Hopeful Updates and a Quick PSA!

Hopeful Updates and a Quick PSA!

Well, about 10 days have passed since my last chemo (still celebrating!), and I thought I’d update everyone on the emotional roller coaster that was the last week. It’s been surprisingly eventful!

I took the past week off to get a few appointments and scans done. I forgot to update on this, but on my last day of chemo last week, my manager at work notified me that we’ll be closing our COVID negative results call center at the end of this week (Nov. 7). It’s not lost on me how lucky I was to be able to have work through this pandemic, especially a safe job that I was able to do from home. I don’t think it’s a coincidence that chemo and that job will be ending at the same time. Time to start thinking about going back to some patient care (eventually)!

On Wednesday, I repeated my mammogram and ultrasound. Mammo was quick & easy but the tech was running behind so didn’t say much about anything she might’ve seen on the images. I’m able to see the ultrasound, however, and it was clear that there continues to be a small mass (6mm – about 1/3 the size of my original tumor) still remaining in my left breast. The poor ultrasound tech probably felt weird with me reading over her shoulder because she called in the radiologist who reminded me that the MRI would give more information. Because the MRI is done with contrast dye, any cancer cells will light up on the image. If no “lights,” then the mass may just be scar tissue.

Thursday morning, I had my MRI, and then in the afternoon I went in to my oncologist’s office for (hopefully) my last Zoladex injection (#SaveTheOvaries). I ran into my oncology APRN there and he printed the impression from my mammo & ultrasound for me and just casually mentioned, “The MRI showed nothing.” I won’t really believe it until I see the words on paper, and don’t worry I’ve been obsessively opening MyChart to see if the results are online. Not yet. Still, not yet. But I’m currently taking his word for it just so I can sleep at night.

Quick PSA: If you have “dense” or “very dense” breasts, a mammogram can be less accurate at detecting tumors or calcifications in the breast. You should talk with your doctor about what other imaging can be done to be sure nothing is ever missed!
I’m going to post pictures below of my mammogram and ultrasound impressions to give you an example.

Otherwise, yesterday was Halloween, and I couldn’t miss a chance to dress up again! (Last year we landed in Japan at midnight on Halloween, and I wasn’t packing a costume with me.) Last night, Justin & I were able to get together for a socially distant dinner with his sister and her boyfriend which was so fun and I’m looking forward to getting to see more friends and family now that I won’t be so immunocompromised. We also got to make a quick pit stop at our friends’ place to see their new baby so all is right in the world ❤

And, as today is November 1, we are celebrating el Dia de los Muertos and reminding you to #FeelItOnTheFirst!! The first of the month is the perfect time for you do your monthly breast/chest self-exam!

Check yoself!

Due to COVID, breast cancer diagnoses are down by 51.8% — NOT because less people are getting cancer, but because they aren’t going in for their appointments! DO NOT DELAY your mammograms and OB/GYN appointments – your doctors and clinics are doing everything they can to keep you safe during this time. It could save your life!
*Remember: Men can get breast cancer, too, so encourage the men in your life to do their screenings!

With Breast Cancer Awareness Month coming to a close, please remember that breast cancer research does not stop needing support at the end of October and cancer survivors do no stop needing support once they’re “cured.” The fear of recurrence and survivorship in general evoke just as many emotions as the diagnosis and treatment. Treat everyone with a little grace and consider donating to cancer research if you have the means. I outlined some great breast cancer organizations in my previous post.

In case you’re following my Instagram page (@bri.d.pt), my sister-in-law Marisa & I had a great conversation about the inevitable thoughts of death/dying after receiving a cancer diagnosis or terminal illness. Check it out! If you’re interested in an intuitive angel card reading with Marisa, you can book one here!

I hope you all have a great week! Please stay healthy and safe, wear your masks, and wash your hands! Going into the holiday season, we want to be able to spend time with family and friends so the safer, the better!

Aloha ❤

Transgender Health & Breast Cancer

Transgender Health & Breast Cancer

As research builds for our transgender community, cancer screenings and preventative health must be encouraged. As hormonal therapy and surgery are often part of transitioning, trans people should be aware of their risk of developing certain cancers including breast cancer, reproductive cancers, or prostate cancer dependent on their individual treatment.

