Breast Cancer Awareness 2022 by On-Line Publishers, Inc.

A breast cancer diagnosis is personal. Your care should be too. Breast cancer is the second most common cancer affecting women in the U.S., but for you it’s personal. And you want a health care provider who understands that. When you choose Penn State Health, you can depend on individualized attention and the latest approaches to find and treat breast cancer. Our experienced breast care clinicians provide innovative treatment and compassionate support every step of the way, from early detection to survivorship.

AWARENESS Month

You are your best defense against breast cancer.

Find a location near you. Penn State Health Breast Center Hershey 717-531-5867 Penn State Cancer Institute Hershey 717-531-8024

Penn State Health Century Drive Cancer Center Mechanicsburg 717-737-4718

Penn State Health St. Joseph Cancer Institute Reading 610-378-2117

Sponsoring Partner:

Penn State Health Lime Spring Outpatient Center Lancaster 717-327-4312

BC-18910-23-182170-0822

You know that You know that mammogram you’ve mammogram you’ve been putting off? been putting off?

Go to pennstatehealth.org/mammogram Go to pennstatehealth.org/mammogram to find a location near you. to find a location near you.

Breast Cancer Awareness

2022 Publisher

Donna K. Anderson

Editorial Vice President & Managing Editor Christianne Rupp

Editor Megan Joyce

Contributing Writers Sandra Gordon Carolyn Kimmel Barry Spark s

Jean Waverka

Art Department Production Coordinator Lauren Phillips

Dear friends and colleagues, The most common type of cancer in women in the United States is breast cancer. Unfortunately, incidence rates of breast cancer have increased by 0.5% per year in recent years. Breast cancer death rates have been steady in women younger than 50, but have continued to decrease in older women. From 2013 to 2018, the death rate for women with cancer dropped by 1% each year. Most everyone knows someone who has experienced a breast cancer diagnosis and the turmoil, mental and physical, that follows. And breast cancer doesn’t just impact the person who has been diagnosed, but also her family, friends, and coworkers. Breast cancer is life changing and can cause anxiety, distress, and depression. It’s important to recognize these changes and see a doctor. When diagnosed with breast cancer, most women will want to learn as much as they can about the type of breast cancer they have been diagnosed with. Patients will want to know how to be proactive and their treatment options. They’ll want to hear from survivors or women currently being treated. And women everywhere want to know how to reduce risks of developing breast cancer. We are grateful to our partner, Penn State Health, for working with us to provide the valuable information included in this Breast Cancer Awareness magazine. Their experienced physicians and surgeons stay up to date on new research, surgeries, drugs, immunotherapies, and other innovations to ensure the best possible patient outcome. And their caring staff manages their patients’ cases, including taking steps to ensure their comfort and that lines of communication are kept open at all times. Take some time to read the articles within and share the information with other women in your life. We still have to make more women aware of the value of scheduling their mammogram because although death rates continue to decrease, incident rates are still increasing. Mammograms – They’re worth a minute of discomfort when it can save a life!

Business Development Senior Marketing Consultant Josh Binkley Events Manager Kimberly Shaffer

Business Manager Elizabeth Duvall

Copyright © 2022 On-Line Publishers, Inc. All rights reserved. All listings and advertisements have been accepted for publication on the assumption that the information contained in them is true and accurate and that all merchandise or services offered in the advertisements are available to the customer according to the conditions warranted therein. The appearance of advertisements or products or services does not constitute an endorsement of the particular product or service. On-Line Publishers, Inc. disclaims any and all responsibilities and liability which may be asserted or claimed resulting from or arising out of reliance upon the information and procedures presented in this guide.

Christianne Rupp Vice President and Managing Editor

Inside:

Breast Cancer Death Rates Falling

Knowledge is Power, Says Mother/Daughter Duo Who Got BRCA Testing through Penn State Health

Innovative Penn State Health Cancer Rehabilitation Program Improves Breast Cancer Patients’ Lives

Penn State Health Expands Access to Free Mammography Services through State Program

Women Find Options for Breast Reconstruction Close to Home with Penn State Health

What Are the Risk Factors for Breast Cancer?

