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What You Need to Know About Breast Cancer

Words by Maggie Downs

October is Breast Cancer Awareness Month, a time to highlight the importance of early detection and education in the fight against the disease. To provide valuable insights, DAP Health Director of OB-GYN Services Dr. Rhett Papa answered key questions about breast cancer, including stages, treatments, and risk factors.

What are some early signs and symptoms of breast cancer?

Most breast cancers are detected through routine screenings, so there aren’t typically noticeable symptoms for patients to monitor at home. That’s why annual gynecologic care is so important. It’s rare for a patient to discover a significant lump that wasn’t already found during a physical exam, and only about 5% experience breast pain.

How can breast cancer be detected early, and what screening methods are recommended?

There is a growing push for easier access to breast cancer screening. In California, for example, patients can now request an annual screening mammogram without needing a doctor’s referral. While there’s some debate about the ideal age to begin screening, I recommend starting at age 40 for women without a family history of breast cancer. However, if you have a first-degree relative (such as a mother or sister) who had breast cancer, it’s advised to start screening 10 years before the age at which they were diagnosed. For instance, if your mother was diagnosed at 45, you should begin screenings at 35.

What are the main risk factors for developing breast cancer?

Contrary to public belief, only about 5 to 10% of patients who are diagnosed with breast cancer have any family history, so lifestyle is a significant area of focus. Some risk factors are obesity, early age of onset of your menstrual cycle (before age 12), a late entry into menopause after the age of 55. All seem to be focused around your body’s production of estrogen. Excessive alcohol consumption can also increase your risk.

What lifestyle changes can reduce the risk of breast cancer?

Maintaining a healthy weight is important. Practicing regular exercise. Eating a healthy diet. There’s some suggestion that a lot of the inflammatory foods and additives we have in our diets could support the development of cells growing abnormally. Breastfeeding, as long as a mother feels that she can, is helpful.

If there is a family history, should a patient consider genetic testing?

I don’t discourage my patients from ever seeking genetic testing. It may be a little bit costly if your insurance doesn’t feel like your family risk is high enough. But yes, certainly everyone who wants to know their risk shouldn’t be discouraged from seeking genetic testing.

What are the different stages of breast cancer?

Breast cancer is categorized into four stages, but fortunately, most cases are now detected early — in stages one and two.

Stage one is the earliest stage, where the tumor is small (usually less than 2 centimeters) and may or may not have spread to nearby lymph nodes. The cancer is localized, making treatment options like surgery (lumpectomy or mastectomy) and radiation typically effective.

Stage two breast cancer involves a larger tumor (2 to 5 centimeters) or has spread to nearby lymph nodes. While it is still considered early-stage, the involvement of lymph nodes may require more comprehensive treatment.

In stage three, the cancer is considered more advanced. It typically involves larger tumors and a higher number of affected lymph nodes. This stage often requires more aggressive treatment.

In stage four, the cancer has metastasized, meaning it has spread to other parts of the body. Treatment at this stage focuses on controlling the disease and improving quality of life, often involving systemic therapies like chemotherapy, hormone therapy, or targeted treatments.

What treatment options are available?

Treatment varies depending on the stage and type of cancer, but common approaches include surgery, radiation, chemotherapy, hormone therapy, and targeted therapies. Surgery is often used to physically eliminate the cancer. Radiation therapy uses high-energy rays to kill remaining cancer cells in the breast or surrounding areas. Chemotherapy involves drugs that target and destroy cancer cells throughout the body, while hormone therapy blocks hormones that fuel certain breast cancers. Targeted therapies focus on specific cancer cell characteristics, like proteins that help the cancer grow. In many cases, a combination of these treatments is used to maximize effectiveness.

How can breast cancer treatments like chemotherapy or radiation affect long-term health beyond cancer itself?

