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September 29, 2019

a guide to

Breast Cancer Awareness a special supplement to



Messenger-Inquirer Sunday, September 29, 2019

Life After Cancer

Yes, you can breast cancer survivors can lift weights, get manicures and garden by Susan Berger | Special To The Washington Post


or more than 25 years, many breast cancer survivors were given a lifelong, life-changing warning: Do not lift anything over five pounds, avoid getting manicures, taking saunas or even gardening since it might lead to a painful complication called lymphedema, which can cause irreversible swelling in the arm and often hardening of skin. The condition is usually caused by the removal of lymph nodes, which is done during breast cancer surgery to determine if the cancer has spread. The nodes are part of the body’s lymphatic system, which protects against invaders. Lymphedema happens when a blockage, often because of scarring from surgery or radiation, causes fluid to accumulate, painfully and often irreversibly. Doctors treating breast cancer patients long thought that infection or injury would cause inflammation, which in turn would overload the lymphatic system causing the swelling and pain of lymphedema. But based on studies over the past

Many breast cancer survivors have been given a lifelong, lifechanging warning: Do not lift anything over five pounds, avoid getting manicures, taking saunas or even gardening since it might lead to a painful complication called lymphedema, which can cause irreversible swelling in the arm and often hardening of skin. But based on studies over the past decade, the old warnings of lymphedema do’s and don’ts have been dramatically relaxed. decade, the old warnings of lymphedema do’s and don’ts have been dramatically relaxed. “We continue to caution women about injury to the hand/arm that is at risk for lymphedema. Meaning, when gardening, you should wear gloves, said Katherine Kopkash, director of oncoplastic breast surgery at NorthShore University HealthSystem outside Chicago. “If receiving manicures, you should not have your cuticles cut. Be careful in saunas to limit your exposure to heat and avoid burns.” Using light weights and very slowly increasing them is also OK. Many of these warnings, said Simona

Shaitelman, associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center, were little more than “old wives’ tales,” which in recent years have been debunked based on results of a group of well-run studies. Kathryn Schmitz, a professor of public health sciences at Penn State Cancer Institute and president of the American College of Sports Medicine, conducted those studies, which showed that a careful return to working out with weights did not increase the risk of lymphedema. Estimates of how many people post-cancer treatment get lymphedema

vary widely. A 2018 study in the New England Journal of Medicine estimated between 14% to 40% of women post-breast cancer surgery got lymphedema, with newer surgical methods and treatments helping to reduce the numbers. (Treatment for other kinds of cancers, including prostate, ovarian and melanoma, can also cause lymphedema.) For years, breast cancer doctors used axillary lymph node dissection (removal of lymph nodes in the underarm) to see if cancer has spread beyond the tumor, often removing between 10 and 40 of the nodes, which made the chances for lymphedema fairly high. In the late 1990s, sentinel node biopsy (removing only the node closest to the tumor, to start with to see if the cancer had spread, and then looking at others only if necessary) came into use to allow fewer lymph nodes to be surgically removed. Although this decreases the chance of developing lymphedema, it can still occur - the New England Journal of Medicine calculated the risk for women using the sentinel node technique at about 6% to 10%. “It depends on how many nodes were removed,” Schmitz said. “Patients need to know how many — I have seen women [with sentinel node biopsy] with

Sunday, September 29, 2019 Messenger-Inquirer

12 nodes removed.” In addition to warnings about working out and not lifting anything heavy, women were told to wear a compression sleeve when traveling by air, to prevent air pressure causing lymph flow problems, and not to have blood pressure readings or blood draws on the affected arm. Shaitelman, who oversees a lymph screening initiative that helps patients treat lymphedema early and is involved in ongoing research, cites a 2016 study by researchers at Harvard Medical School and Massachusetts General Hospital that investigated these warnings and found they were based on anecdotal evidence. “Despite the prevalence and persistence of recommendations to pursue precautionary behavior after breast cancer treatment, few data exist to support these practices,” the study said. “Five years ago, we stopped giving a prophylactic sleeve” for air travel, Shaitelman said. “There is no data to say that even with mild lymphedema you should wear that.” Precautions about manicures and avoiding heat are now also viewed as extreme. A small 2017 study by Florida State University researchers not only found that resistance exercise training in women who have breast cancer-related