Risk of Breast Cancer in Trans Women

According to a Dutch study from 2019, for a trans female on hormonal therapy, the risk of developing breast cancer is slightly higher than in the cisgender male population, but still lower than the general cisgender female population.1 Just as hormonal replacement therapy has been shown to increase breast cancer risk in a post-menopausal cisgender female population, so it is for trans women.

Another Dutch study from 2013 noted that 60% of trans women whose records were reviewed in the study had dense or very dense breasts which is known to limit effectiveness of mammogram studies and puts someone at increased individual risk for breast cancer in all populations.2

Those with BRCA1/BRCA2 genetic mutations likely also have an increased risk of breast cancer, although more research is needed specifically for the transgender population. If someone has a BRCA mutation or significant family history of breast cancer, they should discuss screening options with their healthcare providers.

Risk of Breast Cancer in Trans Men

For trans men on hormonal therapy, the risk of developing breast cancer is lower than in the cisgender female population. Trans men also may choose to have top surgery which could include a breast reduction or removal of the breasts (bilateral mastectomy). The risk of developing breast cancer after mastectomy in this population is unknown at this time.1,3

Breast Cancer Screenings for the Trans Population

In the United States, some studies show that transgender people are less adherent to mammogram screening guidelines than cisgender people (often due to stigma or limited access to healthcare).4 However, it is important for these screenings to take place regularly as early detection of breast cancer can save lives.

Current guidelines for trans women who are age 50 or older and have been on hormonal therapy >5 years, a mammogram is recommended every 2 years.1

Trans men who have not had bilateral mastectomy or who only had a breast reduction should undergo an annual mammogram after age 40. After age 50, mammograms can be done every 2 years (but can be continued annually dependent on patient risk and preference). For trans men who have had bilateral mastectomy, chest wall examinations are recommended.3

Breast/Chest self-exams are recommended monthly for both transgender and cisgender populations to pick up early signs of cancer! To learn more about how to do a self-exam, see my previous post here.

Aloha ❤

Frozen Shoulder & Capsulitis after Breast Cancer Surgery

Frozen Shoulder & Capsulitis after Breast Cancer Surgery

Staying on topic with complications after breast cancer surgery. The two I’ll discuss today are common and can be disruptive to daily life. You’ve probably heard of frozen shoulder (adhesive capsulitis), but you may not have heard about breast capsulitis after breast reconstruction. Let’s dive in a little deeper.

What is capsulitis?

Capsulitis is inflammation of a joint capsule or the capsule around a breast implant that can lead to scar tissue adhesions and stiffening or immobilization of the joint or breast capsule. Uncomfortable – yes. Functionally limiting? Also, yes.

Frozen shoulder

While frozen shoulder (adhesive capsulitis) can occur after any shoulder injury, it can occasionally occur without any injury, and is more common in females and in people with diabetes mellitus or hypothyroidism. Frozen shoulder typically presents as a significant loss of motion in the shoulder with or without pain. To read a bit more about frozen shoulder, click here.

After breast cancer surgery, frozen shoulder is also common. For women aged 50-59, women who had mastectomy, or women who had breast reconstruction, the risk of developing frozen shoulder on the affected side is approximately 10%.1

Functionally, frozen shoulder leads to difficulty getting dressed, showering, combing your hair, lifting and carrying objects, driving, sleeping, and a whole lot of things we do on a daily basis.

Physical therapists treat frozen shoulder using manual therapy like joint mobilizations, teaching passive stretches and gradually strengthening around the joint as motion improves, and educating patients on healing timeline and ways to modify daily activities to improve use of the arm and reduce pain.

Rehab for frozen shoulder can sometimes take close to a year before a person feels “back to normal.” If caught early enough (i.e. during the “freezing phase” when motion loss begins to occur), a steroid injection can help to minimize the symptoms and restrictions. See your doctor right away if you notice a major loss in joint motion after breast cancer surgery.

Post-reconstruction capsulitis

Post-reconstruction capsulitis or capsular contracture can occur when fibrotic changes occur in the tissue capsule that forms around new breast impants. The breast around the new implant hardens, can become painful, and the breast shape can become distorted. To read a bit more about capsular contracture, click here.

Risk for developing capsular contracture is higher after radiation therapy or following infection, hematoma, or seroma that develops around a new implant. It is not clear whether smooth versus textured implants play a role in development of capsulitis.