Breast cancer treatments such as chemotherapy and radiation can have lasting effects beyond the cancer itself. Many patients experience mental health challenges — including anxiety and depression — following a diagnosis and treatment. Physically, overall vitality may decrease, with fatigue being a common issue. Cognitive function, often referred to as chemo brain, can also be impacted, leading to challenges with memory and concentration.

How does breast cancer affect fertility, and what options are available for women who want to have children after treatment?

Chemotherapy is quite toxic to the ovaries, and so if a patient is not done with childbearing and has an evaluation prior to the initiation of radiation or chemotherapy, we can evaluate her future fertility possibilities. Women may choose to freeze their eggs (egg cryopreservation) or embryos (embryo cryopreservation) for future use. Another option is ovarian tissue preservation, where a portion of ovarian tissue is removed and frozen for reimplantation later. In some cases, medications like gonadotropin-releasing hormone agonists can be used to protect the ovaries.

Can men get breast cancer, and what are the signs and risk factors for male breast cancer?

Yes, men can get breast cancer. Men should be aware of any changes in their breast tissue, similar to how they might check for testicular cancer. Key signs include feeling for lumps or nodules, especially under the nipple, as well as changes in texture, fullness, or appearance. Men with a strong family history of breast cancer should discuss screening options, such as an ultrasound or mammogram, with their doctor. Early detection is important for everyone, but currently the risk of breast cancer for a man is about 100 times lower than for a woman.

From October 3 to December 19, DAP Health is offering free mobile health screening mammograms at various locations on various dates. Please click here for more information, and to register.

My Breast Cancer Story 

Words by Elizabeth Peterson 

In 2021, at 33 years old and just two weeks before my wedding, I noticed a small mass on the right side of my chest as I was preparing for bed. Concerned, I scheduled an appointment with my nurse practitioner Tiffany Kaufman in Murrieta. I had only seen her once before, as my fiancé George and I had recently relocated to Southern California. 

With no family history of breast cancer and testing negative for the BRCA gene, I believed I was too young to worry. At 33, most women are still seven years away from when breast cancer screenings become more routine. However, because my nurse practitioner had a close friend diagnosed with the disease in her early 30s, she insisted I get a diagnostic mammogram. 

The following week, I went in for the mammogram, and also received an ultrasound, though some health care providers were hesitant. They thought it unnecessary, given my age, and assumed I was fine. I was preparing for my wedding with gym workouts that were more vigorous than usual. Maybe it was just a pulled muscle. 

After the tests, I was encouraged to go enjoy my nuptials in Scotland. And I did, completely unaware of what was to come.  

While overseas, I had little access to voicemail. Upon returning home, I found seven urgent messages from my nurse practitioner’s office. The news was grim. The mammogram revealed a three-inch lesion beneath my right breast, stretching to my armpit. 

Over the next four months, I underwent numerous tests and procedures, preparing for a mastectomy of my right breast, followed by reconstructive surgery. Because of my age and the nature of my cancer, I was placed on a 10-year treatment plan that induced menopause to prevent the hormones that fueled my cancer from recurring. 

When having children was discussed, the possibility was daunting. It was technically possible but would involve delivering prematurely by cesarean section, followed by chemotherapy to prevent pregnancy hormones from fueling more cancer growth. In the end, George and I chose adoption, and today we have a beautiful 18-month-old daughter named Grace. 

A few months later, I had mammoplasty on my left breast to restore symmetry. Today, I am cancer-free, though I continue monthly exams to monitor my health. Naturally, I hope that the cancer never returns. 

I share my story in the hopes of helping others. When I first opened up about my diagnosis at my previous job, one of my closest colleagues revealed she had been through the same experience, becoming an immense source of support during my initial treatment. Now, I want to offer that same support to anyone at DAP Health who may be facing a similar journey. 

I also urge all health care providers to be vigilant, to trust their instincts, and to take seriously any young woman who suspects something may be wrong with her breasts. My nurse practitioner’s vigilance — rooted in her own personal experience — made all the difference in my early diagnosis. Without her, my story could have had a very different ending. 