lymphedema, or are at risk for it, wasn’t harmful but reported it may in fact be “beneficial to decrease the signs/symptoms and development of lymphedema.” Schmitz said that in addition to her research that showed slow progressive weight training would not cause lymphedema, there are other important benefits of exercise for women who have had breast cancer surgery. Many women lose fitness and cardiovascular function after breast cancer treatment having had chemotherapy and radiation. She often hears breast cancer survivors say they feel liked they “aged a decade in that year of treatment.” “Exercise improves fatigue, anxiety, depression, sleep, bone health, physical function, cardiovascular health and improves body composition,” Schmitz said. She and her research team developed the Strength After Breast Cancer program, where specially trained physical therapists provide rehabilitation services to breast cancer survivors to improve their fitness. The program, funded by National Cancer Institute, has partnered with Klose Training, which provides online training for physical therapists and is being utilized by over 600 physical and occupational therapists worldwide, Schmitz said.


Messenger-Inquirer Sunday, September 29, 2019

Patient & Survivor Resources


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Get the 411 on local breast cancer providers and services in the Messenger-Inquirer’s 2019 Health Care Services Directory. Copies are available at 1401 Frederica St.

Sunday, September 29, 2019 Messenger-Inquirer




Better comfort is possible with some preparation Try this advice to help make your mammogram more comfortable Mammograms remain one of the best woman’s breast is placed between two plates. methods to detecting breast cancers, giving One plate holds the breast in place, while the women the oppor tunity to other takes images, and the start treatment early if canmust be compressed Even though mammograms can breasts cer is detected. In countries to get clear pictures of breast with early access to qual- be essential parts of preventive tissue. Many women find the ity screening and treatment, healthcare, many women avoid process to be uncomfortable. breast cancer sur vival rates them because of pain and other Even though mammo are now greater than 80 pergrams can be essential parts discomfort. However, there are of preventive healthcare, cent. The organization Mam- many ways to avoid pain during many women avoid them mography Saves Lives says mammograms that can make because of pain and other that, since 1990, mammog- the entire experience more discomfor t. However, the raphy has helped reduce screenings should not be breast cancer mor tality in comfortable. put of f because of discomthe United States by 40 perfort. There are many ways to cent. Mammograms usually take around 20 avoid pain during mammograms that can make minutes. During a traditional mammogram, a the entire experience more comfortable.

• Schedule the mammogram for a week after a menstrual period when hormonal imbalances are less likely to increase breast sensitivity. • Caffeine can make the breasts more tender. Reducing caffeine consumption for two weeks before the mammogram can help. • Keep your feet and trunk facing forward and turn your head at the mammogram machine. • Reduce tension by breathing deeply a few times before the procedure. • Try a pain reliever before the mammogram. • Ask the mammography center if it has padding, as cushioning between the breasts and the plates of the mammogram machine can reduce pain.

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Messenger-Inquirer Sunday, September 29, 2019

Food & Health

Prevention measures can include diet Recent study says lower-fat diet may reduce the risk of succumbing to breast cancer