Typically, if capsulitis occurs and is painful, distorts the breast shape or an underlying infection is present, revision surgery is needed. In Australia, approximately 39% of revision surgeries each year are due to capsular contracture.2 With early stage contracture, a physical therapist can use manual therapy to try to restore motion and prevent further fibrosis of the breast. A PT will also be sure to address shoulder, neck, and chest wall motion which could be compromised with post-implant capsulitis.

For both frozen shoulder and post-reconstruction capsulitis, getting into see a physical therapist early is important to prevent loss of motion and to reduce pain. Ideally, PT’s would love to see breast cancer patients within 4-6 weeks after breast surgery or reconstruction. Developing a relationship with a physical therapist during and after breast cancer can be a great asset to your health and wellness beyond cancer. Ask your surgeon for a referral or find a PT in your area here.

Aloha ❤

The Final Round

The Final Round

Celebrating with tears of joy today after finishing my last chemo yesterday. 16 rounds over 20 weeks. Conquering the Red Devil and getting through taxol without neuropathy are major victories, and I’m feeling so relieved to be DONE! I could not have done it without all of your support.

There’s still more treatment ahead, but I’m feeling I can manage anything now that chemo is behind me. I am so grateful to God and for all of the love of my family and friends and this great little breast cancer community I’ve found on Instagram that have gotten me through the past 5 months.

Last infusion day!

I will still receive two GCSF injections to boost my white blood cells this week as my oncologist doesn’t want me too immunocompromised in this COVID life we’re all living in. Then, I’ll re-test my labs in two weeks including a thyroid panel and vitamin D screen that I asked for. My oncologist has been really great about letting me lead my care to some extent and not just telling me what we’re going to do each week. Honestly, I wish every doctor were like that. I am so grateful for her and my whole team of docs who’ve listened to my concerns and took action immediately throughout this whole process.

Next week, I am scheduled to repeat my breast ultrasound, mammogram, and MRI to see where I’m at post-chemo. I am still unable to feel the tumor, but that doesn’t mean I don’t still have a bit of “scanxiety” about the slight possibility that there’s still something there or that the tumor will grow again being off chemo for several weeks before surgery. Please send prayers for good results!

No more ice booties & mittens! Bye taxol. Not gonna miss you.

I’ll meet with my surgeon on November 9, and will hopefully be able to get in for surgery before Thanksgiving. I’m still leaning toward breast-conserving surgery (a lumpectomy) which means I’ll do radiation for several weeks after recovering from surgery. I’ve done a lot of research on different types of surgeries and, besides my intuition telling me not to go for the more aggressive approaches, the research actually backs me up on that decision. For women with similar early-stage cancer to mine, the 5-year survival rate is 94.3% for breast-conserving surgery, 93.3% for mastectomy alone, and 83.7% for mastectomy with radiation.1

I am also biased in that I know that recovery from a mastectomy is really challenging and the complications can be much greater. To have further breast reconstruction on top of that would take multiple surgeries, and honestly, I’m just ready to move on from cancer in so many ways. I know it will always be a part of me, but treatment can end sooner than later if I go this route!

Celebrating with a little lemon crunch cake from Diamond Head Market – heaven! Cute hair, huh?

For now, I’m going to rest and celebrate being done with the hardest part of this little bump in the road. My mom will finally be down to visit in a few weeks and I’m looking forward to that! I wrote down a few things I want to remember from this experience so far and I’ll share a few of them with you here:

  • Faith in God is all you need to conquer anything.
  • The people you love are the most important thing in your life – tell them you love them often and mean it.
  • Find the immense joy in your daily life – there’s no need to search far and wide for it.
  • Spend time in nature – in quiet, being active, barefoot if you can.
  • Know and trust your body. Know that it’s strong and demands to be respected and understood.

Learning you have breast cancer at age 30 isn’t in anyone’s plans for life, and being diagnosed with one of the most aggressive forms of breast cancer doesn’t make it any easier. I want to remind you all that if you think something is off with your body, get it checked out. Don’t take no for an answer from your doctor. You’re not “too young.” You’re not overreacting. YOU are the only one that knows your body well enough to decide if something is off.