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Breast Cancer Awareness Month | 3

Breast Cancer Death Rates Falling By BARRY SPARKS

early 13% of women will be diagnosed with breast cancer in their lifetime. It is the second leading cause of death in women, trailing only lung cancer. Although incidence rates have increased slightly in recent years, the death rate has fallen 1% per year, according to the American Cancer Society. Since 2007, breast cancer deaths have been steady in women younger than 50, but have continued to decrease in older women. Breast cancer mainly occurs in middle-aged and older women. Breast cancer occurs when genes in the breast tissue change and cells divide uncontrollably. Certain factors increase the risk of breast cancer, including increasing age, obesity, harmful use of alcohol, family history of breast cancer, history of radiation exposure, reproductive history, tobacco use, and postmenopausal hormone therapy, according to the World Health Organization (WHO). Approximately half of breast cancers, however, develop in women who have no identifiable risk factor other than gender (female) and age (over 40). Although a family history of breast cancer increases the risk of breast cancer, the majority of women diagnosed with breast cancer do not have a known family history of the disease. Breast cancer most commonly presents as a painless lump or thickening in the breast. Other symptoms of breast cancer include: • Alternation in size, shape or appearance of a breast • Dimpling, redness, pitting, or other alteration to the skin •C hange in nipple appearance or alternation in the skin surrounding the nipple • Abnormal nipple discharge Women with any of these symptoms should contact their physician as soon as possible. The earlier breast cancer is detected, the greater the chance for successful treatment. Don’t wait for symptoms, however, to schedule a breast cancer screening. Breast cancers found during screening exams are more likely to be smaller and less likely to have spread outside the breast. The size of a breast cancer and how far it has spread are some of the most important factors in predicting how well a woman will respond to treatment.

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Mammograms, X-ray pictures of the breast, are the most common way to screen for breast cancer. The American Cancer Society recommends that women age 45-54 have a mammogram every year. There are different types of mammograms: 2D mammograms are taken from two sides of the breast; 3D mammograms are taken from different angles around the breast. Magnetic resonance imaging (MRI) is sometimes used to screen women at high risk for breast cancer. MRIs can create a clearer image of the breast and don’t use radiation. If breast symptoms or the results of an imaging test suggest you might have breast cancer, your physician may do a biopsy. The process involves removing small pieces of breast tissue from the suspicious area. The tissue is then sent to a lab, where it is examined. Most biopsy results are not cancer, but a biopsy is the only way to be sure. There are different kinds of biopsies. They include fine needle aspiration, core needle biopsy, surgical biopsy and lymph node biopsy. Needle biopsies are more common than surgical biopsies. The type of biopsy you have depends on a number of factors, according to the American Cancer Society. They include: • How suspicious the breast change looks and feels • How big it is • Where it is in the breast • If there is more than one suspicious area • Your overall health • Your personal preferences Breast cancer can spread, or metastasize. It can grow into tissue surrounding the breast, or it can travel to other parts of the body. Nearly all types of cancer have the ability to spread, but whether they do or not is often linked to what type of breast cancer it is. According to the Cleveland Clinic, breast cancer can spread in three ways: • It can spread from your breast into surrounding areas (like lymph nodes under your arm).

