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When first diagnosed with breast cancer, there is so much to learn in a very short period of time. Being able to absorb all that the doctor is telling you in the face of a crisis can be challenging at best. This section will give you some basic information about a breast cancer as well as advice that will be helpful regarding surgery. Know that every woman is different in their diagnosis and treatment, and asking questions is the key to understanding your individual situation.
I. Risk Factors: A family history of breast and/or ovarian cancer in a mother, sister, aunt, or even grandparent carries an increased risk. This risk is greatest when the cancer is diagnosed before age 50 and seems to reduce in significance with age. Two genes, BRCA1 and BRCA2, have been identified in women and men. They have been found to be altered in as many as 10% of the women with a strong family history of breast cancer. There is also an increased risk of ovarian cancer and a slight increased risk of breast cancer in men with an altered BRCA2 gene. The risk seems increased in families of Ashkenazi Jewish decent. Genetic testing to identify an altered genes is available. However, because of the complexity of its advantages and disadvantages, it is not advised unless recommended by your physician or a genetic counselor. The results of the test must be explained by a genetic expert. Obesity, high fat high caloric diets, high alcohol intake, no children or having the first child after the age of 30, early onset of menses and late menopause, and use of hormones may have an adverse effect on risk in some women. On the otherhand, exercise and a balanced diet may reduce the risk. In 75% of women, however, there are no known risk factors for the development of breast cancer.
II. Types of Breast Cancers: B. Invasive - The tumor cells have spread into the breast tissue outside of the ducts or lobules. Mammography allows detection in some cases before they can ge felt, however, they can be frequently felt on physical examination. These tumors have the potential to spread to the lymph nodes or other parts of the body.
III. Metastatic Disease: The detection of spread may require specific tests in individual patients. It is important to discuss this with your physician so that unnecessary tests can be avoided and the correct tests can be obtained when important to your care. Cancers can behave differently in each individual. Generally, the earlier a breast cancer is found, the better the outcome. Screening can make a difference.
IV. Prognostic Indicators: A. Tumor Size - the actual size of the tumor is measured by the pathologist. Usually, the smaller the tumor, the more favorable the outcome. B. Presence of Invasion - In-situ tumors are very different from invasive tumors. Treatment may not be the same in each case. C. Lymph Node Status - Evidence of tumor spread to the lymph nodes is important information. Lymph nodes without evidence of tumor are associated with the best prognosis. D. Histologic Type and Activity - Types of tumors (tubular, papillary, medullary, etc.) may behave differently from each other. The activity or aggressiveness of each tumor (called grade), regardless of type, is important information in planning treatment.
E. Other Indicators - Examination of the breast tissue by various chemical tests has also identified factors in a tumor which may affect how a tumor grows or responds to various types of treatment.
V. Staging:
Stages for Breast Cancer are:
Stage II
Stage III
Stage IV
VI. Treatment of Breast Cancer: 2. Simple mastectomy - all of the breast tissue is removed and does not include the lymph nodes in the axilla. 3. Modified radical mastectomy - all of the breast tissue and lymph nodes in the axilla are removed. 4. Breast reconstruction is an option for women who have had a mastectomy. It can be done immediately after the removal of the breast or at a later time. Various options are available and includes using (1) the patient's own tissue or (2) implants which have shown to be safe. Discussion with a plastic surgeon is recommended if this is being considered. B. Radiation Therapy: Radiation may be used to treat the remaining breast tissue after a lumpectomy. It can also be used to treat the chest wall after the breast has been removed. Occasionally radiation is given to the axilla (armpit). Advances in giving radiation now provides excellent cosmetic results while reducing recurrences and possibly improving survival. The side effects of radiation treatment may consist of reddening and possibly blistering of the skin over the breast. It may also cause soreness of breast tissue. Skin changes heal fairly quickly after the treatments are completed, but the breast tissue may remain sore. Firmness of the breast may be increased and may never completely go away. This must be considered when the breast is examined after treatment. Primary breast cancer can be treated with breast conservation surgery (lumpectomy) and radiation therapy or with a mastectomy. The results will be the same if the proper treatment is used in each patient. There are specific reasons why one method may be better than another. It is important that these reasons be discussed by the physician. The decision as to which method is best can only be made when all of the necessary information is available and used in evaluating each individual patient. C. Chemotherapy: Many substances from plants or a combination of various chemicals have been shown to kill cancer cells. This information led to the development of what is called chemotherapy. These drugs can be used to prevent the growth of cancer cells which may remain in the body even though the tumor cannot be located by tests. They are given along with the other methods of primary treatment. Chemotherapy can also be given to treat cancer that can be located by tests. It is most valuable in the treatment of cancers that recur. The chemotherapy drugs can be given by mouth or by injection. Normal cells will also be affected by these