I love you all. Thank you for being with me on this ride.

Aloha ❤

Lymphedema after Breast Cancer Surgery

Lymphedema after Breast Cancer Surgery

Lymphedema, a type of swelling in the arm, is an unfortunate complication after breast cancer surgery. I hope this blog will give you a better understanding of the lymphatic system and how to recognize early signs of lymphedema if you’ve recently had or are about to have breast cancer surgery.
*Technically, lymphedema can occur in any limb after lymph nodes are removed, but to keep it simple, I’ll focus on upper extremity lymphedema today.

Overview of Lymphatic System

The lymphatic system is a network of nodes, vessels and organs that function as the body’s immune system. Lymphatic fluid (or lymph) is a protein-rich fluid which contains white blood cells. Lymph carries bacteria and viruses to be filtered through the lymph nodes and helps to prevent infection in the body.

Unlike blood, which is circulated around the body, lymph only flows one way (toward the heart) and requires a pressure gradient and muscular contractions to flow efficiently.

Anatomy of the Lymphatic System
Photo borrowed from Merck Manual1

Lymphatic Disruption after Breast Surgery

From my last post, you know that surgery for breast cancer usually involves removal of the tumor itself as well as removal of lymph nodes in the axilla (underarm). Lymph node removal is done because cancer cells can break off and travel through the lymphatic system and those nodes in the axilla are usually the first place they go.

To be sure the correct nodes are examined, the surgeon uses a radioactive dye to determine which nodes drain directly from the tumor site. Procedures to remove lymph nodes can range from removal of only a few nodes in a sentinel lymph node biopsy to many nodes (up to 20 nodes) in an axillary dissection.

With any amount of nodes removed (but especially with >5 nodes removed), there can be disruption to lymphatic flow through the axilla. In some cases, the lymph is unable to drain from the arm, resulting in lymphedema.

Lymphedema presents as a “swollen” arm, but this is not your usual swelling for two reasons. One, because lymphatic flow is a one-way street, the extra fluid needs to be physically cleared in some way (more on this in a minute…) and, two, because lymph is full of protein and fats that won’t drain into the venous system the way typical swelling does. The limb can actually grow and harden if left untreated.

Stages of Lymphedema – Photo borrowed from Sigvaris2

Studies show that lymphedema occurs in 0-3% of people who choose lumpectomy and up to 65-70% of those who have a modified radical mastectomy.3 Radiation therapy also seems to increase the risk of lymphedema. While many people will develop symptoms in the first 3 years after surgery, lymphedema can take up to 5 years to develop after cancer treatments. Be sure to ask your doctor or physical therapist what your risk for developing lymphedema is and learn about risk reduction practices.

Signs & Symptoms of Lymphedema

  • Swelling in the arm (usually only on side of surgery)
  • Heaviness/tightness of the arm
  • Reduced range of motion of the joints in the affected arm
  • Thickening/hardening of the skin

Physical Therapy Treatment for Lymphedema

A trained lymphedema physical therapist can be an incredible asset to someone who develops lymphedema. Ideally, a physical therapist will be able to work with a patient pre- and post-operatively to monitor girth measurements of the limb and identify lymphedema early on. Stage I lymphedema is potentially reversible, and both stage II and III can demonstrate significant reduction, so seeing a PT sooner than later is key in managing this condition!

With development of lymphedema, a physical therapist can perform or recommend the following interventions:

  • Bandaging of the limb or prescription of compression garments
  • Manual Lymphatic Drainage (specialized lymphatic massage)
  • Exercise prescription (progressive muscle pump, aerobic activity)
  • Patient education on proper skin care and prevention of infection

It’s important to see your doctor or physical therapist as soon as possible if you notice signs/symptoms of lymphedema. Here is a great resource to find a lymphedema specialist in your area. As always, feel free to reach out to me with any questions!

Aloha ❤

Big thanks to Joanne Zazzera, PT, DPT, WCS, for sharing her knowledge and editing this blog!

Physical Therapy after Breast Cancer Surgery

Physical Therapy after Breast Cancer Surgery

Ever since Angelina Jolie publicly addressed her preventative bilateral mastectomy in 2013, many women have the idea that removing both breasts is typical care for breast cancer. While a bilateral mastectomy is still a popular option (both to prevent recurrence and to reduce anxiety about recurrence), there are actually many options for women with breast cancer to consider.

