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THE HUNTSVILLE ITEM • OCTOBER 24-25, 2020

October 2020 A Special Supplement to

The Significance of Support

Cancer survivor Elizabeth Flore talks life after remission

What to Watch For

Early warning signs and risk factors for breast cancer

The Latest Technology

Huntsville Memorial provides the latest in 3-D mammography

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OCTOBER 24-25, 2020 • THE HUNTSVILLE ITEM

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THE HUNTSVILLE ITEM • OCTOBER 24-25, 2020

Life after remission

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erched at the window of The Buzzed Cup food bus overlooking the Market Creek courtyard, Elizabeth Florer nervously fidgets with a silver bracelet on her wrist. It’s where she spends her days now, in a 31-foot bus she purchased nearly a year to the day of her diagnosis as a means for a way out of a stifling franchise that she could control for herself. Against silver rings and jewelry, the bracelet doesn’t immediately stand out at first, but she turns it just enough to reveal a small emblem. It’s a medical bracelet, identifying that she can’t have blood pressure or pin sticks on her right side due to her history of lymphatic breast cancer. “I hate wearing this, I hate it. This sounds wrong – it feels like a noose around my neck when I wear this,” Florer said. “It does remind me of the cancer, because it’s a very physical representation of it and I

STORY & PHOTOS BY MICHELLE WULFSON always feel it, it’s just always there.” It’s not just the bracelet on her wrist, it’s the depression, the fear and anger in the back of her mind that she carries with her every day. It’s been nine months since Florer went into remission, however, she did not tell people for seven months that she was “freed” because she was afraid that it just couldn’t be real. It was just earlier this month that Florer’s oncologist believed her cancer could be back. After extensive testing, it was determined that Florer had a calcified tumor in her brain and non-cancerous concerns to monitor internally, however, the few days of awaiting the results left her laden with fear. “My cancer markers are good, but it never leaves you, maybe years from now, maybe decades from now I’ll feel differently, but there’s a fear all of the

time,” Florer said. “I keep wondering, when am I going to feel good again? When am I going to stop being fragile?” Florer had been married for two years with a bright future brimming with plans when her life was suddenly placed on hold. On Friday, Oct. 5, 2018, Florer went to see her general practitioner for what she believed to be a heat rash across her breast. 25 days later, she had undergone a double mastectomy, removing 15 lymph nodes from her right side, eight of which were cancerous. “I’m a little angry sometimes, because I didn’t take care of myself well enough to catch it sooner,” Florer said. “During the 25 days while I was waiting for the surgery to occur, I could feel the tumors growing in my breast.” There just wasn’t any time, it was an extremely

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OCTOBER 24-25, 2020 • THE HUNTSVILLE ITEM aggressive lymphatic breast cancer that had developed in the 50 weeks since her last 3-D mammogram, rapidly progressing from a stage two to a hair shy of stage four breast cancer in the 25 days leading up to her surgery. Though she only had cancer in one of her breasts, Florer opted for the double mastectomy to be safe with no reconstruction. A 31” scar runs around her chest with radiation burns from the treatment that literally burned off her skin, leaving tender, exposed flesh. It’s a new normal for Florer that she doesn’t shy away from in the mirror. “I don’t look the same, never will,” Florer said. “To me, it’s not a scar, it’s a mark of triumph, it’s a mark of success.” Life after remission doesn’t magically get better, the battle is long from over. Anger still hangs heavy in her heart, for the disease itself and for the disingenuous outpour of support for breast cancer awareness through the month of October. Looking from the outside in, the fundraisers and sorority rallies seemed like a nice effort at one time, now on the other side, they come across as a personal assault to her. “To be honest, I get really angry when there are breast cancer fundraisers and things like that, I have an emotional reaction to them, I think I feel that a lot of times it’s just such an easy target to do a fundraiser around something and then not really do anything,” Florer said. “When people talk about doing fundraisers and awareness things, I think that a lot of times it’s self-serving to the people that are doing it and it’s not really about the people who are going through it.” She’s not alone, a community of breast cancer survivors share the same feeling. It’s hard to distinguish who views her as a means to an end and who are actually real in their intentions, however, it’s a double-edged sword – Florer realizes that funding and awareness is needed to make progress. “People have suggested that tied to my business I do a fundraiser for breast cancer, and I won’t do it because I know how I would feel about it and I don’t want to use my breast cancer to make people feel sorry for me, I refuse,” Florer said. Florer shifts on her stool with a brimming cup of coffee in front of her. At 11 a.m. she’s already received an iron transfusion before arriving at the bus two hours early to prepare for the day. It’s progress over the previous day, which she spent feeling weak to the point of not being able to leave her bed. “They talk about chemo staying with you for years, and I didn’t really understand it, I still don’t think I do. There’s days I’m just so fragile and tired, and I used to not be that way. I wasn’t fragile, I wasn’t one of those wimpy women that can’t do anything for themselves. I could do things for myself, I was strong willed, now, I’m so dependent on the kindness of my family,” Florer said. “I don’t know if I’ll ever be that strong again.” But she would agree that in some ways she’s stronger now when she’s not “feeling sorry for herself” in private. It’s a process that will take time. The inevitable pitfalls come and go, but for the most part, each day is a little better than the last for the “rack-attack” survivor. “I know that there are millions of women that have done this before me, and I know that I’ll get past this stage, and I know that life will become a part of normal that I accept as normal, not that I figure out how to get through,” Florer said. “I’m grateful to my family, and I’m incredibly grateful to the medical staff that pulled me by the hand through the steps that I had to go through to save my life.”

