The new season calls for a new set of nutrient-rich recipes — ones with the perfect blend of fresh vegetables and hearty flavors.

1⁄4 teaspoon cayenne pepper (omit if you want to keep it very mild)

Heat olive oil and butter/coconut oil in a medium-sized soup pot or Dutch oven for about 2 minutes over medium heat.

Add shallot and ginger and sauté for about 3 minutes. Add carrots and sauté for another 3 minutes. Add vegetable stock, coconut milk, curry powder, cayenne pepper, and salt. Stir well and cover with lid.

Once soup has been brought to a boil, lower heat to simmer for 15 minutes or until carrots are very tender. Remove from heat and let cool for at least 5 minutes. Use an immersion blender (stick blender) to puree the soup until you have reached the desired consistency. Add more salt if desired and serve immediately.

Braised Red Cabbage With Fennel and Pear 

1 fennel bulb, core removed and thinly sliced

1 small head red cabbage, core removed and thinly sliced

2 ripe pears, cores removed and thinly sliced

1⁄4 cup apple cider vinegar (for tanginess)

1. Heat olive oil in a large pot or Dutch oven over medium heat. Add red onion and fennel and cook until softened, about 5 minutes.

2. Add the remaining ingredients and cook on low to medium heat, stirring often, until cabbage and pears are softened, about 10 to 15 minutes.

Rinse the quinoa using a fine mesh strainer and then transfer to a medium-sized pot. Toast quinoa over medium heat for a few minutes until you smell a nutty aroma. Next add the vegetable broth and bring to a boil. Once the quinoa has been brought to a rolling boil, lower the heat. Cook the quinoa about 15 minutes, until just soft but slightly tender. Remove from the heat and transfer to a bowl.

In a medium-sized non-stick skillet, warm the olive oil over medium heat. Add the yellow onion and salt and cook for 5 minutes. Then add the rosemary, grated carrots and lemon zest, and cook for 3 more minutes.

Incorporate the vegetable mixture with the quinoa. Add lemon juice and more salt to taste if desired. Gently mix and set aside.

Using a paper towel, wipe out the skillet and return it to medium-high heat. Place the pumpkin seeds in the pan and dry toast until they start to pop, making sure to stir often. Top the quinoa with the toasted pumpkin seeds once they are just lightly browned.

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Warm Up With Fall Recipes

When Stacy Deems received a diagnosis of breast cancer in September 2019, her first concern wasn’t about her health, it was how she would afford treatment. The divorced mother of two teenaged boys worked for a nonprofit organization with a basic health plan.

“When I brought up (costs) to the oncology team, they were like, ‘You don’t have to worry about that. We’ll discuss it later,’ ” says Deems, 51, of Reisterstown, Maryland. “That’s not how my brain works. I need to know.”

In an initial conversation with the office manager, Deems discovered that although she likely didn’t earn enough to afford her medical bills, she made too much money to qualify for some grant programs. So, she got to work: Deems ensured her doctors all were in the network covered by her health plan and focused on her out-of-pocket maximum cost because she knew she would hit it.

She met with an insurance counselor at the hospital, who recommended a different plan to choose and advised her to get short-term disability insurance in case she needed it. She also used a flexible spending account to cover some bills and medications.

Deems also told family and friends about her plight. Over the past several years, as she underwent chemotherapy and radiation, a mastectomy and reconstructive surgery, she changed jobs and health plans, a family member covered her out-of-pocket maximum costs, and she found other sources of assistance, such as a copay card from her pharmacy. She followed up on any leads for organizations providing grant assistance.

“I just realized I can’t be shy or proud, and I need to just ask for everything and look for any free services that I could get because of what I’m fighting,” she says.

Deems’ financial concerns are common among patients with cancer, says Dr. Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City whose research is focused on affordability and patient costs. Financial toxicity, a term used to describe financial problems and stress caused by medical costs, affects anywhere from 15% to 65% of patients, she says.

Each person’s financial impact will look unique from factors including the type of cancer they have, what their insurance will cover and the complexities of their treatment plan. 