Breast Surgery Overview

The goals of surgery are to remove as much of the cancer as possible and also to examine the lymph nodes nearby to determine how much the cancer has spread locally. Thus, a breast cancer surgery often includes one incision on the chest where the cancer is removed and one in the underarm where the lymph nodes are removed for biopsy. There are also options for breast reconstruction (which is usually multiple surgeries), should someone desire it for cosmetic purposes.

  • Options for breast surgery include:
    • Breast-conserving surgery or BCS (lumpectomy, partial mastectomy, etc.) – removal of part of the breast which contains cancer and a margin of normal cells surrounding the tumor.
    • Mastectomy
      • Simple – removal of all breast tissue including nipple and areola (and usually some skin, but it is possible to have skin- and/or nipple-sparing procedures).
      • Modified radical – removal of all breast tissue along with all lymph nodes under the arm.
      • Radical – removal of all breast tissue and the chest wall muscle (this surgery is rarely done unless the cancer has spread into the chest wall).
  • Types of lymph node removal include:
    • Sentinel lymph nose biopsy (SLNB) – removal of the lymph node(s) to which the cancer would likely spread first
    • Axillary lymph node dissection (ALND) – removal of many (usually less than 20) lymph nodes from under the arm
  • Optional breast reconstruction can include:
    • Implants
    • Autografts – tissue from another part of the body is used to recreate the breast (Reconstruction options are a whole post in itself!)

Many breast surgeons now push for breast conserving surgery (BCS) because having a more aggressive surgery doesn’t always result in better quality of life or reduce cancer survival rates significantly. In fact, having BCS in combination with radiation therapy has been proven to be equally, if not more, effective at improving survival rates than a mastectomy alone.1, 2 This information is especially important for those with triple negative breast cancer who do no have the option of hormonal therapy.

Of course, cancer stage (how large the tumor is and whether the cancer has spread) and grade (how quickly the cancer is growing) both influence the type of surgery and treatment someone may need. Discuss with your oncologist and surgeon which option is the best for you in your recovery.

Physical Therapy

No matter the type of surgery a person chooses for breast cancer treatment, a physical therapist is an integral part of post-surgical recovery. PTs help to maximize the body’s natural healing process, restore range of motion to the shoulder, neck and chest wall after surgery, perform scar mobilization and soft tissue work to the affected muscles, and (most importantly) help people to return to their usual activities!

Some post-op considerations for physical therapy after breast cancer include care of post-surgical drains, observance of proper wound care at the incision site, monitoring for signs of infection, and protecting sensitive skin with post-operative radiation. While all PTs are able to treat a patient post-surgically, there are oncology physical therapists who have more training to look for other complications, especially early signs of lymphedema and cording (stay tuned for my next post).

If you or a loved one are interested in trying physical therapy after breast cancer, ask your doctor for a referral. Most oncologists and breast surgeons work closely with physical therapists and they can send you to a PT they trust in your area. If you want to do some research on physical therapists who are familiar with breast cancer rehabilitation in your area, you can use the APTA PT Locator or search through the APTA Academy of Pelvic Health.

Hope this information is helpful – go schedule with your PT today!

Aloha ❤

Cancer, Sex, & Intimacy

Cancer, Sex, & Intimacy

Cancer isn’t pretty. Besides generally feeling unwell, the hair loss, body composition changes, aches and pains, and hormonal fluctuations are not exactly sexy. Having cancer (or loving someone who does) can certainly challenge intimate relationships. It’s important for cancer warriors to know this isn’t unusual and there are plenty of ways to maintain healthy relationships with their partners ❤

Some cancer- or treatment-related challenges that may affect someone’s sexual function, sexuality, or intimacy with their partner can include:

  • Chemo side effects including fatigue, nausea/vomiting, weight loss/gain, or infertility concerns (etc, etc, etc….)
  • Post-surgical or post-radiation considerations like:
    • pain or restrictions from scar tissue or irradiated tissues (especially with cancer of the reproductive organs)
    • decreased sensation around the nipples after mastectomy
    • urinary incontinence or erectile dysfunction post-prostatectomy
  • New medications that reduce desire or arousal
  • Hormonal changes resulting in low libido, vaginal dryness, or painful sex
  • Body image concerns including attractiveness to self or partner
  • Depression, anxiety, or PTSD surrounding a cancer diagnosis and treatment

There are many ways that pelvic floor physical therapists (PFPTs) can help support both men and women during and after cancer in this realm. PFPTs can treat the physical changes that come with cancer including post-surgical rehab or prescribe general strength/aerobic training. We can treat incontinence after surgery or radiation. We can recommend sexual positions or devices to reduce or eliminate pain with sex. And sometimes, we help our patients find new ways to connect with their partners when they’re not ready to be sexually intimate yet.