Please Mind Your Prostate Health

Words by Daniel Hirsch

For those of a certain age, prostate cancer is an unfortunate commonality. According to the American Cancer Society, one in eight people born with a prostate will be diagnosed with the disease in their lifetime. But like all things connected to sexual health, open discussion of the prostate does not always stack up to its importance and potential vulnerability to cancerous growth.

To shed light on the walnut-sized gland responsible for the production of seminal fluid, I spoke with DAP Health Co-Directors of Adult Medicine Dr. Frederick Afari and Dr. Damoun Rezai.

Because prostate cancer is so common, many people think it’s no big deal. Is that a misconception?

Dr. Afari: There was once this concept: you die with prostate cancer, not from prostate cancer. But there are aggressive forms. So, getting diagnosed early and getting it managed is the best option for everybody who has a prostate — especially after age 50.

Dr. Rezai: Untreated, it’s highly likely it will continue to develop, potentially spreading throughout the whole body.

How do you know if you have prostate cancer? How is it diagnosed?

Dr. Afari: Some patients come in with pain in the pelvic area. Sometimes it feels like a low back pain. It can cause a blockage or an obstruction of the urethra, so some patients can come in with trouble urinating.

If the patient is routinely visiting a provider, especially after age 50, most providers will screen for prostate cancer. We are either doing a blood test for a prostate specific antigen (PSA) and/or doing a digital rectal exam to push on the prostate and see if there are irregularities. And if there are, that usually triggers further workup and evaluation.

How does a PSA test work?  

Dr. Afari: The test measures the levels of an enzyme that comes out of the prostate — the prostate specific antigen. On average, there is a certain range (or score) of this protein produced.

Dr. Rezai: Normal PSA is generally below 4. Once you hit 4.5, 5, or 6, we must find out why. There are many things that can cause it to elevate, such as benign prostate hypertrophy, an infection of the prostate that can result from a sexual encounter. If the PSA is elevated, this is when the urologist gets involved. They perform an ultrasound-guided biopsy to see if it’s normal cellular activity or abnormal.

What does the treatment look like for prostate cancer?

Dr. Rezai: If growth is abnormal, then we talk about radiation or surgery. There are different risks and benefits from both. Chemotherapy is there for when the cancer has spread — or metastasized — throughout the body, but that’s almost like a shotgun or nuke approach.

What are the risks factors? How can someone lower their risk of getting prostate cancer?

Dr. Afari: The main risk factor for prostate cancer is to have a prostate. If you have a prostate, you should get checked. Once you turn 50, the incidence goes up significantly. There are other things that come into play: family history, people who have a high-fat diet have been shown to have a higher propensity, non-Hispanic Black men have been diagnosed more with prostate cancer. But the advice and the recommendation for any of my patients born with a prostate: get tested. [The recommendation for those at higher risk is to start discussions with their doctor as early as age 40 or 45.]

It will likely differ patient to patient, but generally, are there complications to recovery after treatment of prostate cancer?

Dr. Rezai: What you typically encounter — for either surgery or radiation treatment — is you’re not going to be able to urinate like you normally do [temporary or permanent incontinence]. Possibly, you might have [temporary or permanent] erectile dysfunction.

Dr. Afari: In terms of choosing a treatment option, most of the time your doctors try and minimize side effects as much as possible, and try to optimize recovery time. But the mainstay is getting the cancer — especially if it’s aggressive — under control, and to prevent it from moving to other places and causing more damage.

Are there any misconceptions about prostate cancer you’d like to clear up?

Dr. Afari: A lot of people are apprehensive about getting a digital rectal exam. But the exam itself is usually less than a minute, and it’s handled by people who have been trained and have experience in navigating through it. If you have apprehension getting a digital rectal exam, the PSA blood test is also pretty sensitive. That allows us to identify if there’s anything off, and then it can help us get a workup started for you.

Dr. Rezai: If you have a concern or a question, definitely bring it up to your doctor because it’s an easy test to do.

