Dr. Freya Schnabel, director of breast surgery at Perlmutter Cancer Center, performed Christa Avampato’s double mastectomy following a stage 2A breast cancer diagnosis. She encourages her patients to embrace a positive mindset. “You will come out the other side of this,” she told Christa, “and you will be healthy.”
Photo: Claudia Paul
Christa Avampato had no pressing reason to get a mammogram. At age 44, based on the current breast cancer guidelines, she wasn’t due for a routine screening for another year. She had no symptoms. In fact, she felt great. She practiced yoga and ate a plant-based diet. But then came a vivid dream.
A dear friend who had passed away appeared, imploring her to take care of her health. Spooked by the vision, she took it as a sign to find a new primary care doctor and get a mammogram, anticipating a second wave of COVID-19 that “might shut down tests for a long time,” she says.
Her decision to have the screening test on September 11, 2020, at ٺƵ Health proved to be life transforming and, ultimately, lifesaving. Christa was found to have invasive breast cancer. Subsequent diagnostic biopsies performed by Hildegard B. Toth, MD, chief of the in the , showed that tumors were present in both of her breasts and had spread to some lymph nodes, defined as stage 2A. Christa was incredulous at first—“I thought maybe they had the wrong patient file,” she says—but her disbelief quickly turned to gratitude that she would receive her multifaceted care at ٺƵ’s Perlmutter Cancer Center, a National Cancer Institute–designated Comprehensive Cancer Center, with ٺƵ doctors at the ready to meet any issues that might develop.
Surgeon Freya R. Schnabel, MD, director of breast surgery and surgical oncologist at ٺƵ’s Breast Cancer Center, explained that Christa’s treatment would involve surgery, chemotherapy, radiation treatments, and, because the growth of her type of cancer can be enhanced by estrogen and progesterone, hormone therapy. “This is a full-court press to get rid of the disease,” Dr. Schnabel told her.
“It’s unusual to be asymptomatic and come back with bilateral node-positive breast cancer. That’s why the topic of starting screening at age 40 needs to be reopened.”
—Freya R. Schnabel, MD, Director of Breast Surgery at Perlmutter Cancer Center
Christa felt like she had an army supporting her cancer fight, with Dr. Schnabel as the commander. After doing some research, she opted for a double mastectomy with reconstruction rather than a lumpectomy.
On October 27, Dr. Schnabel completed the four-hour surgery, removing both breasts and the lymph nodes under her right arm. To prepare for reconstruction, Oriana D. Cohen, MD, clinical assistant professor in the , placed tissue expanders during the initial surgery to make room for implants, and will perform breast reconstruction later this year.
When biopsies of Christa’s left nodes came back positive, Dr. Schnabel performed a subsequent procedure to remove them. “It’s unusual to be asymptomatic and come back with bilateral node-positive breast cancer,” says Dr. Schnabel. However, she notes that invasive breast cancer in patients under 45, who account for only 9 percent of the 276,000 U.S. women diagnosed each year, tends to be more aggressive. “That’s why the topic of starting screening at age 40 needs to be reopened,” Dr. Schnabel adds.
After the lymph node removal, Christa developed inflammation and restricted arm movement. Jonas M. Sokolof, DO, director of oncological rehabilitation, diagnosed a condition called cording, which can develop when lymph nodes are removed, and prescribed a comprehensive program to treat it at Rusk Rehabilitation.
Postsurgical treatments for breast cancer may include drugs that target specific cancer cells, such as monoclonal antibodies, and immunotherapy designed to block a tumor’s defenses so the immune system can attack it. Women with certain genetic mutations may enroll in one of Perlmutter Cancer Center’s many evaluating new therapies. Due to her relatively young age and diagnosis, Christa was given a state-of-the-art test to scan for heritable gene mutations linked to breast cancer. When results showed no genetic predispositions, a two-stage course of chemotherapy was deemed the best option.
She weathered the first four infusions smoothly, but after switching to a medication called Taxol, she began feeling feverish and short of breath. On February 23, 2021, in respiratory distress, she was taken by ambulance to the Ronald O. Perelman Center for Emergency Services and nearly wound up on a ventilator. A scan revealed severe pneumonitis, a systemic inflammation of the lungs.
Christa was given high-flow oxygen and, with the virus still rampant, tested for COVID-19. But pulmonologist Mark F. Sloane, MD, clinical professor in the at ٺƵ, had a different suspicion. “She didn’t have the classic virus symptoms like loss of smell or taste, and she was on a drug that can, in rare instances, cause a severe immune response,” says Dr. Sloane. He prescribed high-dose steroids to calm Christa’s systemic reaction. She improved rapidly and was discharged after four days. Two weeks later, though, after attempts to cautiously taper her steroid therapy, Christa returned to the emergency department with a recurrence of shortness of breath. Again, she rebounded quickly with oxygen and steroids, tapering over four months under the watch of pulmonologist Ari Klapholz, MD, clinical assistant professor in the Department of Medicine.
Christa’s medical oncologist Yelena Novik, MD, associate professor in the Department of Medicine, says such a reaction is so rare that she’s only seen it once in her career. “This is the gold standard chemotherapy for breast cancer,” she says. Dr. Novik credits the access Perlmutter Cancer Center patients have to multidisciplinary specialists at ٺƵ for ensuring that Christa received the proper treatment. “We provide an individualized approach to cancer care, with access to specialists in every area,” she says.
Christa also benefited from personalized care during external beam 3D conformal radiotherapy, which uses energy beams to precisely target residual cancer cells, on her left chest and lymph nodes on that side. Frequently, Carmen A. Perez, MD, PhD, assistant professor in the , uses a technique in which patients inhale deeply and hold their breath to provide greater spacing between the heart and the targeted treatment area. But since Christa’s lungs—now back to normal—were still recovering when radiotherapy began in April, Dr. Perez used a combination of photon and electron treatment fields, a hybrid strategy that minimized exposure to her heart and lung.
During the 6-week, 30-treatment radiotherapy regimen, Christa enrolled in a Perlmutter Cancer Center clinical trial led by Naamit K. Gerber, MD, associate professor in the Department of Radiation Oncology, to test whether a caffeine-based cream reduces scar tissue formation from radiation. The hope is that the experimental remedy may improve the outcome of Christa’s final breast reconstruction surgery, slated for later this year.
Christa’s cancer treatments aren’t done. She will remain on hormone therapy for up to 10 years and has weathered hot flashes and other menopausal symptoms. Yet she maintains a preternaturally positive outlook. While her last 12 months have been full of unexpected challenges, she notes that “everybody has gone through some kind of craziness during the pandemic.”
Convinced of the advantage of having clinicians who can access her electronic health records instantly, Christa has transferred all of her medical care to ٺƵ. “Having a unified approach saved my life more than once,” she says.
While a recurrence is always possible, Christa’s physicians are optimistic about her prognosis, given the 85 percent, 5-year survival rate for women with stage 2 breast cancer. “The good news is that she had a lot of treatments available to her,” says Dr. Schnabel. “We have removed all the clinically evident disease, and we’re giving her case everything we’ve got.”