“If you need chemotherapy and surgery and radiation, you’re going to generally be at a bigger risk for financial toxicity than if you just needed one of those treatments,” Chino says. Costs can add up both from medical and medication expenses as well as from lost income if people have to miss work.

Chino personally understands the patient and family perspective on cancer costs. Her late husband, Andrew, died from a neuroendocrine cancer in 2007. At the time, his insurance company would cover up to half a million dollars in expenses for a lifetime, which his treatment easily exceeded. At one point, he interviewed for and accepted a different job just to have a new health insurance plan, she said, yet she was still left with debt after he died. The experience inspired her to switch careers from art to medicine.

There are several ways to lessen financial costs, says Daniel Sherman, an oncology financial navigator at a Michigan hospital, and president of the NaVectis Group, an organization that trains health care providers on patient financial navigation services.

Ideally, discussions about cancer finances should begin on the day
of receiving a diagnosis, before any treatments occur, says Sherman: “The earlier that a well-trained financial navigator can get involved, the easier it is to mitigate not all but a lot of the financial distress that patient is going to experience.”

When Sherman sits down with patients, he first assesses the person’s insurance coverage to see if there are any opportunities for insurance optimization, or plan adjustments. Often this can happen outside of traditional open enrollment times, especially if there will be a decrease in income due to the diagnosis or if a patient falls below 150% of the federal poverty level.

Beyond that, there are several other resources where patients can receive assistance. Nonprofit hospitals all have charity programs where patients could qualify for free or reduced care. Pharmaceutical companies often have patient assistance programs to help cover drug costs. A variety of patient assistance foundations exist that help cover assorted medical costs, transportation to treatment and other items such as wigs for those who lose their hair.

Out-of-pocket costs for Health Insurance Marketplace plans, which are plans run by the federal government for individuals, families and small businesses, cannot exceed $9,100 in one calendar year, he says. For members of Medicare Advantage plans, those costs cannot exceed $8,300. For people covered by commercial insurance plans or Medicare Advantage plans, these out-of-pocket maximums are not uncommon.

Some people think they’re not going to qualify for assistance, so they don’t even ask. “That’s a mistake. There is no harm in asking. Most people qualify for something,” Sherman says.

Another myth is that patients who ask about financial assistance will receive substandard care. “Nothing can be further from the truth,” Sherman says. “Financial toxicity, left untouched, does more harm to people than asking for assistance.”

Apply for financial assistance as soon as it is necessary; don’t wait until bills have piled up and treatment is over, advises Joanna Doran, an attorney and the chief executive officer of Triage Cancer, a nonprofit organization that provides free education on practical and legal issues impacting people with cancer and their caregivers. “In some cases, you might lose out on eligibility for assistance, because some programs will only provide assistance while you’re in treatment.”

There aren’t specific federal laws that protect patients from medical bills, Doran says. However, the three major credit reporting agencies as of July 2022 have agreed not to include paid medical debt on people’s credit reports.

Always review medical bills carefully before paying them, Doran says: “It’s a human process, and a large percentage of medical bills have errors.” 

Individuals should compare their bills against the explanation of benefits (EOB), a statement from their health insurer that lists what medical services they had, how much the plan pays for them and what charges are not covered.

“Sometimes providers send bills too quickly, before they’ve actually gotten payment from the insurance company,” she says. If individuals pay before comparing to the explanation of benefits, they might pay more than they are actually responsible for.

Once individuals know for sure what they owe, and notice that the figure is too high, they should communicate with their provider, Doran says. See if they can set up a payment plan, or if the provider will accept a lump sum payment at a lower amount. Those scenarios are common, especially at larger hospitals. 

If individuals need additional assistance, then look into financial assistance through the hospital or other nonprofit organizations. “Most people jump to financial assistance, and the challenge with that is if you haven’t figured out what you actually owe, then you’re worrying about paying a bill you might not owe,” Doran says. “There’s only so much financial assistance to go around, so we want to make sure that people are maximizing their ability to get those funds.”

