As a fellow in the Yale School of Medicine Section of Pediatric Cardiology, Nina Bernstein, MD, had seen her fair share of medical mysteries. So when she began experiencing strange symptoms, she knew to trust her gut that something was wrong.
It started with a pain in her calf, like a sore muscle, that lasted for several days.
In no way did I expect to see cancer. But as soon as I examined her, I knew right away. Elena Ratner, MD
Even though she was only 31 and had no other risk factors, such as smoking or a sedentary lifestyle, Dr. Bernstein suspected it might be a blood clot. “I just had a feeling,” she says.
Her colleagues thought that she was being a hypochondriac (as most doctors are, she says). Eventually, though, her supervisor sent her to the emergency room for tests.
Dr. Bernstein was right. It was a blood clot.
Her brain snapped into “doctor mode.” For someone without obvious risk factors, a blood clot is most likely caused by another underlying condition.
Pregnancy, an autoimmune disease or a blood disorder were all possibilities, but Dr. Bernstein assumed she would have known about any of those. Another potential, if highly unlikely, culprit was cancer.
The relationship between cancer and clots is not fully understood, but it is believed that tumors release chemicals that cause blood to thicken and coagulate. Dr. Bernstein knew this.
She also began thinking about her period, which had started that morning and was much heavier than normal—a symptom of cervical cancer.
When the ER staff told her they wanted to test for clotting disorders, she stopped them short and asked to see someone from the Section of Gynecologic Oncology. Elena Ratner, MD, was working in the clinic that day and agreed to squeeze her in.
“In no way did I expect to see cancer,” Dr. Ratner says. “But as soon as I examined her, I knew right away.”
A surprise diagnosis and life-changing news
Two days later, after a biopsy and more imaging scans, Dr. Bernstein’s illness was diagnosed: Stage IIB cervical cancer.
Despite her hunch, it was still a shock: She had had the HPV vaccine (which protects against the virus that causes cervical cancer) and routine gynecological exams.
But because Dr. Bernstein’s tumor started in her upper cervix—unlike most, which start in the lower cervix near the vagina—it had not been caught during a recent Pap test. It had been growing for some time and had spread into the side wall of her uterus.
To discuss her diagnosis and treatment, Dr. Bernstein and her husband met with Dr. Ratner and Shari Damast, MD, a radiation oncologist who specializes in gynecological cancers.
Together, the doctors told Dr. Bernstein that her cancer was too advanced for a radical trachelectomy, surgery that would remove her cervix but spare her uterus. To get rid of the cancer completely, she would need treatment that included radiation, which would damage her ovaries and send her body into early menopause.
In other words, she would not be able to get pregnant.
Dr. Bernstein, who had recently married and was looking forward to starting a family, was devastated.
“That was the first time I really broke down crying,” she says. “Until then, I was just thinking of myself as a patient. Here’s my diagnosis, here’s my treatment plan, and as long as we keep moving forward everything will be fine.”
Dr. Ratner was prepared for this conversation, and immediately brought in a reproductive endocrinologist to discuss the options with her.
Together, with Dr. Damast, they decided to delay treatment for two weeks—long enough to harvest one cycle of her eggs, in hopes of later having children via a surrogate.
Cases such as Dr. Bernstein’s require quick thinking and a sensitive touch, Dr. Ratner says.
“We take into consideration a woman’s whole life—how old she is and what her plans are for children,” she says. “Initially, we spend more time talking about her future than anything else. I was always confident we would find a way to treat Nina’s cancer, but I wanted to be sure that treating her cancer did not ruin her life.”
Breaking the news was difficult for Dr. Damast, too.
“I remember the look on Nina’s and her husband’s faces as the news sank in,” she says. The saving grace, she says, was Dr. Ratner. “I’m so lucky to have been working with her,” Dr. Damast says. “She really advocates for her patients, so that Nina was given reproductive options, up front, as part of the whole treatment package.”
Of course, Dr. Damast was used to discussing sensitive topics with her patients. She regularly counseled them on radiation’s other sexual side effects, such as vaginal tightness and dryness, before they started their treatments.
“I always bring up sexual health early on with my patients, so it opens the door for them to ask questions they might be wondering about,” she says. “This is a very personal treatment, and it’s important we make our patients comfortable every step of the way.”
Two types of radiation
Dr. Bernstein’s personalized treatment plan involved chemotherapy and two types of radiation: external, in which the patient lies on a table and a machine directs X-ray beams at the affected body part and internal, in which radioactive materials are inserted into the body.
The external beams radiate the entire tumor and surrounding areas, Dr. Damast says, while the internal radiation, known as brachytherapy, can focus on whatever cancer cells are left.
“To ensure that the cancer doesn’t come back, you really need both,” she says.
Most hospitals offer external radiation, but not every center performs brachytherapy.