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THE HUNTSVILLE ITEM • OCTOBER 24-25, 2020

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Huntsville Memorial provides the latest in 3-D mammography

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ammograms take images of breast tissue to determine the presence of abnormalities, including lumps. Women may undergo traditional, 2D mammograms, but increasingly healthcare facilities like Huntsville Memorial Hospital are now employing 3D technology, because it can provide clearer pictures. A 3D mammogram, also called digital tomosynthesis, takes several different X-rays of the breasts and combines those images to establish a three-dimensional picture. The Mayo Clinic says that a 3D mammogram is typically used to search for breast cancer in people who may have no outward signs or symptoms. It also may be used to help diagnose the cause of a breast mass or nipple discharge. Doctors may suggest 3D imaging to get a better look at any growths or help identify the source of any symptoms a person may be concerned about. “3-D is the latest technology for mammography. It enhances the sensitivity to identifying obscured areas and reduces the call back rates (having patients to come back to the facility for further imaging),” said Charles Strahan, the director of the Huntsville Women’s

STORY BY JOSEPH BROWN Center at Huntsville Memorial Hospital. Two-dimensional mammograms are still the industry standard. The 3D versions are obtained in a similar fashion by pressing the breasts between two imaging plates. Rather than just taking images from the sides and top to bottom, the 3D version will take multiple angles to make a digital recreation of the breast. Medical News Today says this enables doctors to look at small, individual sections of the breast tissue that may be as thin as just a single millimeter. According to the American Cancer Society, women over the age of 40 should receive a yearly screening mammogram and conduct monthly self-exams in between. An average of 1-in-6 breast cancers occur in women ages 40-49, and three out of four women diagnosed have no family history of breast cancer. Since screening mammograms became more widespread in the mid 1980s, there has been a 38 percent reduction in breast cancer deaths. A study published in the journal JAMA Oncology also says cancer detection rates are higher in people who do 3D imaging over time. Three-dimensional mammograms can be useful for women with dense breast tissue or those at

higher risk for breast cancer. Although experts at MD Anderson Cancer Center advise any woman who needs a mammogram to get the 3D version. However, 3D mammography may not be covered by all insurance plans. It’s important to note that a 3D mammogram releases the same amount of radiation as a traditional mammogram. It is of no greater risk to the patient, and it is approved by the Food and Drug Administration. Also of note, because 3D mammograms produce more images, it may take a radiologist a little longer to read one than it would a 2D mammogram. Also available to women at the Huntsville facility is an on-site ultrasound, which is available at the immediate discretion of the radiologist. “Our Radiologists are immediately available during a mammography. If an area of concern is recognized, the radiologist can immediately review and proceed to ultrasound of the breast for validation of diagnosis.” The Huntsville Women’s Center is located at 123 Medical Park Lane in Huntsville.