drugs. The amount of drug that is given must be balanced carefully. Benefit obtained against the cancer cells can not be so harmful to the normal cells that the treatment cannot be tolerated by the patient. The side affects of chemotherapy can be different for each drug and for each patient. There may be a loss of hair, nausea, diarrhea, and a drop in the white blood cell count. These drug effects usually clear up shortly after the treatments are finished. It is important that the patient knows what to expect, how serious these effects can be, and how they will be treated. Patients must ask questions before starting treatment and understand the answers. D. Hormonal Therapy: Cells in the breast are influenced by hormones, and some breast cancer cells are more sensitive to hormones than others. A test of the breast tissue can identify those cancers that have hormone receptors. Cancers that are hormone receptor positive may respond to hormone treatment and achieve excellent results. Hormone treatment is generally well tolerated with few side effects. Studies are now being done to learn whether changes in the hormones may prevent the development of breast cancer and to determine when hormones can be harmful. Estrogens are given when the normal body estrogens have stopped or become quite low such as following the onset of menopause or removal of the ovaries. Hormonal drugs such as Tamoxifen or Megace are used to treat cancers. None of these substances should be taken without a discussion of the dangers and benefits. Patients should ask about their cancer and the use of hormones. Contributed by M.C. Wilhelm, M.D., and Diane Cole, M.P.H. This can be a very busy period, and it may be difficult to think ahead when so much time has been spent at doctors appointments and on gathering information. Below are some practical ideas that may be helpful in planning for surgery and the recovery time afterwards. 1. Make child care arrangements. 2. Buy groceries and organize food so that meals will be simple to prepare upon your homecoming (there are usually no diet restrictions). 3. Consider the purchase of a front closure, sports-type bra (no underwire) if you are having a lumpectomy. A T-shirt or camisole is comfortable after a mastectomy. 4. You'll probably find wearing loose, button or zip blouses the first few days post-op the easiest. 5. Organize help around the house so that you will not have to do any ironing, laundry, vacuuming or lifting for several weeks after your surgery. 6. Stay healthy, avoid people with colds and flu. 7. Stop smoking! Engage in exercise that promotes deep breathing. After trying to get a good night's rest, don't eat breakfast, leave your valuables at home, and arrive at the surgical waiting area at your scheduled time. Bring a good book or game to play while you are waiting. Once you go to the Surgical Admission Suite, you'll see several nurses and doctors that complete the pre-surgery details. After you change into a hospital gown, a needle will be put in your arm that will start fluids and medicines. Finally, you will move on to the operating room. You probably won't remember much until you wake up after surgery. You'll be monitored until your vital signs are stable and you are ready to be transferred to a bed in the hospital or to go home.
After surgery, take pain medication as it is ordered. Research shows that people heal faster after cancer surgery if their pain is under control. Most women say that the breast area is not very painful. Some women are more bothered by pain under the arm if their lymph nodes were removed. If lymph nodes were removed, you may have a Jackson-Pratt (J.P.) drain. This helps prevent fluid build-up in the tissues. The nurse will help you with the care of your drain and teach you how to take care of it at home. These usually stay in for approximately 7-14 days. Lymphedema is swelling that occurs when fluid in the lymph vessels does not flow out of the arm and hand. The amount of swelling can vary depending upon the degree of blockage. When the lymph glands under the arm are removed there is a greater chance for swelling to occur. The cause of swelling can vary with each individual. But it is known that swelling can be caused by radiation treatment, injury to the arm, infection in the hand or arm, and rarely recurrent cancer. Lymphedema can occur many years after surgery or radiation therapy and is usually due to injury or infection. There are some practical steps you can take to promote good lymph drainage: 1. You may help drainage by doing light exercises immediately after surgery, such as lifting your lower arm or gently squeezing a ball several times. Maintain full range of motion in the affected arm following the guidelines of your doctor and the instructions provided by the nurse or Reach to Recovery volunteer.
2. Prevent trapping more fluid in the affected arm by: 3. Avoid carrying heavy objects, moving heavy furniture, or doing other activities which require excessive force or strain on your affected arm. Limit activities which require prolonged use of the arm (pulling, digging, raking). 4. Elevate your arm when resting to help lymph drainage. For example, rest it on the back of a chair or sofa when you are seated, and place a pillow under the arm to raise it slightly when you sleep. Below are suggestions to help prevent injury or infections: 1. Avoid vaccinations, injections or having blood drawn from your affected arm whenever possible. 2. Prevent burns by using padded mits near the oven and by wearing SPF 15 or higher sunscreen when outside or in the sun. 3. Avoid cuts and scrapes by wearing gloves while gardening and by using moisturizers to keep hands from becoming chapped, dry or cracked. 4. Take care of cuts and scrapes immediately by washing them thoroughly and covering with a bandage. 5. Use insect spray to help prevent insect bites. Call your doctor early if swelling occurs, if cuts do not heal, or if infection appears. Signs of infection include red streaks that appear on the arm, or a warm, red, swollen or painful arm.
