When a nurse practitioner called Beth Zapola to say, “We need to talk. Can I come to your house?” Zapola, 36, knew the news wasn’t good.
It was 2018, and Zapola had been having back pain and periods so heavy that she needed an adult diaper. She’d moved to the Wilmington, North Carolina, area in 2015 and hadn’t yet needed to find a gynecologist. At her last Pap test, her doctor said she wouldn’t need one for another three years.
Then, when she desperately needed one, she couldn’t find one. She had to make an appointment in Leland, about 25 minutes away from home.
“I saw a nurse practitioner and will never forget what she told me,” Zapola recalled. “She said, ‘Your cervix looks like it’s been mauled by a tiger.’ And I’m like: ‘That can't be good.’”
Zapola was sent to an ob-gyn in Bolivia, another 20 minutes away, where she had a biopsy. Two days later – in her living room – she got the diagnosis. It was cervical cancer.
Zapola’s radiation oncologist, Dr. Michael Nichols of Novant Health Cancer Institute Radiation Oncology in Wilmington, explained what the nurse practitioner was seeing: “The tumor started in the cervix and grew. What the (provider) was seeing was the actual tumor.”
Zapola left work in tears. “Brittany, my wife, left work, too, and came home to be with me. You almost don't hear the diagnosis when they tell you. You're like: ‘What? This can't be me.’ You're just in complete shock. Before this, I was healthy, I ate right, was very active and still am. I had no other medical issues.”
‘Whoa, that’s gonna be me’
Her first appointment at Novant Health Zimmer Cancer Institute in Wilmington was with the now-retired Dr. Walter Gajewski. They discussed her treatment plan, and she saw the infusion room where she’d be getting chemo. “I had never seen anything like that,” she said. “It's like: ‘Whoa, that’s gonna be me.’ They showed Brittany and me and her sister, Mariah, videos so we’d know what to expect. A day or two later, I met my radiation oncologist, Dr. Nichols. He made everything very easy to understand. He’s such a great guy.”
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They showed Brittany and me and her sister, Mariah, videos so we’d know what to expect. A day or two later, I met my radiation oncologist, Dr. Nichols. He made everything very easy to understand. He’s such a great guy.”Although he’s treated women in their 20s and a few in their 70s, Nichols said Zapola was on the younger side of the cervical cancer patients he generally sees. Cervical cancers are most frequently diagnosed in women between the ages of 35 and 44.
“Cervical cancer is often found on a routine Pap test,” Nichols said. “And that really is the key because they can be found early.”
Cervical cancer can be caused by human papilloma virus (HPV), which can be sexually transmitted. “There’s a vaccine that protects against HPV, which is new enough that it's a little bit early to be seeing trends. But cases of cervical cancer have been trending down in recent years, and that’s probably related to the vaccine.”
Zapola had 28 radiation treatments to her pelvis and cervix and an additional six for a “boost” because cancer had spread to her lymph nodes. She also had six rounds of chemotherapy.
In addition, she had four sessions, in which she was under anesthesia, of radiation targeted directly into her vagina. That’s standard of care for cervical cancer, Nichols said. Patients either have four or five doses of it.
“That’s a direct, internal type of radiation,” he said. “The radioactive source right up against the cervix lets us deliver a high dose to the targeted area where the cancer is located. This allows us to spare other tissues that we would otherwise have to ‘shoot through,’ such as bowel and bladder.”
When it rains …
In the midst of Zapola’s six-week course of radiation, Hurricane Florence hit Wilmington. Large parts of the area were evacuated in advance of the hurricane making landfall.
The Zapolas had wanted to stay in Wilmington since they lived outside the flood zone, but radiation oncology treatment centers were forced to shut down.
Nichols had to evacuate. He was in Washington, D.C., and making phone calls on behalf of Zapola and other patients. “It was a hectic, hectic time,” he recalled. “But we did our best to transfer records and data to other facilities.”
Nichols found a radiation oncology center at Mission Hospital in Asheville, North Carolina, that could treat Zapola. She booked an Airbnb nearby so she, her wife and four friends could go “glamping.” They actually managed to turn an emergency evacuation into a fun getaway. “I never felt alone,” Zapola said. “We had a great time.”
It was crucial that treatment not be interrupted. “With cervical cancer, survival rates go down the longer the time between initial and final radiation treatments,” Nichols explained. “So, it's critical that once you start, you finish as quickly as you can. There isn’t data on that for all cancers, but there is data for cervical cancer.”
It was a rare instance of another radiation oncology practice temporarily taking over the care of a cervical cancer patient. “Delivering radiation has a lot of complexity and nuances, and we’re very targeted with it,” Nichols said. “Before getting radiation, patients have a cradle made that holds them in exactly the same position each time. It’s very precise; we make sure we hit the cervix but miss the spinal cord, the bowels.”
When Zapola left for Asheville, no one knew how long she’d be gone or how many treatments she’d have while she was away. As it happened, she needed only four. She came home to minor roof damage on her rental house – and her remaining treatments.
Zapola tolerated radiation and chemo well. She kept working as a bar manager at Bonefish Grill during treatment. Yoga and meditation, which she’d done prior to her diagnosis, likely helped her remain relatively calm during treatment and evacuation. In addition, she said, “Attitude is a very big part of this.” And hers was positive and upbeat.
“The last day of radiation, me and Brittany and her sister went downtown and partied our butts off,” she said. “It was early – when all the restaurants were opening for lunch. I was done by 4.” You know it’s been a raucous celebration when you’re home by 5 p.m.
As can happen after radiation, recovery has been slow. “You don’t realize how sick treatment can make you,” Zapola said. “I understand why they want you to get in the best shape you can be in before treatment begins.
“My energy level was low for a long time,” she continued. “I have blood in my urine and stool sometimes. I've been seen by urology multiple times, and everything’s fine. It's just all the scar tissue you're peeing out.”
On Dec. 20, 2022, Zapola had another health scare related to her 2018 radiation treatments. She was admitted to the hospital with blood clots in her bladder that were preventing her from urinating. “I was in a ton of pain,” she said. “They removed some clots and put a catheter in me for the duration of my stay. I received lots of bladder irrigation and had some tests done. Urology says it’s all from scar tissue buildup from radiation.” She came home on Dec. 23 – in time to enjoy the holidays.
She’s also gone into early menopause, for which she takes over-the-counter supplements, Paxil and frankincense. Essential oils help with her hot flashes, she said, as do “exercising, maintaining a healthy diet and keeping up positive energy.” Weight gain often accompanies menopause, and Zapola said she’s experienced it, too. (Note: Certain supplements can interfere with medications, so it’s important to consult your doctor before taking something new.)
Nichols isn’t surprised by Zapola’s early menopause: “Ovaries, unfortunately, don’t tolerate radiation very well. Radiation, which can harm the ovaries to the point they stop making estrogen, could certainly cause a woman to go into early menopause. That’s a definite downside.”
Doctor and patient formed a mutual admiration society during Zapola’s treatment. They bonded over a shared love of hockey, and Zapola appreciated how “sweet and sincere” Nichols was. For his part, Nichols said Zapola maintained an amazing attitude throughout treatment, and he wasn’t surprised she’d turned her emergency trip to Asheville into a party.
Top photo: Beth Zapola with Maggie (front) and Ridley, who passed away in March. The photo was taken during her second or third week in treatment. "Both of them were crucial to getting me through treatment," Zapola said. "We spent so much time in the backyard playing ball and laying in the hammock watching the sunset and listening to tunes!"