• Cancer cells can travel through the bloodstream to other areas of the body. • Cancer cells can also move through the lymph node system, but it most commonly spreads to lymph nodes, lungs, liver, bones and sometimes the brain. When breast cancer is found, treatment depends on the type of tumor. Today, the majority of breast cancers can be treated with a smaller procedure called a lumpectomy or partial mastectomy, in which only the tumor is removed from the breast. In the past, all breast cancers were treated surgically by mastectomy (removal) of the breast. When cancers are large, mastectomy may still be required. Radiotherapy also plays a very important role in treating breast cancer. With early-stage breast cancers, radiation can prevent a woman having to undergo a mastectomy. With later-stage cancers, radiotherapy can reduce cancer recurrence risk even when a mastectomy has been performed. For advanced stage of breast cancer, in some circumstances, radiation therapy may reduce the likelihood of dying from the disease, according to WHO. Chemotherapy may also be used. Doctors might recommend other treatments as well, depending on the type of breast cancer. “There are three main types of breast cancer,” says Dr. Margaret Gatti-Mays, a breast cancer treatment specialist at The Ohio State University. “The subtype is determined by the presence or absence of three receptors. These receptors respond to hormones, estrogen or progesterone, or a protein called HER2. “If your tumor has estrogen and progesterone receptors, then you can be treated with hormone therapies. These block the action of hormones that can cause certain cancers to grow.” There are newer treatment options called targeted treatments. These block specific proteins that control how cancer cells grow, divide and spread. Targeted treatments for HER2-positive cancer have improved survival over the last decade. Immunotherapy is the most recent type of cancer treatment. It trains your body to fight cancer using your immune system. Triple-negative is the least common type of breast cancer, and it is one of the most difficult breast cancers to treat. Accounting for 10-15% of all breast cancer cases, it tends to affect younger women, black women and women who have the BRCA1 genetic mutation. About 70% of all triple-negative breast cancer patients have the BRCA1 gene mutation. Triple-negative breast cancer is negative for the two hormones, estrogen and progesterone, and the HER2 protein. Therefore, the targeted and hormonal therapies used for other types of breast cancer are unlikely to be successful for triple-negative breast cancer patients. The first line of treatment for these patients isn’t as clearly defined as for other types of breast cancer patients, making it harder to know which treatment will work best for the patient. Scientists continue to look for ways to improve screening, prevention and treatment of breast cancer. “In the next five to 10 years, there should be better ways for women to determine their risk of breast cancer,” says Dr. Montserrat Garcia-Closas, a cancer researcher at the National Institute of Health. Breast Cancer Awareness Month | 5

Knowledge is Power, Says Mother/ Daughter Duo Who Got BRCA Testing through Penn State Health By CAROLYN KIMMEL

f all the things that mothers hope to pass onto their children, susceptibility to cancer certainly isn’t one them. “At first I cried because I knew what she may have to go through,” said Tammy Hughes, an Oley resident who battled breast cancer at Penn State Health St. Joseph Medical Center and found out she carries a BRCA gene mutation, which she later learned she had passed onto her oldest daughter. “I decided to put it in God’s hands and realized that knowing meant we could watch her more closely.” Her daughter, Ashley Hughes, said the news didn’t unnerve her — it emboldened her. “From the moment I found out I tested positive, I told everyone, ‘Don’t be sorry for me’ because I’m going to continue living my life as I was,” said Ashley, who has studied genetics and works in pharmaceutical research. “But I also said I would respect the gene and do what I needed to do to monitor my health, and that’s what I did.” In April, her heightened self-surveillance paid off when a passing discoloration of her breasts prompted her to make an immediate appointment to see her doctor. The news was not what she hoped — breast cancer at age 31 — but it was caught early, and her prognosis is excellent. Knowing about the gene mutation could very well save her life, Ashley said. “Of course, I cried at first, but after the initial shock, I just wanted to know what I needed to do next,” she said. “I consider that discoloration as divine intervention. I was really lucky that my cancer was caught so early.” 6 | Breast Cancer Awareness Month

A Telling Family Past Tammy Hughes always knew that cancer ran in her family. Her father and uncle died from prostate cancer, and ovarian cancer claimed the life of her grandmother. Several cousins and other relatives had breast cancer. Still, when she was diagnosed with breast cancer at age 46, Tammy didn’t know anything about a BRCA gene mutation, which can cause cell damage that could lead to, most notably, breast and ovarian cancer in women and breast and prostate cancer in men. Although some people would rather not know of their cancer risk, Tammy said she didn’t hesitate to be tested. “I wanted to do everything I could for my own care and for my children,” said Tammy, who knew she had a 50% chance of passing the gene mutation onto them. Her positive test result made Tammy decide to have a bilateral mastectomy, even though the cancer was contained to just one breast. She underwent surgery, chemotherapy and removal of her ovaries, which took up the first seven months of 2013. (She had her uterus removed previously due to other issues.) Although her prognosis was good, Tammy said the threat of breast cancer continued to loom over the family, but they chose to channel that energy into being proactive. A Way to Be Proactive Tammy credits the genetic counselors at St. Joseph Medical Center for suggesting she consider a genetic source for her cancer and guiding her through the process of analyzing known risk factors. They include having breast cancer before age 50 or having breast and ovarian cancer, one or more family members