Contributed by Patrice Neese, M.S.N., R.N., C.S., A.N.P., Good health care requires a good relationship between the patient and the doctor. As with all relationships, effective communication is essential to assure your needs are met. Cancer treatment usually requires the services of more than one doctor and sometimes involves a number of other health specialists. Information can come from several sources. However, it's a good idea to choose one doctor as the primary source of information - the person you can turn to with any concern. Ask How much do I want to know? Only an overview might be necessary. Some people find it threatening to know all the details of what's happening to their bodies and what different treatments are designed to do. They just want to be told what pill to take or what their treatment will be and when it will be completed. They prefer to have most decisions rest with the doctor. Some patients want a simple yet thorough explanation. They may feel better when they know all the facts about what is happening to them. They need to make sure the doctor knows how important it is for them to hear specific details and background information.
How Information is Shared Some women want their doctor to be business-like. Some prefer doctors who are very direct and concise. They don't want a personal relationship - just a sharing of necessary facts. Other women may prefer the more friendly communication style of a doctor who will be warmly sympathetic - especially when an illness requires long-term treatment.
Understanding Your Doctor Although some doctors vary their styles, others have firm views on their dealing with patients. Some doctors try to share everything with patients but use complex technical language. Ask for an explanation when something isn't understood. Try to express as clearly as possible the changes in bodily functions - from sleep and bowel habits to changes in sensation anywhere, from headaches to foot fatigue. Talk over concerns and observations with the doctor, as well as any changes in lifestyle. Here are some basic questions which might be helpful:
What type of cancer do I have?
Remember that the circle of communication exchange is continuous. Write the physicians instructions down and make sure they are understood before leaving the office, so the recommended regimen can be followed properly. Taken from: Talking With Your Doctor, American Cancer Society, Inc. 87-10M-No. 4638-PS
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So much of what people do when faced with a serious illness is to concentrate on the medical aspects of diagnosis and treatment. . . what kind of surgery is needed . . . is radiation necessary . . . . what to do about chemotherapy. Although this is important, women diagnosed with breast cancer can be bombarded with information from which to make decisions. If this is the case, you may be left exhausted and in a place where it is difficult to take care of yourself. The next section of this book is dedicated to giving you information to help you recover not only physically, but emotionally and psychologically. Some call it complementary medicine, we call it taking care of the whole person - inside and out. Complementary medicine includes more than what this book contains. But when it is added to your regular treatment, a more successful recovery is guaranteed as has been proven by breast cancer patients time and time again. If questions come up while reading these chapters, many resources available to you are listed in the last section of this book. It is hoped that you will take advantage of these resources.
Although time can be healing in itself, all women who have experienced breast cancer must deal with the initial emotions that come with being told they have cancer. Emotions are a very real and important part of our lives. How we feel and express our emotions is a big part of who we are and how we deal with various events. A number of emotions can be felt in varying degrees at the time of diagnosis and for months later. Feeling a certain amount of fear is expected, and a normal amount of fear can range anywhere from panic to denial. Usually, what we are thinking at the time will determine how we respond. The first thing we must do to help us cope is to identify any distortions in our thinking. Then we must determine what is, in fact, reality or the truth of our situation. We can put things in perspective by identifying positive examples of our ability to be in control, to love and to be loved. We should recall examples of areas in our lives where we are not helpless (use of unique talents or skills, maintaining a job, caring for a family, participating in our medical care) and areas where our ability to be loved is evident (relationship with spouse and family members, friendships, etc.) Women cope with the diagnosis of breast cancer is a variety of ways, all of which include individual styles depending on the woman's personality. None of these styles are necessarily right or wrong, but it is best to use a variety of coping techniques. Some women are information seekers. They gather information and try to learn as much as possible about the situation. Developing a better understanding can help us feel more in control. Other women take action by jogging, asking someone to pray for them, or by doing the things that they know will help them feel better. Some are very cautious and at times, want to take things very slowly. Others may spend a lot of time thinking over the situation. It is ideal when you can move up and down these coping techniques, using the one that is most appropriate for the circumstance at the time. For many of us, participating in our own care is a very positive way to take control in a situation which can feel very much out of control. How you feel may be different from day to day. Most breast cancer patients report that certain days or certain times of the day are much more difficult than others. Experiencing the emotions discussed in this chapter are normal after a breast cancer diagnosis. But if you find yourself in a depression which seems to significantly affect your daily activities, you should not be afraid to ask for professional help. It is important to take charge of not only physical, but also emotional well-being.
