a high quality of life.
Exercise
Exercise pays numerous dividends for cancer patients. Exercise may help keep cancer, particularly breast cancer, in remission. The American Cancer Society says physical activity has been linked to a 24 percent decrease in breast cancer coming back, and a 34 percent decrease in breast cancer deaths. Exercise also can affect the following: • balance • control weight • self-esteem • strength of bones • lessening risk of blood clots • reduction of nausea and fatigue
Stress reduction
Cancer patients also can benefit from therapies that promote the reduction of stress and anxiety. The Mayo Clinic studied formal sessions that promoted physical therapy, coping strategies or addressing spiritual concerns, and deep breathing or guided imagery to reduce stress. Those who engaged in these therapies showed marked improvement at a critical time in care. Exercise, talking about the cancer and reducing feelings of stress are important to maintaining quality of life during cancer treatment.
Get to know your
breast density By Melissa Erickson
Facts and figures
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According to Susan G. Komen: • Breast density is a measure used to describe mammogram images. It’s not a measure of how the breasts feel.
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any women still have a lot to learn about their breasts. A 2018 Harris Poll completed by Hologic, a medical device maker, found that 64% of U.S. women do not know that the density of a woman’s breasts affects her risk of developing breast cancer, while more than two-thirds of U.S. women (68 percent) do not know their breast density score. “Density, which is only identifiable on a mammogram or other imaging system, is a reflection of how much fibrous or glandular tissue is in the breast,” said Dr. Susan Harvey, vice president of medical affairs and radiologist for Hologic. “That tissue shows up as white on a mammogram, similar to breast cancer, and also increases the chances that a woman will be recalled for additional imaging.” For women with dense breasts 2D mammograms are limiting; 3D mammography provides radiologists with a series of images for a more in-depth, layer-by-layer look at the breast. What’s your score?
Breast density can be categorized into four groups, sometimes referred to as a breast density score. The four categories, according to Mayo Clinic, are: • Almost entirely fatty • Scattered areas of fibroglandular tissue • Heterogeneously dense tissue • Extremely dense tissue “Because density is best characterized on a mammogram but can be assessed on other imaging systems, it is important that women remain committed to their annual breast cancer screening and talk to their doctor or breast imaging specialist about whether or not they have dense breasts and — if so — whether additional screening is necessary,” Harvey said.
• Breasts are made up of breast tissue (the milk ducts and lobules, which may be called glandular tissue) and fat. Connective tissue helps hold everything place. • High breast density means there’s a greater amount of breast and connective tissue compared to fat. Low breast density means there’s a greater amount of fat compared to breast and connective tissue. • Women with high breast density are 4 to 5 times more likely to get breast cancer than women with low breast density. • In the U.S., 40% to 50% of women ages 40-74 have dense breasts. • Dense breasts are more common in both young women and thin women. • Women who take menopausal hormone therapy tend to have denser breasts than they would if they didn’t take MHT (also called postmenopausal hormones). As women age, their breasts become less dense and more fatty. Taking MHT slows this process. • Many states in the U.S. have laws requiring health care providers to notify (send a letter to) women found to have dense breasts on a mammogram. Although this may seem helpful, there are no special recommendations or screening guidelines for women with dense breasts at this time. • Although women with dense breasts have an increased risk of breast cancer, it’s not clear that lowering breast density will decrease risk.
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What to know if you’re
newly diagnosed By Melissa Erickson
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ou’ve been diagnosed with breast cancer. Now what? You may feel scared and alone, but information is power. As you ponder your options and consider your course of action, consider this advice from experts.
Tell it like it is “Be open and honest with your cancer doctor about the symptoms from your cancer or from the side effects of treatment. In some cases, your physician can offer easy, practical solutions to make living with breast cancer and chemotherapy more tolerable,” said Dr. Katisha Vance, a board certified medical oncologist in Birmingham, Alabama. Take care of yourself “Maintain a healthy diet, try to get enough sleep and exercise. Bring a water bottle to your appointments; doctors can run late and you should stay hydrated. Try a meditation app to help manage stress,” said Dr. Heather King, breast surgical oncologist with Texas Breast Specialists, part of Texas Oncology in Austin. Involvement equals empowerment “In the age of precision medicine, no one’s treatment is alike and sometimes less is more. Work with your team of doctors to determine a treatment plan that works best for your cancer and your lifestyle. An involved patient is empowered, and an empowered patient will thrive and survive,” said Dr. Anjali Malik, a breast imaging and intervention radiologist at Washington Radiology in Washington, D.C. Spare the nipple
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“If you need surgery for breast cancer, find a breast surgeon who is able to do nipple-sparing mastectomy … Especially with small breasts, if you need a significant lumpectomy and radiation, you will have a far superior aesthetic result with a nipple-sparing mastectomy and natural tissue breast reconstruction with sensory restoration in that with a good nipple-sparing mastectomy and reconstruction it may be difficult for other people, including your spouse or medical provider, to tell that you have even had a mastectomy,” said Dr. Constance M. Chen, a board-certified plastic surgeon and breast reconstruction specialist in New York.
Question until you get answers “I would make sure that you are persistent when it comes to learning whether or not your cancer has spread and to what extent. It’s important to have solid and thorough understanding of the stage of the disease, the extent of the disease (size, lymph nodes and the pathologic type). By asking those questions of your physician and care team, you can get a thorough understanding of what you are facing and the best approach to address each of those areas,” said Dr. Miral Amin, surgical oncologist and oncoplastic breast surgeon at Cancer Treatment Centers of America, Chicago. Don’t freak when diagnosed “I realize it’s tough when you find out and it seems like a death sentence. However, realize that the vast majority of breast cancer patients are stage 1 or 2 and they are cured. You are much more likely to die with breast cancer than due to it,” said Dr. Bilal Farooqi of Comprehensive Hematology Oncology in Tampa Bay, Florida. Don’t go it alone “Take someone with you to your appointments because there is no way you will remember everything that was said once you’ve left the appointment,” said Beth Pauvlinch, co-author of “Two Women 1 Disease,” which she wrote with her mother, whom she lost to breast cancer. Rely on developed skills “Most couples do not realize that they already have the tools to cope with cancer based on previous crises. Remembering how they overcame difficult situations in the past may help a couple develop coping strategies in the current situation,” Amin said.