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OCTOBER 24-25, 2020 • THE HUNTSVILLE ITEM

Early warning signs for breast cancer

reast cancer affects millions of women across the globe every year. According to the World Health Organization, breast cancer is the most frequent cancer among women, affecting 2.1 million women each year. As daunting as that may seem, the WHO also notes that early diagnosis can greatly reduce a woman’s risk of dying from breast cancer. Women can be proactive in the fight against breast cancer by learning to identify early warning signs of the disease. The nonprofit breast cancer advocacy organization Susan G. Komen® notes that the warning signs for breast cancer are not the same for all women, but the most common signs include a change in the look or feel of the breast or a change in the look or feel of the nipple. A discharge from the nipple is another common warning sign of breast cancer. Physical changes in the breast can vary, but Susan G. Komen® advises women who notice these changes to bring them to the attention of their physicians immediately: • Lump, hard knot or thickening inside of the breast or underarm area • Change in the size or shape of the breast • Swelling, warmth, redness or darkening of the breast •Dimpling or puckering of the skin Women with breast cancer also may notice physical changes in their nipples, including: • Itchy, scaly sore or rash on the nipple

• Pulling in of the nipple or other parts of the breast It’s important that women recognize that physical changes in their breasts are not necessarily indicative of breast cancer. In fact, the American Breast Cancer Foundation notes that not all lumps in the breast cause cancer and that many such lumps are benign. Fibroadenomas and intraductal papillomas are examples of benign lumps, though it’s important to note that even benign conditions such as these may put women at greater risk of developing breast cancer. Susan G. Komen® notes that breast tissue naturally has a lumpy texture. If lumpiness can be felt throughout the breast and it feels like your other breast, then it’s likely that this is just the normal texture of your breasts. However, women concerned by a lump or lumpy texture are urged to discuss those concerns with their physicians immediately. Discharge from the nipple is another potential sign of breast cancer, but Susan G. Komen® notes that such discharge is rarely a sign of cancer. Discharges that occur without squeezing the nipple, occur in only one breast or are bloody or clear are potentially indicative of more serious conditions, including breast cancer. Breast cancer is a formidable foe. But women who arm themselves with knowledge of the disease, including its early warning signs, are in better position to overcome it.

COVID-19 and breast cancer

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he novel coronavirus COVID-19 first appeared in late 2019 and has changed life for the forseeable future. While many people are quick to focus on the ways COVID-19 has impacted their abilities to shop, visit with friends and relatives or travel, the virus has made life especially difficult for people with preexisting health conditions. Medical News Today reports that the symptoms of COVID-19 may be more severe for breast cancer patients. Furthermore, the Centers for Disease Control and Prevention notes that undergoing cancer treatment can weaken the immune system, further increasing a person’s vulnerability to infection. Specifically, targeted therapies, chemotherapy and radiation can weaken the immune system and compromise its ability to fight off the coronavirus. Furthermore, these treatments also may cause lung problems that can exacerbate COVID-19 symptoms, particularly among breast cancer patients whose cancer has metastasized to the lungs. In April 2020, new guidelines for the

prioritization and treatment of breast cancer patients during the COVID-19 pandemic were released, compiled by a group of U.S. medical organizations, including the National Accreditation Program for Breast Centers, the American College of Radiology and the Comprehensive Cancer Network. At hospitals where resources and staff have become limited due to COVID-19 treatment efforts, doctors have had to define which breast cancer patients need urgent care and which can have delayed or alternative treatments. These measures can help balance maintaining positive survival outcomes as well as reducing risk of exposure to the virus, according to the American Society of Breast Surgeons. Breast cancer patients have been broken down into priority levels of A, B and C for urgency of care. Priority A: A patient has conditions that are immediately life-threatening or require urgent treatment. Priority B: A patient has conditions that don’t require immediate treatment, but he or she should

begin treatment before the end of the pandemic. Priority C: A patient has conditions for which treatment can be safely put on hold. Breast cancer patients are further urged to take extra caution in their daily activities to help reduce the risk of contracting COVID-19. That means always wearing a mask or another face covering when interacting with other people. This advice may be applicable even if a six-foot distance can be maintained. Wash hands frequently, especially when coming in from public places. If possible, ask a friend or family member to do your shopping or run errands for you to limit exposure to other people and crowds. Breast cancer patients may have to discuss the possibility of altering or delaying treatment for breast cancer with their oncologists because of increased risk factors presented by COVID-19. Together, patients and doctors can work to keep breast cancer patients as healthy as possible.