The trial involved more than 48,000 women and how much they eat. “This is dietary who did not have breast cancer when they moderation, it’s not like eating twigs and enrolled in the study conducted at 40 centers branches,” he said. “It’s what people were across the United States. From eating, say, 20 years ago, 1993 to 1998, the women were “(The results) are exciting before you could pick up 900 randomly assigned either to in one candy bar.” and empowering for the calories follow their usual diet, in which The dietary intervention BY LAURIE MCGINLEY patient. This is a wake-up lasted for 8.5 years and fat accounted for 32 percent THE WASHINGTON POST of daily calories on average, call for women — there’s included several sessions omen who followed a lower-fat diet or to try to reduce fat intake with nutritionists. The latest something they can do rich in fruits, vegetables and grains to 20 percent of calories while represents a follow-up rather than just waiting analysis had a lower risk of dying from consuming daily servings of of almost 20 years. for the shoe to drop.” breast cancer than those on a higher-fat diet, vegetables, fruit and grains. Breast-cancer experts according to results from a major new study The dietary-intervention generally praised the study but Elisa Port expressed some reservations. released in May. group fell short of the goal; chief of breast surgery at For one thing, the study was The conclusions, from the latest analysis they managed to reduce their Mount Sinai Health System designed not to determine of the federally funded Women’s Health fat consumption to about Initiative, provide the first 24.5 percent, whether a low-fat diet provided randomized clinical trial and then “drifted up to about a mortality benefit but whether such a diet “This is dietary evidence that diet can reduce 29 percent,” according to could reduce the risk of developing breast moderation, it’s not postmenopausal women’s risk lead study author Rowan cancer in the first place. like eating twigs and of dying from breast cancer, Chlebowski of the Los Angeles Previously released data showed the branches. It’s what the researchers said. Past Biomedical Research Institute diet did not result in that in any statistically observational studies — which people were eating, say, at Harbor-UCLA Medical significant way. In addition, the breast-cancer don’t measure cause and Center. Members of the group experts noted, the mortality benefit took 20 years ago, before you lost 3 percent of their body effect — have had inconsistent almost 20 years to emerge. Some also said it could pick up 900 calories weight on average. Still, the findings. was not clear which dietary component was The results “are exciting and in one candy bar.” women in that group who responsible for the benefit — the reduced fat empowering for the patient,” developed breast cancer had or the additional fruits, vegetables and grains? Rowan Chlebowski a lower risk of death than the said Elisa Port, chief of breast The study authors said the dietary-modifiLos Angeles Biomedical women who followed their surgery at Mount Sinai Health cation group used a diet similar to one called System, who was not involved Research Institute at regular diets and developed the DASH — for Dietary Approaches to Stop in the study. “This is a wake-up Hypertension — which is designed to prevent Harbor-UCLA Medical Center disease. call for women — there’s Chlebowski said the study or treat high blood pressure. something they can do rather than just showed that women could improve their waiting for the shoe to drop.” health by making modest changes in what SEE DIET/PAGE 7







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Awareness Events



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The new study “adds more evidence on the impact of diet but I wouldn’t rely on it to recommend a specific diet to a patient,” given that people react dif ferently to dif ferent diets, depending on their biology, said Neil Iyengar, a medical oncologist at Memorial Sloan Kettering Cancer Center. “I tell patients if they eat more plant-based food, less red meat, decrease alcohol and maintain a healthy weight, they might have a reduced risk of breast cancer recurrence or death.” The study didn’t look at the impact of diet on risk of recurrence of breast cancer. A separate study is looking at whether weight loss, achieved through cutting back calories and increasing physical activity, leads to a reduction in the risk of recurrence. The study, called the Breast Cancer Weight Loss Study, or BWEL, is being led by Dana-Farber Cancer Institute.



The study comes as more evidence is accumulating about the link between being over weight or obese and a number of cancers. Being obese and over weight — long implicated in hear t disease and diabetes — has been associated in recent years with an increased risk of getting at least 13 types of cancer, including stomach, pancreatic, colorectal and liver malignancies, as well as postmenopausal breast cancer.

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Messenger-Inquirer Sunday, September 29, 2019