One big issue contributing to financial toxicity is denials, where an insurance company denies coverage for medical care or services. Only 0.1% of people with Marketplace plans appeal those denials, Doran says, but when they do, and it gets to an external medical review process where an independent party reviews the company’s decision, they are successful about 50% of the time.

Scott Matsuda, 69, of Mountlake Terrace, Washington, and his wife, Jennifer Matsuda, have become experts at navigating the finances of cancer treatment. Scott Matsuda was diagnosed approximately 16 years ago with thrombocytosis, a blood disorder in which the body produces too many platelets. But his doctor told him it could turn to leukemia, and a year later, it did.

The first thing Scott Matsuda did was review his family’s finances and contact his insurance company. As photographers who run their own business, the Matsudas purchased the best health plan they could afford to cover Scott Matsuda’s medical costs. For several years he took a cocktail of medications and had minimal copays. Then he started experiencing side effects and doctors switched him to a new, more expensive medication.

For the first three months, Scott Matsuda qualified for a clinical trial and received the drug for free. When the trial ended, he discovered the medication cost about $104 a pill, and he needed two pills a day. His health plan would only cover about 20% of the charges.

“We were floored with the cost and didn’t know how to pay for it,” Scott Matsuda recalls. “We’re solid, middle-class people. We pay our bills and have really high credit ratings, and suddenly, everything was going to blow up in our faces.”

“It was over $6,000 a month, and the options for us were don’t take it, knowing this might be a lifelong drug, or sell the house and drain your retirement account,” adds Jennifer Matsuda.

He stopped taking the drug, which sent his platelets skyrocketing. Then, his oncologist connected the Matsudas with the PAN Foundation, an independent nonprofit group that helps cover medication costs for people living with chronic and rare diseases. They qualified for a copay grant that covered the medication for a year at a time.

Three years ago, Scott Matsuda needed a bone marrow transplant, which he received from his sister. By then he was old enough to qualify for Medicare, which covered most of the cost. Now in remission, he is back on the expensive drug to combat graft-versus-host disease. But before he started taking it, Jennifer Matsuda contacted the pharmacy, which told her they had some grants available to cover the medication. Scott Matsuda is now receiving funds from his fourth grant foundation to help pay for the medication, leaving him with copays averaging $200 a month.

“There’s a whole community of organizations out there that provide different aspects of care and support and help,” Scott Matsuda says. “That’s a revelation when you start going down that avenue.”

As for Deems, she currently has no evidence of disease but is on a maintenance medication and receives mental health services for the trauma and post-traumatic stress disorder brought on by her diagnosis and surgeries. She covers those expenses with pretax dollars through a flexible spending account.

Healing should be the primary focus of patients and survivors. But for many, the effects of high medical costs can become a burdensome challenge. Care providers, experts and family work to provide assistance.

The Financial Toxicity of Cancer Treatment

Identifying the risk of breast cancer-related lymphedema (BCRL) has become easier based on new advances in which highly accurate preoperative and postoperative predictive models can aid with interventions based on independent risk factors, according to findings from a recent study.

 have found that there are 2.3 million new cases of breast cancer annually, with 300,000 of these cases in the United States. Additionally, findings from a study in 

 have established that approximately 16.6% of women develop breast cancer-related lymphedema at some point after breast cancer treatment.

BCRL is a chronic disease that entails the accumulation of fluid in the fat and tissues, typically in the arms. Common symptoms can include swelling, tightness and heaviness, which cause limited mobility in the arms. Findings from two sections in the book “Multimodal Management of Upper and Lower Extremity Lymphedema” from Springer Publishing also emphasized that women who are in the later stages of BCRL face lower health-related quality of life, including a higher risk for physical disfiguration, lack of response to treatment, functional impairment and cellulitis (a common bacterial skin infection).

While preventing BCRL is crucial, previous prediction models have not been as accurate at identifying the risk for BCRL in patients. Instead, strategies were employed to slow disease progression at an early stage such as closely monitoring women who were at high risk for BCRL, using compression garments immediately after surgery and quick intervention through complex decongestive therapy. This type of therapy entails lymphatic drainage, compression, exercise and skin care.

 from a team of researchers
at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, and the Mayo Clinic in Jacksonville, Florida, established that, with a developed and validated prediction model for lymphedema, both patients and doctors can see a change for the better.

