Women warriors

Fresh out of California State University, Fullerton, Maya set out on the Zionist path chosen by select 20-something American Jews who feel a pull to the Jewish state: she volunteered in the IDF. Stationed at the tense Kerem Shalom crossing on the Gaza border, she had to adapt to a new language, mentality and culture – on top of a renewed battle with Hamas. Just as she arrived to serve in the foreign relations unit, Gilad Schalit was kidnapped. “I cried so much during that time period, but looking back, that year gave me so much,” said the cheerful 28-year-old at a café in Givatayim, a colorful scarf adding spunk to a green summer dress. It's hard to tell that the brown wisps falling along her hazel eyes emanate from a wig. She credits the IDF with preparing her for a type of battle she never thought she'd face as a 25-year-old: the fight against breast cancer. “I have to say the army gave me the tools for life, and also to deal with the situation.” One semester shy of graduation from an MA program at Ben-Gurion University, Maya felt a pain in her breast while on vacation. “It was a gift that it hurt because otherwise I wouldn't have gotten checked,” she said. A series of tests – from a mammogram to a PET scan – revealed a malignant tumor. What followed was the grueling fight against the disease: a lumpectomy, exhausting chemotherapy and radiation. She went through treatment “like a robot.” “What people don't realize is that when you finish treatments, it doesn't mean you're finished. Only then do you start coping with what you went through,” explained Maya, who asked that her last name be withheld to protect her privacy. But Maya thinks it's important to tell her story, however uncommon. According to the Israel Cancer Association, 21 percent of the 4,500 women diagnosed with breast cancer in the country last year fell between the ages of 30 and 50. To mark the current Breast Cancer Awareness Month, several women who were diagnosed while in their 20s and 30s are telling their stories to promote breast health awareness, reigniting a debate as to how and when a woman under 50 should be examined. NOT LONG after Orly Harel, 49, quit her successful job as an executive at Pelephone to pursue her dream of becoming an interior designer, the then-36-year-old mother of two felt compelled to get checked because her mother had been diagnosed four months earlier with breast cancer. “If I hadn't started this change and taken this break, I don't think I would have stopped to make an appointment with the doctor,” said the red-headed Harel, from her stylish living room/studio in Rishon Lezion. Candles and a statuette reading “HOME” set on the coffee table add coziness to the condo while also serving as an instructive demonstration in tabletop styling, her specialty. “And the doctor said I didn't need to do anything because I was too young,” she related. “Something in my gut told me not to listen to her, and I insisted on getting checked.” Making a career transition better prepared Harel to cope with the disease, but “it's never a good or comfortable time. It's generally an active age. You raise your children. It's your peak age, and you don't want to deal with this stuff.” Women in their 30s, she finds, often get caught up in their careers and relationships, forgetting to check in with their bodies, both mentally and physically. Maya shared the sentiment. “Every woman is busy, but who thinks of cancer at that age? But at the same time you go to a gynecologist once a year for a check-up, because that's part of your health. This is also a part of your health.” Maya wonders if a routine physical breast exam would have detected the tumor earlier. “In Israel when I went to the gynecologist, they said, 'In Israel we don't do this exam,'” she said, recalling receiving routine examinations from gynecologists in the US. “That's a point that makes me very angry, because I think they could have caught it earlier. I'd been to the gynecologist six months before I was diagnosed, but who knows? I don't know what could have been done earlier, but my tumor was large.” Today, the Health Ministry mandates a biannual mammogram for women over 50 yet routine examinations are not required for women under 50. Usually, it's up to the woman to take the initiative. Dr. Gad Rennert, director of the Clalit Health Services National Cancer Control Center and National Personalized Medicine Program, says Israel's approach matches that of most Western countries, which do not recommend a periodic check-up for women under 50, including a periodic check-up at the gynecologist. “There are no recommendations for routine testing [screening] for average-risk premenopausal women anywhere in the world because none of the techniques was shown to be effective in the younger age groups, and because there is a good chance that the harmful effects of routine testing will be much greater than any expected benefits,” Rennert said via email. Still, some breast cancer awareness advocates are pushing for reform to make screening among younger women more routine and systemic. “If you tell women it's not your issue until you're 50, this issue is not on the radar,” said Sara Siemiatycki, founding director of Bishvilaych, a private organization focusing on health awareness and wellness among haredi women. Bishvilaych works with Israeli clinics to conduct breast examinations, which, in Israel, is generally the province of breast surgeons. Nurses and physicians assistants, Siemiatycki added, should also be equipped to conduct physical breast examinations. “It shouldn't be a hospital-based specialty; it should be a community service.” SARA BROM, a 66-year-old retired teacher, tries not to ask the tempting “what if” questions. “I think all the 'what if' questions are very dangerous.” Fortunately, her gynecologist had been “obsessive” about conducting breast examinations. Two months after she gave birth to her youngest daughter, her gynecologist checked for any irregularity, and found a lump. She was 35 years old. “Young women were never sick,” said Brom. “There was no Internet, no knowledge, so I was led by the medical team and they decided for me what I should have. In retrospect, I see I