Often, seeing a licensed counselor or psychologist for individual and/or couples therapy can be very helpful to maintain or restore intimacy. Remember, cancer is not pretty, and there is no shame in asking for help! If you’re having concerns or challenges in your relationship, please reach out to me to see if pelvic floor PT or a referral to a mental health professional might be right for you.

Aloha ❤

*This blog is part 3 of Pink October’s Pelvic Floor Series, a way to raise awareness of pelvic floor problems during cancer treatment and discuss sex & intimacy after a cancer diagnosis.

Pink October

Pink October

Today is October 1, and there are so many things to celebrate this month! Before I get carried away – I want to remind you all that the first of the month is a great time to schedule or do your preventative screenings including your breast self-exam! Performance of routine self-exams help to identify cancerous tumors in earlier stages and can save your life! Go ahead and #FeelItOnTheFirst, and if you haven’t yet, schedule your annual mammogram!

Fun fact: 40% of all breast cancers are discovered by a self-exam!1

October has always been one of my favorite months for many reasons, but as a pelvic floor PT, I am thrilled that I get to celebrate National Physical Therapy Month and Breast Cancer Awareness month in one shot! I consider myself an “educator” by nature, and I always look forward to sharing information with my family and friends about the benefits of physical therapy, especially for our breast cancer thrivers and survivors.

I have several posts lined up for the next few weeks regarding breast cancer surgery, rehabilitation, and complications as well as some common pelvic floor concerns during breast cancer treatment. I look forward to sharing how a physical therapist can play an important role for our oncology patients as I experience my first Breast Cancer Awareness Month as someone living through breast cancer.

I also wanted to bring some awareness to something I hadn’t really given any thought to before I was diagnosed with breast cancer. It’s no secret that every October, things turn pink all over the place. I’m talking pink products in stores, pink foods, pink cleats in the NFL…you catch the drift. Companies all over the place are eager to jump on board with Breast Cancer Awareness Month, and yet, not all of these companies have the best intentions in mind.

In fact, many companies profit tremendously by slapping a pink label on their product and saying that a certain amount of proceeds go to breast cancer research. We call this “pinkwashing,” and as it turns out, many companies are capitalizing on this terrible disease and only donate a small portion of their sales (or none at all) to support breast cancer research or patients.

Unfortunate as it is, I ask that if you do want to support those who are or who will be affected by breast cancer (remember 1 in 8 women will be diagnosed with breast cancer in their lifetime), please do your research on which companies provide support to breast cancer research or directly to breast cancer patients before you buy that pink label.

Let’s turn Awareness into Action! Here are a few of my favorite breast cancer organizations to support:

  • Breast Cancer Research Foundation – your donation goes to sponsor research grants in many areas related to breast cancer. BCRF is recognized by Charity Watch as a top-rated cancer fundraising organization.
  • TNBC Foundation – your donation will go to improving research and quality of life and education for those living with Triple Negative Breast Cancer. I personally have benefited tremendously from the community associated with the TNBC Foundation and the educational events this foundation hosts!
  • METAvivor – your donation will go to improving research for those living with stage IV metastatic breast cancer.
  • Compassion that Compels – if you’re looking to donate to a smaller organization that provides direct support to cancer thrivers – this is a great one! Your donation will go to providing emotional support, chemo care packages, and prayer to women with breast cancer. I loved receiving a Compassion Bag from this lovely organization!

I hope you are as excited about the possibilities in October as I am! I am also on track to complete chemotherapy at the end of the month (actually, I completed #13/16 TODAY) so it’s going to be a party for sure! Take care of yourselves and I look forward to sharing a TON of good info with you this month!

Aloha ❤