Sisters Face Cancer TogetherMultiple risk factors, age at treatment make for complex histories.
Some sisters share everything. For sisters Amanda Nuñez, 32, of Fox Point, and Liz Oke, 36, of Brown Deer, that has also meant facing two kinds of cancers.
Looking for treatment options, they came to Froedtert & The Medical College of Wisconsin, where they found personalized, comprehensive care for their complicated medical challenges.
It started in 1996 when Liz was 20. She was diagnosed with Hodgkin’s disease, a cancer of the lymphatic system that is also known as Hodgkin’s lymphoma. She was treated at a different hospital with “mantle” radiation, which covered the area from the neck to about the middle of the chest. Standard treatment at the time, the radiation was curative, but also increased Liz’s risk of developing other cancers, including breast cancer.
Four years later, in 2000, Amanda was also diagnosed with Hodgkin’s lymphoma at age 20. She was treated with chemotherapy and mantle radiation. Although Amanda received less radiation than Liz, her breast cancer risk increased, too.
More Precise Treatments and Monitoring Help Control RiskTreatment for Hodgkin’s lymphoma used to involve a significant amount of radiation, according to Timothy Fenske, MD, MS, Medical College of Wisconsin medical oncologist who specializes in the disease. Now, radiation treatment for Hodgkin’s is much more precise. For some patients, Dr. Fenske said, doctors try to avoid radiation completely if appropriate.
“Once patients are done with Hodgkin’s treatment, there are several factors we continue to watch for,” he said. ”We monitor risk for cancer, plus possible cardiac, pulmonary and thyroid complications. Women treated for Hodgkin’s when they are younger than 21 are in a higher risk group.”
“In general, young patients may not regularly see doctors,” Dr. Fenske added. “But it’s particularly important for them to stay in touch long-term with a physician who knows their treatment history and is tuned into the risks.”
Team Care, Breast Cancer Treatment OptionsLife after Hodgkin’s lymphoma went on for both sisters. Liz, who met her husband just before she was diagnosed with Hodgkin’s, married in 2003. Later that year came a breast cancer diagnosis. She knew she was at higher risk, but she didn’t expect it so soon. She was only 27.
Two doctors she saw recommended a mastectomy, but she wasn’t ready for that.
“Froedtert was my third opinion,” Liz explained. “After evaluating me, the doctors were willing to do chemo and radiation to an area that had already been irradiated.”
Liz saw Alonzo Walker, MD, Medical College of Wisconsin breast surgeon and director of the Froedtert & The Medical College of Wisconsin Breast Cancer Program. Liz’s team also included Mary Beth Gonyo, MD, Medical College of Wisconsin radiologist, John Hijjawi, MD, and John LoGiudice, MD, Medical College of Wisconsin plastic surgeons, and a medical oncologist, among other specialists.
“We have a comprehensive center,” Dr. Walker explained. “All of the practitioners involved in the care of those with breast diseases are available here. That includes the plastic surgeons, genetic counselors, nurses, nurse practitioners, psychologists, radiologists, medical oncologists, radiation oncologists and surgeons. And we meet and communicate with each other on a regular basis.”
Liz appreciated the team approach. “It’s not just one doctor making the decisions,” she said. She underwent radiation, chemotherapy and lumpectomy to treat her breast cancer, all taking into consideration her previous Hodgkin’s treatment.
As a result of Liz’s diagnosis, Amanda also began having regular mammograms and breast MRIs, and was seen regularly by Dr. Fenske at Froedtert & The Medical College. Although it was encouraged by their physicians, Liz and Amanda decided against having genetic testing.
Facing Breast Cancer AgainFive more years passed with regular screenings and checkups for both sisters, and in 2008, Liz had her first baby. When her daughter was five months old, Liz felt another lump.
“It was a new primary tumor, rather than a recurrence, which meant the treatment in 2003 had worked,” Liz recalled. That meant radiation and chemotherapy could still be an option to treat her second breast cancer. “My doctors always gave me options and the opportunity to decide for myself how I wanted things to go, which I think is important,” Liz said. This time, she made some difficult choices.
Genetic Risk for Breast CancerNow, Liz was ready to proceed with genetic testing, which confirmed she carried the BRCA1 gene, a genetic mutation associated with a higher risk of breast and ovarian cancer.