Tammy and Ashley Hughes, mother and daughter duo, share the same diagnosis.

with breast cancer, a male family member with breast cancer, or having Ashkenazi (Eastern European) Jewish ancestry. Testing is done with a blood or saliva sample. Those who are positive have more frequent screening tests, such as mammograms and ultrasounds, and may choose to remove healthy breasts and ovaries preventively to reduce the risk of developing cancer. “I felt a lot of guilt as a parent, but there’s no way I could have known I had this mutation,” said Tammy, who still fights bouts of guilt as she watches her daughter battle the same cancer she had. Ashley followed her mother’s successful game plan and had a bilateral mastectomy with immediate reconstruction and is in the middle of eight rounds of chemotherapy. She plans to have her ovaries removed at age 35 — a difficult decision made easier because Ashley doesn’t have a desire to have children. Her mother accompanies her to every appointment and treatment and is her biggest cheerleader and sounding board, she said. “Knowing that my mother and father have walked this journey in different ways gives me comfort,” Ashley said. “I can trust they know what to do.” Tammy has also walked beside other women, as a volunteer with Breast Cancer Support Services of Berks County and an assistant with a young survivors’ support group in her area. “I guess maybe that’s one of the positive things that came from all this,” she said. She advises women to be their own advocate and always bring someone to appointments who can take notes because the information can be overwhelming.

A Call to Action for Others Both Tammy and Ashley encourage women with risk factors to undergo BRCA genetic counseling and testing — even if they are fearful of the result. “Do it,” Ashley said firmly. “Knowing is better than not knowing. Knowing means you can be proactive. Knowing means you can lower your risk of finding out you have cancer at a much later stage.” Both Tammy and Ashley were counseled, tested and treated at St. Joseph Medical Center and say they wouldn’t go anywhere else because of the excellent care they received. “Everyone at St. Joseph Medical Center is so helpful, aware and knowledgeable,” Tammy said. “It gave me peace of mind during one of the scariest times of my life.” Agreed Ashley, “I can’t say enough good things about St. Joseph. Everybody there genuinely cares, and they remember you as a person, not just a patient.” What was once a devastating discovery has become “a blip” on the screen of their active lives, the mother-daughter pair say. “I’m a school nurse, and I run an antique store and a bed-andbreakfast,” Tammy said. “Life goes on, and you do the best you can with the information you have — for us, that information was lifesaving.” To find out more about genetic testing through Penn State Health, visit cancer.psu.edu/genetic-testing.

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Innovative Penn State Health Cancer Rehabilitation Program Improves Breast Cancer Patients’ Lives By JEAN WAVERKA

hile improved cancer treatments are adding years to patients’ lives, many aren’t necessarily gaining quality of life. That’s why Dr. Sara Lay, a Penn State Health cancer-focused physiatrist, has made a career out of meeting her patients’ goals and functional challenges. “Oncology physiatrists have training and education on how serious illness or injury, like cancer, affects your ability to live the life you were planning,” said Lay, adding that breast cancer in particular presents quite a few changes that patients might not think about or realize will happen. “We do our best to minimize these effects during cancer treatment and improve survivors’ lives.” Lay joined Penn State Cancer Institute in 2021 after determining its leaders shared similar goals. “What drew me to Penn State Cancer Institute was that they want patients to live full and complete lives,” she said. “In addition to hiring their own oncology physiatrist, they’ve developed several programs, such as the Cancer Assistance and Resource Education Center and the Oncology, Nutrition and Exercise Group, to address the multifaceted concerns of cancer patients.“ Improved Survival Rates Fuel New Mindset The expanded programs demonstrate that cancer is no longer considered a life-ending disease. “Thankfully, individuals are surviving cancer, and it is becoming less of a ‘death-sentence disease’ and more of a chronic disease state,” said Lay, while acknowledging that there are still more cancer-related deaths than wanted. “Patients are dying with cancer, not because of cancer. But, as treatments have advanced, different concerns fill patients’ lives.” Instead of wondering if they’ll go back to work, they wonder how. They also feel confident to plan for the future, whether going on a trip or attending an event for a loved one. At the 8 | Breast Cancer Awareness Month