For Trans Women

Yes, trans women can develop prostate cancer. The prostate gland is present in all individuals assigned male at birth, including trans women, unless it has been surgically removed during gender-affirming surgery (which is uncommon).

Even though hormone therapy (such as estrogen) that trans women may take can reduce prostate size and lower testosterone levels, the risk of developing prostate cancer still exists, though it may be lower than for cisgender men. The risk tends to increase with age, and screening considerations for trans women should be discussed with health care providers who can tailor recommendations based on individual health history, hormone use, and other factors.

To discuss your prostate health, or to schedule a DRE or PSA test, please make an appointment with your DAP Health primary care physician. If you are not yet a DAP Health primary care patient, and would like to become one, click here.

As promised, DAP Health is providing monthly updates regarding its administration of the Palm Springs Universal Basic Income Pilot Program.

On Monday, September 16, 2024, direct deposit payments of $800 were sent by DAP Health to all 14 participants in the Universal Basic Income pilot program it now oversees on behalf of the city of Palm Springs. There was a systems error that impacted one participant, requiring them to pick up their check in person. 

To recap the meeting between DAP Health and all participants, which was held on Monday, August 26: 

• The request to change direct deposit day from the fifteenth of every month to the first of every month has been received and accepted, and will take effect in October until the end of the program. 

• A quarterly survey was sent out to all participants the week of Labor Day (September 2) and the deadline for them to be submitted is October 31, 2024. 

• DAP Health case management services were offered to all participants, with a request that those in need email Chief Transformation Officer C.J. Tobe, who is overseeing the program, and who will connect participants to their assigned case manager. 

• Currently, there is no additional funding available to extend the UBI program past the 18 months/payments. Should this change, participants will be so advised. 

• DAP Health is still in the process of gathering information to discern when each participant received their first monthly direct deposit to determine the date of the 18th and final direct deposit. Tobe suggested participants email him their first month of payment, and once he is able to cross-reference, he will schedule a time with individual participants. 

• The next monthly check-in with participants will be on Sunday, September 29, at 4:30 p.m. at DAP Health’s library on the Sunrise campus, and via Zoom.

HIV/AIDS & Aging

HIV/AIDS has become a manageable condition with which people can lead long, happy lives. Each year, on September 18 — National HIV/AIDS and Aging Awareness Day — we spread wisdom … and love.

Words by Trey Burnette 

“We are in an incredible era of treating HIV,” says Dr. Jason Halperin, director of specialty programs at DAP Health. “Treatment is safer and more effective than ever, giving people with and without HIV the same life expectancy.”

Dr. Clayton Barbour, an HIV and hepatitis C specialist at DAP Health, remembers the bad old days. “When I started working with patients who received an AIDS diagnosis, they generally had a year to two to live,” he says. “But now I have patients who have lived for more than 30 years with HIV, well into old age.”

The Center for Disease Control estimates 54% (596,044) of people living with diagnosed HIV in the United States are 50 and older. Barbour adds that early detection and antiretroviral therapy (ART) are key factors for patient longevity, but HIV does come with extra challenges.

First, the virus creates premature aging and inflammation in the body. “HIV+ people have a two times higher risk of cardiovascular related complications, such as stroke and heart attack,” says Halperin. Furthermore, diabetes, renal disease, and cancer are more common in people with HIV.

HIV.gov states, “HIV and its treatment can also have effects on the brain. Researchers estimate that between 25 and 50% of people with HIV have HIV-associated neurocognitive disorder (HAND), a spectrum of cognitive, motor, and/or mood disorders categorized into three levels: asymptomatic, mild, and HIV-associated dementia.”

Mental health is also a consideration of aging with HIV. Loneliness and stigmatization can contribute to depression. “Many of my older patients have lost most of their social network, a traumatizing event,” Barbour says. “And unfortunately, some patients have coped by using drugs, alcohol, and tobacco. People made choices based on the idea they wouldn’t be here, but here they are — living.”