Even fewer hospitals perform a newer type, high-dose rate (HDR) brachytherapy, which reduces treatment time and does not require overnight hospital stays. Luckily for Dr. Bernstein, Yale Medicine is one of the few centers in the Northeast that performs this treatment regularly for cervical cancer.
She started with external radiation: 28 sessions, about five minutes each, over the course of six weeks.
“I was in and out in 15 minutes every day,” Dr. Bernstein says.
The process was painless, and the “table” used for her treatment—which had been molded to fit her body to help keep her from moving—was quite comfortable. “I’d close my eyes and the technicians would play Top 40 music for me,” she said. “I actually started enjoying my time there!”
Dr. Bernstein’s brachytherapy, which overlapped with the last week of her external radiation, involved five sessions over a period of three weeks. Each took place in the hospital under general anesthesia.
During the first session, Dr. Damast sewed a 5-millimeter “placeholder sleeve” into Dr. Bernstein’s cervix. Then, she inserted two metal rods, using real-time ultrasound imaging to position them near her tumor.
Next, Dr. Bernstein was given a computerized tomography (CT) scan, so her doctors could make sure the rods were in place correctly.
High-dose rate brachytherapy
The CT images from the scan were then used by Dr. Damast and her team, who designed the customized brachytherapy treatment plan.
Once the calculations were done, it was time for the treatment: The rods were connected to tiny catheters and hooked up to an afterloader, a machine that delivered a tiny computer-controlled radioactive pellet through the tubes and into Dr. Bernstein’s uterus and cervix.
The pellet can deliver a high dose of radiation to the tumor, says Dr. Damast, without having to give a dose to the body’s healthy organs nearby.
It dwells in small steps along the metal rods every few millimeters for a few seconds before moving to the next position. As it moves, the pellet continuously gives off radiation, ultimately crafting a radioactive cloud perfectly sculpted to the tumor cells. When the treatment is completed, typically after about 10 minutes, the pellet travels back to the afterloader.
The catheters and metal rods are removed after each treatment; patients go home with only the placeholder sleeve inside them between sessions.
With HDR brachytherapy, treatments last only a few minutes (although each appointment can take several hours), and patients can go home between sessions. There is no radiation left inside the body; once the treatment is completed, the patient is not radioactive.
Having the placeholder sleeve inside her for five weeks was not painful, Dr. Bernstein says, though it was uncomfortable at times. “I could feel it in there when I moved certain ways, and it had these long strings that hung down, like tampon strings but stiffer, that bothered me occasionally,” she says.
She could not have sex while the sleeve was in place, and she experienced a lot of discharge— dying tumor cells and tissue—on the days after her radiation treatments.
“I had to wear a pad, because panty liners weren’t cutting it,” she says. After her fifth treatment, the sleeve was removed, also under general anesthesia.
Throughout her radiation treatments, side effects were minimal.
“I got really exhausted, and I’d sleep in the car on the way home from treatments,” Dr. Bernstein says. “I’d feel really weak for a few days, but then I’d be back to normal.” And when she began going through menopause, her doctors started her on hormone-replacement therapy to relieve symptoms such as hot flashes and night sweats. “Within the first week on HRT,” Dr. Bernstein says, “I was completely back to normal.”
Looking toward the future
Throughout this process, Dr. Bernstein also had weekly low-dose chemotherapy treatments intended to make her radiation more effective. And after she finished brachytherapy, she enrolled in a clinical trial at Yale for treatment with two additional cutting-edge chemotherapy agents.
“My doctors told me I had a 90 percent chance of being cured without it, [but] I needed to know I’d done everything I possibly could to ensure that my cancer wouldn’t come back,” she says. “Yale is one of the few places doing this trial right now, so why not take advantage of everything available to me?”
About a month after she finished her clinical trial, Dr. Bernstein had her first PET scan to check for any remaining tumor cells.
She used her hospital credentials to get an early look at the scan and knew that it looked cancer-free, but she would not let herself believe it until Dr. Ratner and Dr. Damast told her in person.
“Even then, I wanted to have it in writing,” she says. “I think the doctors were more excited than I was. I actually sent Dr. Ratner an email apologizing that I didn’t seem happy enough when she gave me the news!”
Dr. Bernstein will need regular checkups to make sure that those cells do not come back, but her doctors are optimistic.
“Nina’s case really speaks to why we form such close relationships with our patients,” Dr. Damast says. “It really is a long-term relationship. I’m going to see her every few months for many years to come.”
As for those interrupted plans to start a family? There’s good news there, too.
Dr. Bernstein’s sister, serving as a surrogate, gave birth last July to a baby girl on her behalf.
“Thanks to her, our dream came true,” Dr. Bernstein says. “Thanks to her, and to my doctors who made all of this possible.”
And while Dr. Bernstein’s story is exceptional, her happy ending is not.
“It’s what we strive for with all young women in her situation,” Dr. Ratner says. “Not only do we want our patients cancer-free, but we want them to have their lives back.”