same time, they may worry about other illnesses, relationships, and financial concerns. It is because of the advanced treatments and these questions that oncology rehabilitation has become a growing profession. “There is a shift in the mindset from traditional rehab when working with cancer patients. Orthopedics is known for rehab because there is a natural line through it. That doesn’t happen with cancer,” said Lay, explaining that not every patient’s body responds in the same way. “That is why we provide safe, timely, and efficient restorative therapy that is individual to each patient’s needs. Once we make a breakthrough, we’ll keep working to see where it takes us.” Focus is on Prehab Lay continues to develop the cancer rehabilitation management program at Penn State Cancer Institute and hopes to make it an interdisciplinary “prehab program.” This innovative program improves patients’ functional capabilities before a surgical procedure and minimizes the need for other interventions as treatment progresses. “I’d love to have patients see me as soon as they figure out they have cancer and determine their treatment plan so we can start improving function and making their quality of life better,” Lay said. “Studies show the more functional you are, the better you will tolerate cancer treatments.” For now, Lay’s breast cancer patients seek relief for a variety of conditions, such as post-mastectomy pain syndrome, aromatase inhibitor-associated musculoskeletal syndrome — known as AIMSS — shoulder dysfunction, neuropathy, and lymphedema, a buildup of lymphatic fluid in a limb that occurs when the lymph system is damaged or blocked. “It can be quite disfiguring and limiting in how they can use their arm,” she said. “The good news is there’s been a lot of research on lymphedema and different ways to minimize the impact it can have. While it still happens, with the proper

preventive treatment, it’s not as devastating as it may have once been for women.” Support Network Grows To deliver the necessary therapy and interventions that improve patients’ lives, Lay continues to develop a network of experts throughout the region whose services complement her own. “I use a big team to effectively get patients the care they need. I have physical therapists, occupational therapists and exercise physiologists,” she said. “We include mental cognitive treatment, social workers who help with the financial piece, and recreation therapists to help with job-finding skills.” In Penn State Health Exeter Outpatient Center in Reading, Pa., clinical exercise physiologist Cheryl Buskirk takes a preventive approach to lymphedema with breast cancer patients. Meeting with them prior to surgery, she demonstrates simple exercises and explains the importance of movement in their rehabilitation. “Often, cancer patients feel that they’ve lost control of what is happening to them,” she said. “From my perspective, these exercises are something they can do to be proactive and take control of their recovery. Performing these exercises can have a very positive effect on their mental well-being as well.”

Big Dreams Have Small Beginnings Although cancer rehabilitation programs continue to grow, many oncologists have limited education about the skills oncology physiatrists have and how they can improve cancer survivors’ lives. While more than 90% of breast cancer survivors have some form of functional disability, Lay says the referral rate to rehabilitation programs is less than 15%. “Many factors influence the low referral rate,” she said. “One is that it’s a new field, and not many physiatrists have been able to complete the formal training, which goes beyond the training required of a general physiatrist. Also, patients have the misconception that they should be lucky to be alive, even if it’s not the life they planned.” By developing a comprehensive oncological rehabilitation program that starts with prehabilitation and continues through survivorship, Lay hopes that both physicians and patients will see the benefits, and more people will be referred. She admits it has been a slow start for the program but isn’t letting that discourage her. “I tell my patients it takes longer to get better than it does to get sick. And, sometimes, big dreams have small beginnings.”

Dr. Sara Lay, a Penn State Health cancerfocused physiatrist.