breakthroughs in imaging technologies can help fight cancer

Doctors and patients have many different tools available in the war against cancer. Imaging is one of the essential resources used in such battles. Imaging helps screen and diagnose cancer and can be used to guide treatments and determine the efficacy of various therapies. Therefore, advancements in imaging can have profound effects on the ability to manage — and hopefully in the future — prevent or cure the disease. The goal of cancer imaging is to detect the smallest possible number of tumor cells at the earliest possible time. Traditionally, X-ray, ultrasound, magnetic resonance imaging, single-photon emission computed tomography, and positron emission tomography have been utilized as key cancer imaging techniques. These technologies are being studied and advancing. Imaging probes are one area of imaging worthy of attention. The Center for Probe Development and Commercialization, a supplier of radiopharmaceuticals, is developing the next generation of molecular imaging probes. They are designed to detect responses to chemotherapy in breast cancer patients. CPDC also has started to manufacture another probe designed to identify hypoxic tumors. These probes work on a molecular level, according to data published in 2013 in the International Journal of Biomedical Imaging. Molecular imaging has the potential to greatly enhance understanding of various cancers. Another cancer imaging and evaluation tool that is being produced and tested is called the MasSpec Pen, which enables a controlled and automated delivery of a water droplet to a tissue surface during tumor surgery

or diagnostic exploration to extract biomolecules. The sample taken can immediately tell if cancer cells are present and distinguish tumors from healthy tissue. Imaging has merged nanotechnology and conventional imaging tools with new developments. These technologies are still in the testing phase. Novel diagnostic probes with nanoparticles can improve imaging results. A 2018 review paper published in the Journal of Controlled Release looked at how nanotechnology could improve the imaging and treatment of lung cancer. For example, gold nanoparticles work better than iodinebased agents for CT imaging. Similarly, superparamagnetic iron-oxide nanoparticles can be utilized with MRI for the ultra-sensitive reactions they produce. Other imaging technologies in the works involve combining and improving the workflow of various methodologies. Philips Medical Systems’ Ingenia MR-RT Oncology Configuration is a comprehensive solution that allows radiation oncology departments to integrate MRI into their computed tomography-based radiation treatment planning. In addition to the imaging evolution itself, researchers have realized the limitations of the human eye to discern abnormalities or small changes from images collected. Therefore, technological advancements are enabling artificial intelligence to look for key signs in images and correlate changes to the aggressiveness of the disease. This can improve treatment success rates and reduce the chances for human oversight.

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Medical Care

Area cancer care providers Whether facing a breast cancer diagnosis, a family history of illness or a loved one battling the disease, local breast cancer care providers can help ease the road ahead OWENSBORO HEALTH MITCHELL MEMORIAL CANCER CENTER


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Owensboro Health’s cancer care facility includes a 16-bed outpatient oncology unit, advanced technology, physician offices, a medical library and a cancer registry. Chemotherapy, radiation therapy, patient education and consultation services are offered at the Cancer Center.

Cancer services include surgical oncology, chemotherapy, infusion, radiation therapy, genetic counseling, nutrition and social counseling, and acupuncture for cancer patients.

(a Deaconess facility)

Deaconess Hospital Cancer Services has collaborated with The Women’s Hospital to provide a multidisciplinary breast cancer program that connects multiple physicians to create a personalized treatment plan for each patient.

Inpatient services are rendered at Owensboro Health Regional Hospital at 1201 Pleasant Valley Road in Owensboro.

The Women’s Hospital’s affiliation with MD Anderson Cancer Network enables local providers to collaborate with other physicians within the MD Anderson network to provide patients with an extensive network of care.

Owensboro Health also offers Hologic 3D Mammography, an advancement in diagnostic imaging that helps detect breast cancer in its earliest stages. This service is also available at Owensboro Health healthplexes in Henderson, Madisonville and Powderly.




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Palliative Care

Palliative care a whole-health approach A rising trend in cancer care targets physical and existential threats that patients confront