Knowing her elevated risks and having a baby at home, Liz chose to have a double mastectomy to prevent further breast cancers.
“I just couldn’t see going through six weeks of radiation with a baby,” Liz said. Her decision was made understanding all of her options, including choices about breast reconstruction.
Two surgeons worked together during one procedure, with Dr. Walker performing the double (bilateral) mastectomy, and Drs. Hijjawi and LoGiudice preparing Liz for later breast reconstruction. Liz also had chemotherapy with Medical College of Wisconsin medical oncologist John Charlson, MD, after surgery to minimize the chance of recurrence.
Having so many resources and treatment options helped Liz again when it came time to make a decision about breast reconstruction. Because she had sustained some changes to the skin on her chest due to previous radiation treatments, she opted to have DIEP flap breast reconstruction rather than implants. DIEP flap is an advanced microsurgical procedure that uses the patient’s own abdominal tissue without sacrificing abdominal muscle to construct new breasts. This choice would prove vital later on when Liz wanted to have another baby. Drs. Hijjawi and LoGiudice worked together to perform Liz’ bilateral DIEP flap reconstruction.
History RepeatsAll was quiet for about two years. Then in 2010, Amanda, was diagnosed with breast cancer.
She had been alternating having mammograms and breast MRIs every six months, in addition to other checkups.
“They found a really small area on my MRI,” Amanda recalled. “Rather than wait for the next MRI, Dr. Gonyo decided to biopsy it, and it was found to be very early stage breast cancer. “I feel like Dr. Gonyo’s decision to biopsy saved me from going through chemo again.”
Like Liz, Amanda decided to follow through with genetic testing, and found that she also carries the BRCA1 gene.
“It’s important for patients with genetic mutations such as BRCA1 to sit down with a genetic counselor and discuss the implications of being a carrier,” Dr. Charlson said. “Further, it’s vital to understand the risks and treatment options.”
Now it was Amanda’s turn for difficult decisions. She had the same team of specialists as her sister, and had met some of them already. Ultimately, Amanda also chose a double mastectomy to avoid the risk of future breast cancers.
“I got as much as information as I could to make an educated decision,” Amanda said. “I was 31. I didn’t want to have to keep having biopsies and worrying, especially after seeing my sister go through breast cancer twice.”
Dr. Hijjawi and Dr. Walker performed the surgery together, and Amanda had reconstruction with implants earlier this year.
“Having our multidisciplinary team at her disposal allowed Amanda to consider her surgical options carefully,” Dr. Charlson said. “These are complex decisions and patients are always part of the decision-making process.”
Screenings Vital for Young Hodgkin’s SurvivorsThe breast cancer team guided both sisters through a multitude of choices and questions, and knew how to tailor treatments based on multiple risk factors and previous therapies. Unfortunately, some young Hodgkin’s survivors don’t receive ongoing monitoring.
“If these individuals are not closely followed by their primary care physician, they should be referred to a comprehensive breast program to make certain they get mammograms and MRIs with the intent of detecting other possible cancers early,” Dr. Walker said.
Living Well With RiskLiz and Amanda have gone on with their lives, each remaining vigilant about regular check-ups and aware that they will always be at a higher risk of cancer. Liz had another daughter in 2012, but not before another round of tests and questions.
Because her DIEP flap breast reconstruction surgery preserved her abdominal muscles, she was able to deliver her second daughter naturally. “It shows that the advanced surgical options we provide can still allow a woman to have a vaginal delivery, which is probably one of the most stressful functions the abdominal muscles are called on to support,” Dr. Hijjawi said.
Liz worries about her daughters being at higher risk due to the genetic factors, and hopes for a cure by the time her girls grow up.
Amanda got married in fall of 2012.
Together, these sisters have faced physical and emotional challenges and frustrations over the years. Both appreciate the thoughtful care they received, and the dedication of the cancer team at Froedtert & The Medical College of Wisconsin.
“I can’t say enough good things,” Amanda said. “Everyone took their time and let me ask as many questions as I wanted. All of the doctors and the nurses – they’re just awesome.”
Author: Dustin Kehrmeyer
Date: Feb. 8, 2013