Anger It is very easy to become angry, but dealing with anger takes time. There are a number of ways to deal anger:
1. Ask yourself if anger is helping you. If it is, talk with a person you trust and feel comfortable with when you express feelings of anger.
Denial
1. Helps you to struggle against what appears to be a hopeless situation.
Denial can be ineffective if it:
Depression
Combat depression by: Working through depression takes time and effort. As you work through it, recognize that some things about your life are not in your control. Begin to develop a long-term plan for coping and living fully with breast cancer, and give yourself time to implement your plan. Don't be hard on yourself if it takes a long time or if you find yourself slipping into depression again. Reward yourself with positive activities. When you fall into depression, be persistent yet kind to yourself, in pulling out of it.
Fear Fear of losing control: This fear can be particularly difficult if you are an independent person or if you have high regard for helping or providing for others. Perhaps you are a mother, a homemaker, or a breadwinner for your family. The inability to carry out these roles may cause you to fear a loss of control in your environment and in your own well-being. Fear of physical change: The changes from surgery and/or radiation as well as losing a breast may represent a loss of sexuality and a loss of self-worth. You may feel incomplete, and this can cause:
a. a loss of interest in normal activities including sexual behavior Fear of rejection or abandonment: Cancer, like every serious illness, can give you a sense of rejection or abandonment by friends or family. Normal behavior in your family's past may be misinterpreted. Talking about these fears and letting them understand your feelings can bridge the gap. Family counselling may be necessary to reach better understanding by all members. Fear of Death: The fear of dying may not be as great as the fear of not living to do all the things you've dreamed of and planned, such as seeing your children grow, building a house, and being a grandmother. Breast cancer is life threatening, but most women do not die from this disease. Coping with the possibility of death may require counselling. It is important to express this fear with your doctor or other health care professional. They can give you information which will help to put your situation into perspective. Faith and or religion can provide an inner strength and can help you to live with your disease. Contributed by Carla Wheaton, U.Va. Student Intern, Robert S. Brown, M.D., Ph.D., Clinical Professor of Psychiatric Medicine, and M. C. Wilhelm, M.D. References: Johnson, Judi and Linda Klein. I Can Cope. Minneapolis, Minnesota: DCI Publishing, 1988.
Coping A cancer diagnosis takes a toll on the patient and her family physically and emotionally. When something comes along that is out of the ordinary, we may need to look for help and develop new coping skills. There are sources of help which will be discussed in this chapter.
Support Groups Some patients report that their friendships change when they are diagnosed with breast cancer. Friends may begin to distance themselves from the relationship, and it is difficult to understand why this happens. Usually it is because hearing that a friend has cancer can be very frightening for them, and they may begin protecting themselves from their own fears. It is important to understand that this is usually not a personal rejection, but perhaps a painful reminder about their own mortality which they may have difficulty dealing with. Support groups are particularly helpful when it comes to understanding personal situations such as changing friendships and family relationships, body image, children's questions, and personal fears. It is a place where patients can cry and laugh together, a place where people do not have to feel alone. Support Groups are not for everyone, and each individual should make their own decision as to whether they should attend.
Visualization and Imagination Provided for you is a relaxation exercise which can be used at any time. Remember that learning to relax takes practice and time. Try this exercise at least a couple of times a day. Good times to relax are in the morning before getting out of bed and again at night. With practice, this will become an easy way to relieve stress anytime. VISUALIZATION EXERCISE Get in a comfortable position, either sitting in a comfortable chair or lying down. Uncross your legs and arms. You might want to put on some relaxing music. Take a deep breath, and hold it as you let go of your thoughts. Then let your breath out slowly as you think relax and let go. Do this three times and then begin to enter your imaginary place as you continue to breathe deep comfortable breaths. Today your imaginary place may be a vacation spot, your own back yard, the woods where you walk or a fantasy place - any place where you can feel comfortable. Now fill in the details. Look around. Are there trees, flowers, grass, the ocean, a favorite chair? How is the air - warm and balmy, cool and refreshing? What do you smell? What are the sounds -birds singing, leaves or grass rustling, waves lapping the shore, children's voices? Now walk around, feel the ground under your feel, the air brushing your cheek; begin to become part of the scene. Now it's up to you. Wander around or find a nice place to sit. Create your own story. Enjoy yourself as long as you wish. When you are finished, imagine yourself slowly returning. Give yourself time to stretch and adjust before you sit up. It will feel as if you were on a mini-vacation.