found that nearly a quarter of cancer patients suffer from depression, and cancer sur vivors are 50 percent more likely to die by suicide than the general population. Once a luxur y of larger cancer centers, the mandate to offer such ser vices gained new urgency in 2008 when the National Academy BY SARAH ELIZABETH RICHARDS with terminal cases — and often confused with of Sciences issued its landmark report “Cancer SPECIAL TO THE WASHINGTON POST end-of-life hospice care — it’s actually designed Care for the Whole Patient,” which stressed the importance of offering emotional and social hen Tori Geib learned she had for patients suffering from many types of support as part of quality cancer care. And terminal metastatic breast cancer serious illnesses, regardless of how long in 2016, the American College of Surgeon’s in 2016 on the week of her 30th they’re expected to live. Commission on Cancer decreed birthday, she was automatically booked to see Such “whole-person” that to be accredited, cancer a palliative care coach at Ohio State University care can include ever ything “The biggest thing programs must ask patients Comprehensive Cancer Center in Columbus. from mind-body practices, during an office visit about There, in addition to receiving a targeted massage, stress and symptom initially is that you’re whether they are experiencing therapy pill to slow the spread of the cancer, management to cognitive dealing with grieving emotional distress. she was offered a host of ser vices that she says behavioral therapy to help this life you just lost “There’s a growing shaped her quality of life for the next three patients cope with insomnia and awareness that if we take care years: acupuncture, pastoral comfort, nutrition the fear of cancer coming back and the idea of what of how people are feeling, they advice and pain expertise to control her nausea after treatment. As part of the your life would be like. will be better able to focus on and back pain because the cancer had spread growing recognition of the link Your peers don’t treatment,” says Jeremy Hirst, a to her spine. She also saw a mental health between poor lifestyle factors understand. I had to palliative psychiatrist at Moores counselor who helped her come to terms with and cancer, many centers also Cancer Center at UC San Diego the brutality of her diagnosis. offer weight loss, alcohol and quit my job as a chef Health. “We find that validating “The biggest thing initially is that you’re even exercise counseling. two years out of school. people’s experiences by giving dealing with grieving this life you just lost and That’s in addition to better When I learned my them the space to talk about the the idea of what your life would be like. Your medications for nausea and cancer wasn’t curable, nightmare of a cancer diagnosis peers don’t understand. I had to quit my job as advances in cancer drugs such and how the experience steals a chef two years out of school,” says Geib, of as immunotherapies that are I just communicated so much of their life helps their Bellefontaine, Ohio. “When I learned my cancer easier on the body and don’t to my palliative care physical symptoms improve.” wasn’t curable, I just communicated to my result in hair loss or debilitating doctor, ‘If I don’t live Paying attention to patients’ palliative care doctor, ‘If I don’t live long, I want fatigue. comfort and emotional mindset to make sure I live my best life.’ ” “I have patients who are long, I want to make Geib benefited from a rising trend in cancer really anxious about treatment. sure I live my best life.’ ” isn’t just the humanitarian thing to do to reduce suffering. care: making the experience of undergoing They tell me about a family treatment as gentle as possible for the more member who was treated 10 — Tori Geib A growing body of evidence shows that it may extend their than 1.7 million Americans years ago and breast cancer survivor sur vival. diagnosed with cancer each how horrible Often called palliative A much discussed 2010 year. the side effects study in the New England Journal of Medicine Often called palliative care were and how hard it was to care or integrative found that patients with terminal lung cancer or integrative medicine, the watch,” says Nathan Handley, medicine, the who received early palliative care lived nearly comprehensive approach a medical oncologist at comprehensive focuses on patients’ emotional Thomas Jefferson University in three months longer than those who didn’t. needs and physical symptoms Philadelphia. “I tell them we’re And a 2017 study published in the Journal of approach focuses on the American Medical Association concluded in addition to treating the living in a different time. We patients’ emotional that metastatic cancer patients who answered disease. In 2016, 1,831 have a lot more to offer. There needs and physical U.S. hospitals — about are more options, more support weekly questions about their symptoms via an symptoms in addition online tool that reported any severe problems three-quarters — had a and more hope.” palliative care program, Cancer specialists have long to a clinical nurse experienced a median life to treating the disease. extension of five months. compared to less than recognized the importance of In a new initiative, Handley’s team at one-quarter in 2000, according addressing patients’ emotional Jefferson’s Sidney Kimmel Cancer Center is to the Center to Advance Palliative Care. concerns since the 1970s, when the field of rolling out a model that communicates with While palliative care is often associated psycho-oncology was created. Studies have