“We figured out that if you ask (patients) a very simple question and if you have their history, you can calculate a number, which will give you an idea of whether they have swelling now or lymphedema now and (whether) they should come in for measurements. So this way, we can limit the number of postoperative visits that patients need to come in for,” Dr. Babak Mehrara said during an interview with 

Mehrara is senior author of the respective study and chief of plastic and reconstructive surgical service at MSKCC. “And then, the other point is to try and decrease the number of clinic visits that patients have. The way we follow patients is by having them come in and do measurements repeatedly. But that’s very time intensive, both for the patient and for us.”

Mehrara also emphasized that constant visits to the clinic can quickly become costly for patients. Certain factors, Mehrara noted, can make a patient more likely to develop BCRL, including race, obesity, advanced age and chemotherapy treatment. He emphasized that it’s ideal to cultivate a good diet and exercise regimen to maintain a healthy weight, which relates to modifiable interventions.

Use of predictive models is crucial regarding lymphedema interventions in patients with breast cancer, the authors of the study determined. They acknowledged that preoperative models used for patients who are at high risk for BCRL can provide help regarding interventions that are modifiable, such as weight reduction for obesity through both aerobic and anaerobic exercise.

Diet is another modifiable intervention that patients can implement alone. “There have been some studies to show that dietary modifications, such as a Mediterranean diet or a ketogenic diet, do decrease the severity of lymphedema, ... (as) dietary interventions like low inflammatory diets are good,” Mehrara said.

The study authors also found that other interventions include early postoperative complex decongestive therapy and/or immediate lymphatic reconstruction using a lymphovenous bypass. The latter is a procedure that forms a path for fluid to draw away from the arms.

Patients with a lower risk for BCRL can also benefit from the new postoperative model. 

“I think it’s helpful for patients to understand their risk,” Mehrara said. “I think some patients are very, very worried about it ... (and it) causes a lot of anxiety for them. It’s helpful for them to know that their risk is 3%, 5% or something very low. I think it’s also good for providers to be able to divide patients into categories of risk. So rather than bringing everybody in every three months and measuring them and putting them through the rigmarole of screening, we can concentrate on the patients who are at highest risk. The other patients we can send questionnaires.”

Existing models predicting BCRL failed to account for potential racial differences, according to Dr. Danielle Rochlin, lead author of the study and plastic and reconstructive surgeon at MSKCC. Previous data published in the journal 

underscored Rochlin’s statement and concluded that many individuals who develop BCRL and experience lower health-related quality of life are Black. Specifically, the data showed 42 of 190 Black patients developed BCRL compared with other races: 10 of 80 Asian patients, 158 of 1,558 White patients and eight of 54 patients who identified as another race.

Current models are now better at considering racial differences when predicting BCRL, as demonstrated in the 

“We know there are differences between races with regard to proclivity to developing inflammation or fibrosis, the two main pathologic features of lymphedema. I think you have to take that into consideration, understand that and see how that changes the baseline risk,” Mehrara said. “I think the nice thing about our model is that adding that factor improves our ability to predict significantly, so that is an independent risk factor that we can use to improve our model.”

However, he also recognized some of the challenges regarding models that consider race. 

“The problem with race (as a variable) is that most of our patients are self-reported. And so it’s hard to know exactly what the racial contribution is,” Mehrara said.

Because there are many combinations of races, Mehrara noted that simpler models are not great at predicting risks of lymphedema. “I think the next step is to develop a machine- learning algorithm that can take more of these variables into consideration, rather than the logistic regression analysis that we did,” he said.

New preoperative and postoperative models can help identify those at high risk of breast cancer-related lymphedema following surgery.

Heal Fall 2023

Warm Up With Fall Recipes

The Financial Toxicity of Cancer Treatment

Improved Way to Predict Breast Cancer-Related Lymphedema

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