WHAT IS BREAST CANCER? Cancer causes cells in the body to change and spread out of control. The cells eventually form a lump or mass called a TUMOR. Most breast cancers either begin in the breast tissue made up of glands for milk production, called lobules, or in the ducts that connect the lobules to the nipple.

SIGNS & SYMPTOMS

WHAT YOU NEED TO KNOW ABOUT

The most common sign is a painless LUMP in the breast. Sometimes breast cancer spreads to underarm lymph nodes and causes a lump or swelling, even before the original tumor is large enough to be felt. Less common symptoms include breast pain or heaviness, persistent changes such as swelling, thickening or redness, and nipple abnormalities such as discharge or retraction.

BREAST CANCER THE SECOND LEADING CAUSE OF DEATH AMONG AMERICAN WOMEN A WOMAN LIVING IN THE U.S. HAS A

GETTING A DIAGNOSIS Breast cancer is typically detected either during a screening examination before symptoms develop or after a woman notices a lump. If cancer is suspected, microscopic analysis, through needle BIOPSY or SURGICAL INCISION, is required to diagnose the disease and determine the stage and type.

STAGES OF BREAST CANCER: 0 (least advanced), I, II, III and IV (most advanced)

12.4% LIFETIME RISK OF BEING 1 IN 8 ORDIAGNOSED WITH BREAST CANCER

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INCIDENCE & DEATH RATES

271,270

42,260

Estimated NEW CASES in 2019 (Female and male cases combined)

Estimated DEATHS in 2019 (Female and male cases combined)

123.6 20.6 INCIDENCE RATES, 2011-15 Average annual rate per 100,000

DEATH RATES, 2012-16 Average annual rate per 100,000

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MORTALITY TRENDS Overall breast cancer death rates increased by 0.4 percent per year from 1975 to 1989, but since have decreased rapidly for a total decline of 39 percent through 2015.

WHO GETS BREAST CANCER? AGE FACTORS Breast cancer incidence and death rates generally INCREASE WITH AGE. At 80 and older, however, rates go down, likely due to lower rates of screening or detection of disease before 80.

Median Age of Diagnosis

62 YEARS OLD The median age of diagnosis is younger for black women (59) than it is for white women (63).

GEOGRAPHY Breast cancer mortality rates among WHITE WOMEN tend to be highest in the North Central, Mid-Atlantic and Western regions of the U.S. Among BLACK WOMEN, the highest death rates are found in some of the South Central and Mid-Atlantic states as well as California. A recent study found incidence rates were more then two-fold higher among women in ALASKA than those living in the Southwest U.S. during 1999-2009.

RACE/ETHNICITY

That’s up from a 1 in 11 risk in the 1970s. The increase is due to longer life expectancy.

TRENDS IN CANCER RATES

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Incidence rates of breast cancer rose rapidly in the 1980s and 1990s largely because of the increases in mammography screening. Rates stabilized between 1987 and 1994, then dropped sharply between 2002 and 2003, likely due to decreased use of menopausal hormones associated with higher risks of the disease. From 2005 to 2014, the rate has been stable.

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U. OF S. W BR OM EA EN ST L CA IVIN NC G ER WIT RISKS YOU IN H H CAN’T CHANGE 20 IS 19 TO l Getting older RY l Genetic mutations

Incidence and death rates for breast cancer are HIGHER among non-Hispanic white and black women than other groups.

Incidence Rates 2011-15 Average annual rate per 100,000, age adjusted to the 2000 U.S. standard population: Non-Hispanic white: 130.1 Non-Hispanic black: 126.5 American Indian & Alaska Native: 100.9 Hispanic: 93 Asian & Pacific Islander: 92.9

l Reproductive history l Having dense breasts l Personal history of breast cancer or non-cancerous breast disease l Family history of breast cancer l Previous treatment using radiation therapy l Having taken diethylstilbestrol while pregnant

Death Rates, 2012-16

THOSE YOU CAN CHANGE l Not being physically active l Being overweight or obese after menopause l Taking hormones l Reproductive history l Drinking alcohol

Average annual rate per 100,000, age adjusted to the 2000 U.S. standard population: Non-Hispanic white: 20.6 Non-Hispanic black: 28.9 American Indian & Alaska Native: 14.5 Hispanic: 14.3 Asian & Pacific Islander: 11.3 Non-Hispanic black women have the highest rates before age 40 and are MORE LIKELY TO DIE from breast cancer at every age.