Muscle Relaxation It may be helpful to train the body to relax the muscles. This can also help us feel better. One way to do that is to use relaxed breathing, then give different parts of your body signals to relax and let go. It's good to start at one point of our body and work towards another. Some people like to start at their head and work down to their feet. Others like to start at their feet and work up to their head. It's best to start away from the place of discomfort. For example, if our head hurts, we might want to begin relaxing our feet first. MUSCLE RELAXATION EXERCISE Get in a comfortable position, and turn on some relaxing music if you'd like. Take a deep breath, and hold it as you let go of your thoughts. Then let your breath out slowly as you think relax and let go. Continue to breathe deep comfortable breaths. Begin sending messages to specific areas of your body as you slowly repeat the following message: My right foot is heavy and warm. My right foot is heavy and warm. Relaxation is flowing into my foot. My right leg is heavy and warm, my right leg is heavy and warm. Relaxation is flowing into my leg. My foot is heavy and warm, etc. Continue to move around your body relaxing legs, pelvic area, back, abdomen, chest, shoulders, neck, face, and scalp. Now you will feel heavy and relaxed, warm and comfortable. You can remain this way for awhile or allow yourself to drift into sleep. Always remember to stretch before you get up.
Thought Stopping Using Thought-Stopping is a way to help you deal with these irrational feelings without ignoring them. Here are some things that can be done: Take a deep breath and say stop very firmly. Tell yourself that this is not a good time to deal with this. Do this persistently each time irrational thoughts come to mind. Get up, write down irrational thoughts, read, or walk around to help you gain perspective. Before going back to bed, try a visualization or relaxation technique to help you relax and get to sleep. When irrational thoughts come to mind, it is important to recognize that a problem should not be approached in a panic. But it shouldn't be ignored, either. Find ways to help reduce the panic (get up, listen to music, etc.), with the understanding that emotional thoughts can be dealt with this in a much more rational way at another time. Sleep is a very important part of healing. This thought stopping technique may not work well the first time. But practice will help you be better able to relax and go back to sleep.
Other Stress Management Suggestions 2. Use music and art constructively in helping you deal with your cancer diagnosis. Listen to soothing music and express your feelings through music and drawings. 3. Take care of yourself by getting exercise, eating right, and by getting enough sleep. This makes you feel better physically and emotionally.
4. Pamper yourself- Contributed by Lee Adams, Ed.S., U.Va. Pain Management Center Exercise for the patient who has had breast surgery is important to the entire body and mind. But specifically, it will speed up recovery from the effects of surgery. Any surgery on the breast, whether a lumpectomy, removal of nodes under the arm, or a mastectomy, will cause soreness and discomfort. While the immediate healing process is occurring, exercise of the area (including the arm or shoulder) should be at the physician's direction. Once healing is progressing, exercise of the arm and should is very important. The shoulder joint and the muscles will tighten. If they are not used, their function will be limited. This will lead to discomfort as well as unnecessary loss of use. The Reach to Recovery Program of the American Cancer Society has an excellent manual which gives specific exercises to assure a full range of motion. These include reaching, pulling, and rotating the arm behind the back to further stretch the shoulder joint. These exercises must be done on a regular schedule to assure full use of the arm and shoulder. Programs using aerobics and swimming can also accomplish the same results but should be done under the direction of a knowledgeable instructor. Fitness levels will vary among women according to age and whether you have exercised in the past. The amount of energy you may expend will also depend on the type of surgery or treatment you have had. Someone recovering from a lumpectomy, for example, may feel like exercising sooner than a woman recovering from a mastectomy. Similarly, women undergoing radiation treatment may have different energy levels from someone undergoing chemotherapy. Setting reasonable goals, therefore, is important. We should always keep in mind our own physical limitations and not exceed the pace which is comfortable. We should not hesitate to slow down or even stop exercising is any unusual pain is experienced. The University of Virginia's Breast Resource Center holds a weekly Getting Stronger exercise class for women who've had cancer. Started in 1995, it is led by a knowledgable instructor who can provide guidance on appropriate exercises based on individual situations. A video is also available if you are interested in exercising at home. Call the Breast Resource Center at 434-243-6015 for more information. If you are unable to carry out the exercises, and if you do not have a near normal use of the arm and shoulder, you should consult your physician and consider the help of a physical therapist. Above all, you should try to balance your daily life with moderate amounts of exercise, plenty of rest, relaxation, and good nutrition. Contributed by Brenda Good Physical Exercise and the Sense of Well Being One of the best things you may do to help cope with the diagnosis and the treatment of cancer is to become physically fit. Physical fitness is the ability to use your body athletically to the fullest extent of your potential. Your potential for physical fitness may seem small or insignificant to you. You may think that even the slightest amount of exercise is impossible, that illness has sapped your energy, or you just never exercised much