Sunday, September 29, 2019 Messenger-Inquirer



patients through a third-party portal about their well-being. Not only do patients feel “There’s a growing awareness that if we take care of how people are feeling, they will more cared for, addressing early symptoms, be better able to focus on treatment. We find that validating people’s experiences by such as dehydration from nausea or fever, also giving them the space to talk about the nightmare of a cancer diagnosis and how the increases their chances of successful treatment, experience steals so much of their life helps their physical symptoms improve.” he says. The attention to patients’ quality of life is — Jeremy Hirst a stark contrast from the early days of cancer palliative psychiatrist at Moores Cancer Center at UC San Diego Health medicine, when doctors focused mostly on keeping patients alive and less on the physical Cancer Center in Houston, psychologist “The current billing system separates and emotional toll of treatment. Lorenzo Cohen is tr ying to make the case for out mental health and cancer ser vices,” she “When the War on Cancer was originally says. “Your cancer doctor might refer you to conceived in the 1950s, it was a war at all costs. routine screening of patients for cancer risk factors, including obesity and lifestyle habits. psych-oncology, but your insurance might not We were so obsessed with winning that we As part of a newly launched pilot program at cover mental health at that particular center.” accepted the idea that a patient being invaded the hospital’s breast center, clinicians talk to Or your insurance provider might not cover with chemotherapy, radiation and surger y was patients about their weight and ask them how ser vices in between or after treatment — when the price someone had to pay to get through much plant-based food patients might be anxious that their cancer the deadliness of the they’re eating, how often could return or are seeking nutritional advice disease,” says oncologist they’re exercising and on staying healthy, says Linda House, president Siddhartha Mukherjee, Such “whole-person” care can how they’re coping with of Cancer Support Community. author of “The Emperor include everything from mindstress In many cities, nonprofit groups like hers of All Maladies: A body practices, massage, stress “We have over whelming have been left to fill the gaps. Biography of Cancer.” and symptom management to data on the importance “People are sur viving longer, and they’re “Since that time, things of these factors on living better with their disease. Now we’re able have changed vastly. We cognitive behavioral therapy to outcomes,” says to focus on all the other issues like depression don’t always give the help patients cope with insomnia patient Cohen, director of MD and anxiety,” says House, whose organization maximal treatment. We and the fear of cancer coming Anderson’s integrative runs support groups, educational sessions do symptom management back after treatment. As part of medicine program and and social activities for patients and families early. As a community, we co-author of “Anticancer in the United States, Canada, Israel and Japan. woke up and realized we the growing recognition of the Living: Transform Your “Where we need to go as a field is to recognize weren’t giving patients the link between poor lifestyle Life and Health With the that emotional support is as important as psychological, spiritual factors and cancer, many centers Mix of Six.” “What’s new medical ser vices and needs to be reimbursed.” and palliative care they For Geib, her palliative care doctors helped needed.” also offer weight loss, alcohol and is that we’re studying how to incorporate that into soothe her back pain so she eventually was Yet there’s still a even exercise counseling. clinical care.” able to stop walking without a cane. She also lack of consensus about Despite the learned strategies to manage her anxiety about what ser vices should be Commission on Cancer’s recent requirement undergoing imaging scans ever y three months considered “nice to have” and what should that cancer patients must be asked if they’re to see if her cancer has advanced — what be standard of care at most cancer centers. suffering from distress, many cancer centers counselors call “scanxiety.” Last summer, the American Society of Clinical don’t have a good system in place to refer “I’ve since learned that not ever yone gets Oncology cautiously endorsed guidelines for patients to appropriate ser vices, adds access to this kind of care, so I feel lucky,” says integrative therapies, including meditation, oncologist Lidia Schapira, director of the cancer Geib, now 33. “No one knows the right way music therapy and yoga, during and after sur vivorship program at Stanford University how to do cancer. They’re just there to help breast cancer treatment as complements to Medical Center. Nor can they guarantee you adjust to a new normal and be present in conventional therapies. ever yday life.” But at the University of Texas MD Anderson insurance will cover those ser vices.

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