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Penn State Health Expands Access to Free Mammography Services through State Program By JEAN WAVERKA

ammograms are the best way to detect breast cancer early when treatment is most likely to be successful, yet access remains an issue for many uninsured and underinsured women. Helping to alleviate that problem in Pennsylvania are health care providers like Penn State Health, who partner with the Pennsylvania Breast and Cervical Cancer Early Detection Program (PA-BCCEDP), which is funded by the Pennsylvania Department of Health and the Centers for Disease Control and Prevention, to ensure more women take advantage of this lifesaving X-ray of the breast. “In 2022, many people remain uninsured. A huge number of people also are underinsured, have high deductibles, high co-pays,” said Tracy Frank, cancer screening program manager with Adagio Health, which manages the PA-BCCEDP through a network of providers across its 62-county service area. “We also see some people who are in cost-sharing programs that aren’t regulated by the Affordable Care Act and usually offer low coverage. Others may need more regular screenings than their insurance company will pay for.” In addition to free mammograms, the program provides Pap and HPV tests and follow-up diagnostic tests for abnormal screening results to those women who meet the age, residency, income, insurance and gender eligibility standards. At Penn State Health Breast Center in Hershey, Pa., providers offer only the breast portion of the service. “For women over 40, we recommend an annual screening mammogram. A good prognosis is early detection,” said Annie Arguin, a nurse practitioner at Penn State Health Breast Center. “With this program, we’re hoping to find cancer when the patient is at stage 0 or 1 instead of stage 4.” The program also covers services for women under 40 years old who show symptoms of cancer. “They can come in, and we will work them up to the point of resolution,” Arguin said. “If they have a mass and need a biopsy, the service is paid for by this program. If we find out it is noncancerous, then we say goodbye [until their next mammogram]. If there is cancer, we refer the patient to Medical Assistance to help pay for breast cancer treatment.” Arguin is quick to point out women do not need a doctor referral to come to the program. They should call the clinic directly and let the staff know they have no insurance and would like a mammogram. 10 | Breast Cancer Awareness Month

Shanna Gillette, director of ambulatory practices, Penn State Health Medical Group, Community Practice Division.

“They will be asked a few financial questions, but it is all selfdisclosed,” she said. “They don’t have to bring in any financial proof.” Although more than 8,500 women statewide took advantage of the PA-BCCEDP free screenings in the most recent fiscal year ended June 30, the number of women who access the program through the Breast Center has fallen off in recent years. Arguin believes that while there is a lack of awareness that the service exists, many delayed care due to the pandemic. “Unfortunately, people were having issues but were afraid to come in and get care. They didn’t want to get COVID,” said Arguin, adding that October 2021 was a difficult time as she diagnosed many cancers when patients started to return. “I’m hoping now that people are ready to come back in.”

A group of staff members who’ve been involved with the Breast Center’s efforts to provide free mammograms since it first partnered with the Pennsylvania Department of Health in 2011 are looking to help. Shanna Gillette, who managed the site’s participation in the PA-BCCEDP (formerly called the HealthyWoman Program) while she served as chief technologist of breast imaging, remembers a time when they served 15-20 women a month through the program. “Right now, it’s really like people don’t know it exists anymore,” said Gillette, who serves as director of ambulatory practices, Penn State Health Medical Group, Community Practice Division. “Many of the providers who knew about the program years ago have left. We need to increase awareness in the community to get more women in.” The group is looking to fund their efforts to expand services for uninsured and underinsured women with the help of a $250,000 endowment fund that was set up when the program first started but has remained untouched in recent years. They have set their sights on women not served by the PA-BCCEDP. “Currently, we’re trying to figure out a way to use the endowment money for women who don’t meet the PA-BCCEDP income guidelines but still need help,” Gillette said. “However, we’re still in the early stages of discussion.” At the same time, Penn State Health will expand its participation in the PA-BCCEDP beyond Hershey, hoping to reach women unable to travel to Hershey, those who may have delayed getting a mammogram because of COVID, as well as those who are unaware of the free service. “The program recently opened at Penn State Health

Diagnostic Center – Union Deposit, and we’re hoping to open it at other locations,” Gillette said. “Because we know early detection is key to better outcomes, we’re committed to removing barriers to what could be a lifesaving screening mammogram and proud to offer this service to those most in need in our community.” To schedule a free mammogram at Penn State Health Breast Center in Hershey, call 717-531-5867. To schedule at Penn State Health Diagnostic Center – Union Deposit, call 866-896-2666.