anyway. You may be correct. Is it possible, on the other hand, that you haven't given this matter very much thought? Think it over now. Do not reach down and try to touch your toes, but reach up and try to grab the stars. Life is an athletic event. Fundamentally, life is physical movement or exercise. To live fully, in the physical sense, you need to move your body regularly, athletically, and sensibly - achieving your optimum physical fitness level. Exercise alone, of course, will not bring you contentment or peace of mind. Physical exercise is the focus of this chapter, but I want to acknowledge the important balance between the body, the mind and the spirit. The motto of the U.S. Army is be the best you can be. This principle conveys the message: strive to be the best you can be in your body, mind and spirit. Do it like an athlete. Set reasonable goals, train regularly, and reach your potential. I encourage you to find ways to nurture your spirit and to stimulate your mind - to exercise them daily, while I talk with you about exercising the body. As a Psychiatrist, I have rarely if ever treated a physically fit depressed person. I rarely treat psychiatric patients of any type who are physically fit. Over the years I have worked with patients who were coping with cancer. When they were able to exercise, they felt better. Sometimes, however, physical limitations created the need for innovative forms of exercise: squeezing a ball with the hand, touching a board with the feet, weight lifting with books. These and many other forms of exercise can be performed even by those confined to bed. It has been found that exercise reduces anger and hostility and increases cheerfulness. People who exercise regularly are more accepting, confident, hopeful, helpful, optimistic and patient; and they are less tense and anxious. There is general agreement in the scientific literature that regular exercise improves mood, work behavior, cognitive performance (provisional), and psychological functioning in mentally retarded children. Contrary to intuition, regular exercise increases energy level. Many people are tired at the end of an exercise session, but after a shower they notice more energy and can work more efficiently. The following is the National Institute of Mental Health Consensus Statement on Exercise and Mental Health:
1. Physical fitness improves mental health and well being. Becoming physically fit is an excellent way to enhance your capacity to cope with the diagnosis and treatment of cancer. By striving for your most realistic level of physical fitness, you become an athlete. You don't have to run a marathon in order to be physically fit. Even people who are confined to bed can find some way to exercise on a fairly regular basis. All that is needed is a commitment. I hope you will seriously consider the known advantages of exercise. Regular exercise can help you cope with your condition. When you start thinking and acting like the best athlete you can be, your sense of well being may pleasantly surprise you and your family. (See Appendix A for Dr. Brown's recommendations for starting and exercise program.)
References Contributed by Robert S. Brown, Ph.D., M.D., Clinical Professor of Psychiatric Medicine, School of Medicine, University of Virginia, Charlottesville, Virginia
The American Cancer Society has developed guidelines to help Americans reduce their chances of developing cancer. Although some diets have been associated with cancer, it does not mean that a certain diet actually causes the disease. There is no doubt that eating nutritious foods is good for overall health. A variety of foods in the diet give the body the nutrients needed for proper metabolism and function and optimal immune status. Nutritional needs may be different for patients getting chemotherapy or radiation therapy. Several resources are available which might be helpful. Contact the UVa Breast Resource Center (243-6015) for more information. Outlined in this chapter are the American Cancer Society guidelines which provide a basis for good overall health along with possible protection against cancer and cancer recurrence. They are meant to assist you in making more healthy food choices.
DIETARY GUIDELINES: Reducing Total Fat Intake In general, studies done on animals suggest that a low fat diet reduces overall cancer risk. However, human studies do not show a clear cut relationship. Currently, researchers are working to determine if different types of fat (such as olive, fish oils, and fat from red meat) effect breast cancer cells. Daily amounts of fat may play a role as well. Dietary guidelines recommend that the total daily fat intake should be reduced to 30% or less of our daily calories. The average American fat intake accounts for about 40-60% of daily caloric intake. Dietary fats are also very high in calories and can contribute to extra pounds. Cut down on the amount of high fat foods you eat each day. High fat foods include whole milk dairy products, red meats and butter or margarine. Substituting leaner foods such as baked poultry, skim milk products and reduced or fat-free salad dressings and margarine will help lower fat intake.
Lowfat Cooking and Meal Planning Hints Use non-stick pans. Use canola or olive oil cooking sprays to reduce or eliminate oils when cooking meats or vegetables (such as stir-fry). Bake, roast, or simmer meat to reduce fat, and drain off excess fat before serving. Serve one or more meatless dishes each week. Some ideas include pasta, beans and rice, vegetable and bean soup or vag-burgers made with soy. Use a gravy skimmer to pour off excess fat from pan drippings. Then make gravy by letting liquids cool then adding flour or cornstarch slowly and blending well. Refrigerate soup or stew that contains meal or poultry until the fat hardens on the surface. Then, remove the fat before serving. Read labels carefully! Ingredients are listed in the order of quantity. Choose foods that do not have fats or oils, or foods that have fat and oil very near the end of the listed ingredients.