Early detection and adherence to medication are imperative to longevity. Both doctors — Barbour at Stonewall Medical Center in Cathedral City, and Halperin at both Stonewall and Centro Medico Escondido on the San Diego coast — provide hope and health advice for people aging with HIV: eat a healthy (preferably Mediterranean) diet, exercise regularly, and stay connected to community.

Additionally, the physicians agree with current medical advice that anyone HIV+ and over the age of 40 should be on a statin to lower levels of blood cholesterol and reduce risk of heart disease and stroke — and to seek treatment for any tobacco, drug, or alcohol addiction.

Today — September 18^, 2024 — is the sixteenth National HIV/AIDS and Aging Awareness Day. A long time ago, my community taught me not to fear the virus — or those who have it. Until there’s a cure, all of us must be proactive in fighting not just the virus, but the stigma and shame associated with it. All of us must stand with those living with HIV/AIDS.

We Have Every Tool to End the HIV Epidemic Now

Know your status. Get tested for free at DAP Health. If you’re negative, get on PrEP (a daily pill or long-lasting bimonthly injection) to prevent HIV. If you’re positive, get treatment so your viral load can become undetectable and so that you can become untransmissible, meaning you can’t pass the virus on to others (U=U). To get tested, click here. To access HIV/AIDS care, click here.

Sexual Wellness 101: Embracing Health and Safety

Words by Daniel Vaillancourt

In the spirit of September being Sexual Health Awareness Month, it’s essential to spotlight the significance of sexual wellness — an integral part of our overall well-being. “Good health is sexual health, and sexual health is good health,” says DAP Health Director of Specialty Programs Dr. Jason Halperin.

DAP Health has three sexual wellness clinics (in Palm Springs, Cathedral City, and Indio) because we understand that sexual health is more than just the absence of disease. It’s about understanding, embracing, and managing our sexuality in a way that is positive, safe, and empowering. No stigma or shame. Ever.

For more information, or to schedule an appointment, please visit daphealth.org or call 760.992.0492. And by all means, read on!

Understanding HIV and STIs

Sexually transmitted infections (STIs), including HIV, are infections that can be passed from one person to another through sexual contact. While some STIs can be cured, others, like HIV, are chronic conditions that require ongoing management.

HIV, or Human Immunodeficiency Virus, attacks the body’s immune system and, if left untreated, can lead to AIDS (Acquired Immunodeficiency Syndrome). However, advancements in medicine have transformed HIV from a fatal disease into a manageable condition.

Antiretroviral therapy (ART) is the cornerstone of HIV treatment, allowing people with HIV to live long, healthy lives. ART works by reducing the amount of virus in the body, lowering it to undetectable levels. When the virus is undetectable, it is also untransmittable — a concept known as U=U (Undetectable = Untransmittable). This means that people living with HIV who adhere to their treatment and achieve and maintain an undetectable viral load cannot sexually transmit the virus to others.

Unfortunately, even in 2024, many people are unaware that they may be living with HIV. That’s why it’s important to get tested regularly. If you’re negative, get on PrEP or PEP for HIV prevention, and on PEP for STI prevention (see more below). If you’re HIV positive, get treated so that you can age well with HIV, and become U=U. If you're positive for an STI, get treated ASAP. And remember, HIV testing — and STI testing and treatment — are always free at DAP Health. Free from cost, and free from stigma and shame. 

Prevention: Protecting Yourself and Others

Prevention is a vital aspect of sexual wellness, and there are several strategies to protect oneself from HIV and other STIs.

1. PrEP (Pre-Exposure Prophylaxis) for HIV Prevention
   PrEP is a daily pill (or a bimonthly, long-lasting injection; brand name Apretude) for people at high risk of contracting HIV. It’s a powerful tool that, when taken consistently, can reduce the risk of HIV transmission by up to 99%. PrEP is especially recommended for individuals with HIV-positive partners, those who have multiple sexual partners, or people who engage in sex without condoms.