4 Reasons to Start Annual Mammograms at 40 The American College of Radiology recommends that women start getting annual mammograms at age 40 because: • 1 in 6 breast cancers occurs in women in their 40s. • Mammography has helped reduce breast cancer mortality in the U.S. by nearly 40% since 1990. • One study shows mammography screening cuts the risk of dying from breast cancer nearly in half. • 3 out of 4 women diagnosed with breast cancer have no family history of the disease and are not considered high risk.

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Women Find Options for Breast Reconstruction Close to Home with Penn State Health By CAROLYN KIMMEL

hen a woman hears she has breast cancer, there are immediate decisions to be made about treatment, and the thought of future breast reconstruction options might seem overwhelming. That’s why it’s so important to choose a breast surgeon who is well connected to a health system that offers all the expertise and support she will need, says Dr. Angela Soto-Hamlin, breast surgeon with Penn State Health Century Drive Cancer Center in Mechanicsburg. “You want to choose a breast surgeon who is part of a whole care team that includes the plastic surgeon, and at Penn State Health, we are,” she said. “You start the planning with your breast surgeon, doing what is oncologically appropriate first and foremost for your health and future, while taking into account

functioning and aesthetics afterward.” When she began practicing in the 1980s, Soto-Hamlin said only two-thirds of women with breast cancer survived, but now the cure rate for breast cancer is almost 90%. “Women can now look forward to an excellent chance for cure and a whole team focused on survivorship, part of which is good reconstruction,” she said. “Some of the oncoplastic techniques are new and something that women should ask about.” Breast reconstruction — surgically making the breast look and feel as close to a real breast as possible — has seen major advances in techniques and options. Reconstruction after Lumpectomy Oncoplastic breast surgery, which is most often performed in conjunction with a lumpectomy, involves removing the cancer and a rim of normal tissue around it and then rearranging the breast tissue to create a breast with appropriate shape and contour, SotoHamlin explained. “This requires different levels of skill and complexity, and many breast surgeons have level-one competency in oncoplastic surgery, which means we draw on both our oncologic and aesthetic principles,” she said. Breast surgeons pay close attention to blood supply to different parts of the breast and to tissue arrangement. They also design their incisions and tissue rearrangement with future radiation treatments in mind. If the surgery requires a large amount of tissue rearrangement or encompasses other aesthetic challenges, the breast surgeon works in concert with a plastic surgeon. Options after Mastectomy Women whose cancer is advanced enough to require a mastectomy can also take advantage of recent improvements in breast reconstruction techniques that can help them look and feel more natural. Again, the breast surgeon and plastic surgeon work together for the best outcome, Soto-Hamlin said. “A skin-sparing mastectomy involves removing the cancerous tissue and leaving enough skin to put in what the patient wants — an implant or tissue moved from another area, such as the

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Dr. Angela Soto-Hamlin, breast surgeon, Penn State Health Century Drive Cancer Center, Mechanicsburg.

abdomen,” she said. Reconstruction options include several different types of flaps, including a transverse rectus abdominis (TRAM) flap, which brings fat and muscle, needed for blood flow, from the abdomen to the chest. A drawback is loss of muscle in the abdomen. A deep inferior epigastric perforator (DIEP) flap reconstruction is a microsurgery technique that isolates the blood supply to the fat being brought up from the abdomen or buttock, which is then sewn into the blood supply under the breast bone or under the arm, Soto-Hamlin explained. For women who choose an implant, they and their team must decide whether it should be inserted above or below the chest muscle, and either option has pros and cons that must be weighed. A nipple-sparing mastectomy, possible when there is a cancer-free margin around the nipple, leaves the nipple and areola intact, along with the breast skin, while removing all the breast tissue underneath. An implant or tissue from another part of the body can be inserted under the skin. “Nipple-sparing mastectomies are a big deal because you get