Reducing Intake of Salt-Cured, Smoked, and Nitrite-Cured Foods
Nitrite-Cured Foods:
Smoked-Cured Foods: Smoked and Cured Foods to Cut Down On:
Anchovies Eating More High-Fiber Foods High fiber foods may be cancer-protecting foods and are loaded with nutrients required for good health. Most Americans get very little fiber daily, and the recommendation is to eat 25-35 grams of fiber each day. It is also important to drink plenty of water when consuming a high fiber diet to prevent constipation. High Fiber Cooking and Meal Planning Hints
Use more fresh fruit for desserts and snacks. Include Foods Rich in Vitamins A and C Daily Vitamin A, C, and E seem to act as cancer-protecting substances, and they are important in maintaining good nutrient balance. The recommended amount of vitamins A and C can be obtained through fresh fruits and vegetables. Vitamin E is found in vegetable oils, wheat germ, nuts, seeds, and whole grains. It may be harder to obtain optimal amounts of Vitamin E if following a lower fat diet. While a daily multivitamin/mineral supplement is acceptable, it appears that all of these vitamins are best used by the body when taken in their natural food form." Ways to Add Vitamins A and C to Your Meals Eat dark, leafy vegetables such as spinach or collard and mustard greens. These can be sauteed lightly with olive oil and garlic, or used as substitute for lettuce in salads. Add vegetables such as carrots, broccoli and sweet potatoes to salads and casseroles. Drink 100% real fruit and vegetable juices rich in vitamin A and C rather than drinking coffee, tea, and carbonated beverages. Snack on moderate amounts of trail mix made with nuts, dried fruits, and sunflower seeds. Sprinkle wheat germ or sunflower seeds over steamed vegetables for a nutty change of taste. Including Cruciferous Vegetables in the Diet Cruciferous vegetables, named because of leaves bearing the shape of a cross, may also be cancer-protecting and are good sources of fiber. Cruciferous vegetables include:
Keeping Alcohol Consumption Moderate Breast cancer risk may increase with increasing alcohol intake. Alcohol is high in calories and lacks nutrients. Consume no more than the equivalent of 2 ounces of alcohol a day. Two ounces of 80-proof liquor is equal to 6-1/2 ounces of wine, 18 ounces of regular beer, or 25 ounces of 3.2 beer. Avoiding Obesity Diets low in fat and high in fiber tend to also be low in calories. Too many extra pounds may be risky so it is important to follow the guidelines listed:
Special Tips for Eating Out and Traveling Soy Soybeans and soy products such as tofu, soy flour and soymilk contain compounds that can help lower elevated cholesterol and may play a cancer protecting role in the diet. While the cancer protective role of soy is far from proven, soy is a high protein, cholesterol free and low saturated fat food. It may be worthy to include more soy foods in the diet as a meat replacement. Of note, it is not recommended that people take soy supplements (such a genistein or soy isoflavones) until soy's role in cancer prevention is more clear.
Taken from: American Cancer Society, Minnesota Division, Inc., Twin Cities Oncology Dietitians Organization Char Kilgore, M.P.H., R.D., Project Coordinator
Body Image, Sexuality, and Fertility Body Image
For many women, body image is the way we look physically. But it is also how our body's function and our sense of control over it. Actually, our body image depends on many things - our sense of self; our identity and sexuality; our culture and societal values; our ability to bear children and our age. Body image is who a person believes they are as an individual. Sexuality
Sexuality means different things to different women. A woman's sense of their sexuality is related to their body image. Sexuality isn't about pleasing others, or proving ourselves more beautiful than others. It is about really caring for ourselves. Sexuality can include sex drive, intimacy, physical closeness, and touching.