2. PEP (Post-Exposure Prophylaxis) for HIV Prevention
   PEP is an emergency treatment for HIV-negative individuals who may have been exposed to the virus. It involves taking antiretroviral medications for 28 days, starting within 72 hours after possible exposure. PEP is most effective when started as soon as possible, and it’s crucial to complete the full course of treatment to reduce the risk of infection. 

3. DoxyPEP (Doxycycline Post-Exposure Prophylaxis) for STI Prevention
   DoxyPEP is a newer strategy being explored for preventing bacterial STIs like syphilis, gonorrhea, and chlamydia. This approach involves taking 200 mg (two 100 mg pills) of doxycycline 24 to 72 hours after unprotected sex to reduce the risk of these infections. While not yet a standard practice, DoxyPEP is showing promise in studies and may become a useful tool in STI prevention.

4. Regular Testing and Communication:
   Routine testing for HIV and STIs is crucial for maintaining sexual health. Regular testing helps in early detection and treatment, preventing complications and transmission to others. Open and honest communication with sexual partners about STI status, testing, and protection methods is also key to fostering trust and safety in relationships.

Treatment: Managing STIs

For those diagnosed with an STI, early treatment is essential. Many STIs, such as chlamydia and gonorrhea, can be cured with antibiotics. Others, like herpes and HIV, cannot be cured but can be managed effectively with antiviral medications.

For HIV, adhering to ART not only improves the health of the individual but also prevents the transmission of the virus to others. For bacterial STIs, completing the prescribed course of antibiotics and avoiding sexual activity until the infection is cleared is crucial to prevent reinfection and spreading the infection to others.

Embracing Sexual Wellness

Sexual wellness is a lifelong journey that involves education, communication, and proactive health management. By understanding the risks, embracing prevention methods like PrEP and PEP, and seeking regular testing and treatment, we can take charge of our sexual health.

This September, let’s honor Sexual Health Awareness Month by prioritizing our sexual wellness, supporting our partners, and advocating for the health and safety of our communities. Remember, taking care of your sexual health is an act of self-respect and love — for yourself and others.

DAP Health has three sexual wellness clinics (in Palm Springs, Cathedral City, and Indio). For more information, or to schedule an appointment, please visit daphealth.org or call 760.992.0492.

As promised, DAP Health is providing monthly updates regarding its administration of the Palm Springs Universal Basic Income Pilot Program.

On Thursday, August 15, 2024, direct deposit payments of $800 were sent by DAP Health to all 14 participants in the Universal Basic Income Pilot Program it now oversees on behalf of the city of Palm Springs. (One participant whose bank information had changed was unable to receive the direct deposit. A check was promptly mailed to them.)

Results of a baseline survey (March 2024) and a first quarterly survey (June 2024) — taken by 11 of the 14 participants — revealed the following: 

• The average amount of debt held by participants is $27,025, and for most participants, their largest source of debt is credit cards or education/student loans.  

• A large majority of participants use their monthly $800 to pay for housing, spending an average of 56% of the monthly stipend on housing, followed by food, paying off debt, utilities, and transportation.  

• The two most common community-based programs recently used by participants are food support systems and mental health services. 

• As for DAP Health programs and services used in the last month, it was reported that: 

• • 69.2% used health care and sexual wellness services (primary care, HIV/AIDS care, hepatitis care, gender-affirming care, dental, testing, vaccines, PrEP).

• • 30.8% used behavioral health services (psychiatry, psychotherapy, substance use support, group therapy).

• • 23.1% used social services (food and/or transportation assistance, housing, home care, case management).

• • 23.1% used no DAP Health programs and services. 

One notable change between the two surveys was a decrease in the use of an emergency room/hospital as a usual place to seek health care.  

Further comparisons will be made across all questions and with future surveys (two more quarterly surveys and one final survey) in the final report. 

On Monday, August 26, 2024, DAP Health and HARC (Health Assessment and Research for Communities) will hold their monthly meeting with all 14 participants.