didn't want to take responsibility because I didn't have the knowledge.” With a five-year-old, two-year-old and a newborn, and a husband in the IDF, she relied mostly on friends and family for support. “Wow. It was such turmoil,” she sighed. Today, she lives in the home in Karmei Yosef she was determined to build even in the midst of her chemotherapy treatments. For the past two decades, she has volunteered as a counselor at the Israel Cancer Association to help guide patients with a similar profile through the process of treatment and recovery. “I was lucky; I was married and had my children. After I finished the treatments, I had a hysterectomy and they removed my ovaries and my womb so I couldn't have more children. What happens if a young, unmarried woman is sick? It's a big issue.” Given the unique challenges of young women with breast cancer, Tel Hashomer's Sheba Medical Center in 2002 established the Breast Cancer Service for Young Women, headed by Dr. Shani Paluch-Shimon, an immigrant from Australia. “Breast cancer in young women strikes them at the peak of their careers, reproductive years and most active years of motherhood and family life,” Paluch-Shimon said. “There are of course a multitude of issues related to body image, relationships, the impact of being diagnosed with a life-threatening illness at a young age, juggling motherhood and caring for young children while receiving chemotherapy, dealing with older parents who want to care for their daughters who are no longer children but grown adults, feelings of isolation and loneliness, anxiety and fears about future fertility and pregnancy.” Yael Shapira is director of the One in Nine organization, which strives to raise public awareness of breast cancer and advance breast health in Israel. She encourages women over 30 to visit a breast surgeon, and for the country's healthcare system to develop a more concrete policy of counseling and screening for this age group. “Although the importance of early detection is known to all, the State of Israel takes an outdated approach that calls only upon women aged 50 and up to be screened for early detection and to conduct mammograms,” Shapira said. “For women under 50, there is no such instruction. “About 1,000 women under 50 are diagnosed with breast cancer each year. This is a population for which there is essentially no clear policy. Young women aren't aware of the need to be screened; they don't know what they should do and to whom to turn to be checked.” At the same time, Miri Ziv, director of the privately funded Israel Cancer Association, cautions against undue hysteria and extraneous mammogram testing among this less vulnerable age group. The best defense is prevention through a healthy lifestyle and breast health awareness. “But of course,” Ziv said, “women who are at high risk should be screened before, and they should have – every year – a combination of examinations depending on their risk factors.” FAMILY HISTORY of breast cancer is one of the most important risk factors, noted Paluch-Shimon. “Women with a family history of breast cancer, ovarian cancer and pancreatic cancer should seek genetic counseling to assess whether genetic testing is warranted.” Maya learned only after being diagnosed that she carries the BRCA gene mutation, known to be the cause of 10% of breast cancer and 40% of ovarian cancer among Ashkenazi Jewish women. A recent study showed that half of BRCA carriers show no family history, raising questions about the necessity of routine BRCA screening among all Ashkenazi women, as covered in The Jerusalem Post in September. The BRCA mutation was catapulted into public awareness when actress Angelina Jolie underwent a risk-reducing double mastectomy after testing positive for it. (Maya, ever quick for a laugh, jokes that she and the gorgeous Jolie share the same gene pool.) Paluch-Shimon recommends that annual breast examination by a breast surgeon begin at age 25, even when no risk factors or family history are apparent. “Self breast examination is no longer routinely recommended; women are, however, recommended to be 'breast aware.' That is, to be aware of any changes in their bodies and, if they notice any changes in the appearance or shape of their breast or if they feel any lumps in their breasts or armpits, they should seek medical advice.” Mammograms are generally less effective among women under 50, due to higher breast density. In fact, screening tools vary in efficiency among each individual case. IN HAREL'S case, it took an ultrasound to reveal the eight-millimeter lump that would have gone undetected in a physical breast examination. She takes pride in her early detection, which she ascribes to awareness. “Because I discovered it in time, I had a life after,” she said. Upon celebrating and styling her son's bar mitzva a few months after being diagnosed, Harel threw a party to say farewell to the cancer. “I stood on my feet and said – yes, I'm bald. Yes, I have no eyebrows. And yes, I'm healthy. I'm continuing on this new path.” In addition to running Kinamon Design, she counsels women at One in Nine and speaks about the importance of breast awareness to women in the workplace. Like Harel, Brom believes that mentally overcoming cancer contributes to the healing process. “It was a very tough year,” Brom said, “but very quickly I decided that I didn't want to live in a sick environment. So I extended my maternity leave for one more month, and I returned to the school where I was working and worked three days a week. I think I was such a bad teacher that year, but the school was amazing.” CANCER PATIENTS aren't the only ones who need support. One mother tells the tragic story of a young woman who didn't live to tell it. Ilana Dubnov's daughter Anat was diagnosed with breast cancer at age 31, as a wife and mother to a oneyear- old boy. The doctor conducted a mammogram right after the birth of her first child. It came up without a trace of cancer, but then, just a few months later, a lump was discovered.

Women warriors

Twenty-one percent of the 4,500 women in Israel diagnosed with breast cancer last year were between the ages of 30 and 50.

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