EARLY DETECTION MAMMOGRAMS are the best tool we have to detect breast cancer early when it’s most treatable. Who should have one? l Women age 44 to 54 should get mammograms every year. l Women 55 and older should switch to getting one every two years.

TREATMENTS FOR BREAST CANCER LOCAL TREATMENTS

Meaning they treat the tumor without affecting the rest of the body. Most women will have some type of SURGERY to remove the tumor. Some will undergo targeted RADIATION treatments. Local treatments are typically combined with other forms.

SYSTEMIC TREATMENTS

Drugs used to treat breast cancer are considered systemic therapies because they can reach cancer cells almost anywhere in the body. Depending on the type of cancer, treatments that may be used include CHEMOTHERAPY, HORMONE THERAPY or TARGETED THERAPY.

Source: American Cancer Society - Breast Cancer Facts & Figures 2017-18, breastcancer.org

Graphic by Heather Bremer | CNHI News Indiana

DISEASE IN MEN Men are more likely to be diagnosed with advancedstage breast cancer. new 2,670 Estimated cases in men in 2019

THE HUNTSVILLE ITEM • OCTOBER 24-25, 2020

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What to expect after cancer treatment ends

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nce the initial shock of a breast cancer diagnosis wears off, many patients are ready to get down to business and begin treatment. Based on data collected by the SEER database, which is maintained by the National Cancer Institute, five-year survival rates for breast cancer in the United States are excellent. If the cancer is localized or regional (spread to nearby structures or lymph nodes), the survival rate is 99 percent and 86 percent, respectively. If the cancer has spread to distant parts of the body, the five-year survival rate is 27 percent. These survival rates underscore the importance of early detection and treatment. Treatment may induce feelings of anxiety among patients. Equally scary can be what to expect after treatment ends. Here’s a closer look at what comes next. AFTER SURGERY If treatment involves surgery for a lumpectomy or mastectomy, patients will move to into the recovery room after surgery to wake up from anesthesia. BreastCancer.org says if you are feeling any pain, now is the time to speak up, as staff in the recovery room assess your pain and vital signs. Many surgeries are completed on an outpatient basis. However, more invasive surgeries that involve lymph node dissection require a hospital stay. Doctors will set up a schedule of follow-up care to check surgical sites and monitor healing. Radiation or chemotherapy may be used in conjunction with surgery and may continue even after surgery. AFTER CHEMOTHERAPY Chemotherapy causes an “enormous assault” on the body, according to Marisa Weiss, MD, founder of Breastcancer.org. Many of the hurdles

that people feel post-treatment are lasting fatigue. WebMD says a phenomenon called “chemo brain” can occur. This is a mental change characterized by an inability to focus and memory deficits. In addition, after chemo ends, it may take up to six months for hair to start to grow back, and hair that grows back may be a different color and have a different texture. AFTER RADIATION The American Cancer Society says side effects from radiation may vary depending on the patient. Extreme fatigue is often noted, and such feelings may come and go. Some people experience skin changes in the radiation treatment area. The skin may appear red, irritated, swollen, or blistered. Over time, the skin may become dry, itchy or flaky. Depending on certain types of radiation treatment, radioprotective drugs may be offered to help protect certain normal tissues. FOLLOW-UP Doctors will prescribe a regimen for follow-up care. Every few months women may expect a visit at first. The longer you have been cancer-free, the fewer follow-up visits will be required. Mammograms on any remaining breast tissue will be scheduled between six and 12 months after surgery, and annually thereafter. Bone density tests and blood and imaging tests also may be recommended if you are taking certain medications or have physical indicators that the cancer might have come back. Getting back on track after breast cancer treatment can take time. Eventually, life can return to normal, especially for patients with a good support team in place.


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