a much more natural appearance, more like a natural cone shape than a mound,” Soto-Hamlin said. If the nipples can’t be spared, alternatives include a reconstructed nipple using skin or tissue taken from the inner thigh, or a nipple tattoo that looks three-dimensional, thanks to shading within the pigment of the ink. A Brighter Future Whatever reconstruction option a woman chooses, she is looking at months before the new breast is complete. However, she has more years to look forward to than women fighting breast cancer ever have, according to Soto-Hamlin. “Women here are very fortunate to live in an area where all these options are available,” she said. “Because we don’t want to just live — we want to thrive.” To find out more about Penn State Health’s comprehensive approach to breast care, from preventive screening to advanced diagnosis and treatment of breast cancer and other breast conditions, visit pennstatehealth.org/services-treatments/breastcare. Breast Cancer Awareness Month | 13

What Are the Risk Factors for Breast Cancer?

tudies have shown that your risk for breast cancer is due to a combination of factors. The main factors that influence your risk include being a woman and getting older. Most breast cancers are found in women who are 50 years old or older. Some women will get breast cancer even without any other risk factors that they know of. Having a risk factor does not mean you will get the disease, and not all risk factors have the same effect. Most women have some risk factors, but most women do not get breast cancer. If you have breast cancer risk factors, talk with your doctor about ways you can lower your risk and about screening for breast cancer. Risk Factors You Cannot Change • Getting older. The risk for breast cancer increases with age. Most breast cancers are diagnosed after age 50. • Genetic mutations. Women who have inherited changes (mutations) to certain genes, such as BRCA1 and BRCA2, are at higher risk of breast and ovarian cancer. • Reproductive history. Starting menstrual periods before age 12 and starting menopause after age 55 expose women to hormones longer, raising their risk of getting breast cancer. • Having dense breasts. Dense breasts have more connective tissue than fatty tissue, which can sometimes make it hard to see tumors on a mammogram. Women with dense breasts are more likely to get breast cancer. • Personal history of breast cancer or certain noncancerous breast diseases. Women who have had breast cancer are more likely to get breast cancer a second time. Some noncancerous breast diseases, such as atypical hyperplasia or lobular carcinoma in situ, are associated with a higher risk of getting breast cancer. • Family history of breast or ovarian cancer. A woman’s risk for breast cancer is higher if she has a mother, sister or daughter (first-degree relative) or multiple family members on either her mother’s or father’s side of the family who have had breast or ovarian cancer. Having a first-degree male relative with breast cancer also raises a woman’s risk. • Previous treatment using radiation therapy. Women who had radiation therapy to the chest or breasts (for instance, treatment of Hodgkin’s lymphoma) before age 30 have a higher risk of getting breast cancer later in life. • E xposure to the drug diethylstilbestrol (DES). DES was given to some pregnant women in the United States between 1940 and 1971 to prevent miscarriage. Women who took DES, or whose mothers took DES while pregnant with them, have a higher risk of getting breast cancer.

14 | Breast Cancer Awareness Month

Risk Factors You Can Change • Not being physically active. Women who are not physically active have a higher risk of getting breast cancer. • Being overweight or having obesity after menopause. Older women who are overweight or have obesity have a higher risk of getting breast cancer than those at a normal weight. • Taking hormones. Some forms of hormone replacement therapy (those that include both estrogen and progesterone) taken during menopause can raise the risk for breast cancer when taken for more than five years. Certain oral contraceptives (birth control pills) also have been found to raise breast cancer risk. • Reproductive history. Having the first pregnancy after age 30, not breastfeeding and never having a full-term pregnancy can raise breast cancer risk. • Drinking alcohol. Studies show that a woman’s risk for breast cancer increases with the more alcohol she drinks. • Research suggests that other factors such as smoking, being exposed to chemicals that can cause cancer and changes in other hormones due to night shift work also may increase breast cancer risk. Who Is at High Risk for Breast Cancer? If you have a strong family history of breast cancer or inherited changes in your BRCA1 or BRCA2 genes, you may have a high risk of getting breast cancer. You may also have a high risk for ovarian cancer. Talk to your doctor about ways to reduce your risk, such as medicines that block or decrease estrogen in your body, or surgery. Source: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

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