- Decreased sensation can cause decreased arousal and excitement because of nerve removal. Side effects of chemotherapy and radiation can also change body image because they can affect how your body feels. Some of the more common side effects are:
Side effects of cancer treatment that can be especially hard are hair loss and fatigue. Your nurses and doctors will talk to you about these throughout your treatments. Feel free to talk to them anytime. Hair loss - Hair loss can be devastating. In our society, it can be associated with personality, femininity, religion, and attractiveness. Certainly this can affect our identities and self-image. Hair loss can be a sign to others that a person is sick, and it can remind you of your illness when you look in the mirror. Fatigue - Fatigue can be an overwhelming feeling of tiredness. For cancer patients, rest doesn't always help them feel better. Fatigue affects each person differently. It can keep a person from doing their daily activities, and can alter a woman's image of themselves as a mother, partner, and friend. Fatigue can lead to feelings of frustration, sadness, and even depression. Response to Changes in Body Image and Sexuality How your family and partner respond to you can influence your sense of sexuality and body image. Expressing love through touching and holding can be very helpful. It is most important to talk to your family about the changes the cancer diagnosis has had in your lives as a couple and as a parent. Infertility Some chemotherapy causes early menopause. Symptoms of menopause include hot flashes, sweats, sleeplessness, mood swings, irritability, and vaginal dryness. Many women also have less sexual drive which can be frustrating and stressful. Adjusting to menopause is hard enough for any woman, let alone for the woman who has had a cancer diagnosis. This, too, requires adjustment in a woman's sexuality and self-image. Chemotherapy can also cause infertility, or the inability to have children. This can affect how a woman sees herself, and possibly her role in life. Since the type, dose, and length of treatment can cause infertility, women who want to keep their fertility should talk with their doctors. This might influence their recommendation for treatment. Emotional Factors It helps to know that the feelings you go through (see the chapter on Dealing With Emotions) affect your sexuality and self-image. How you respond to treatment will depend on many things. It might be helpful to think about each of these points and how they might apply to you.
1. Your feelings about your femininity. Ideas to Help Yourself
1. Take some time to explore your thoughts. Think about what you value in yourself. The image you have of how your body appears and how it works has been changing all your life. It may continue to change during your cancer treatment and recovery. Your body needs plenty of time to recover, and your mind and emotions do also. It helps to understand how your image has changed and how you feel about yourself. Your recovery can only be helped along if you let someone close to you know how you are feeling.
Contributed by Patrice Neese, R.N., M.S.N., C.S., A.N.P.,
No matter how long it has been since your surgery, the selection of a breast form is an important step in restoring confidence and comfort. There are many styles to accommodate every surgery, every shape, and size, and every circumstance. The teardrop shape has always been a popular prosthesis. It can be worn on either right or left side. The underarm extension follows the natural shape of the breast and is often suggested for radical or modified radical mastectomy. Another style is an asymmetrical form, precisely designed for either side. It offers a soft, full shape, with upper chest and underarm extensions. A most popular style is the triangular shape which has a natural drape. The underarm extension is minimized to fit the latest techniques of retaining more underarm tissue. It is also available with skin-friendly support offering the freedom some women desire. A very soft, flexible silicone shell answers the need to supplement missing tissue and enhance reconstruction. Many ladies have asked for a lighter weight prosthesis - yet meeting the comfort of balance. A new prosthesis has be very well received - 15% lighter! For post-surgery and radiation, a camisole has been designed of soft cotton knit which has polyfill fluffs for shape and a shirttail that will keep in its natural position. Each breast form is hand-crafted, giving a look and feel that is soft and natural. The silicone is shaped to offer a comfortable and secure fit. Thinly tapered edges eliminate bulges, and a perfectly balanced weight mains that even larger sizes can be worn with ease. Swimwear is of important interest to many women. Beautifully constructed and detailed swimwear is now available. Features include slightly higher necklines for some people and built-in bra pockets. There is also a slightly weighted, inexpensive swim form that many ladies enjoy for leisure wear. Remember that a woman's beauty and joy of living cannot be dismissed by an operation. Most needs and desires can be met with the vast selection of products available. Contributed by Edna P. Wood, The Something Special Shop
Looking Your Best During Treatment Just as radiation and chemotherapy treatments are designed to meet your medical needs, caring about physical appearance is important for emotional well-being. While receiving treatment dry skin, hair or eyebrow loss, skin discoloration, or changes in your nails may occur. These conditions are not unusual, and are most often temporary, but that doesn't make dealing with them any easier. And when you are not feeling your best, either physically or emotionally, it's hard to maintain an interest in appearance. Attention to skin and make up during this time can actually help make you feel better. Just a few minutes and a few simple steps can make such difference! Regular skin care routine may need to vary somewhat. Generally, skin is drier and more sensitive during radiation and chemotherapy treatments. Each morning and evening, cleanse with a mild soap or creamy cleanser designed for dry or sensitive skin. Use a gentle touch rather than a scrubbing motion, rinse well with cool to lukewarm water (never hot) and pat dry. Always follow cleansing with a moisturizer. A sunscreen is also advisable, and a moisturizer/sunscreen combination is a convenient choice. Don't neglect the chin and throat areas; suggestions for the face also apply to those areas, too. Make-up shades used in the past may not be quite right during this time. A matching foundation is always best. A slightly darker or lighter foundation may have to be used. It can be kept fresh by applying a translucent, loose powder. Adding some color to the face with blush and lipstick in an flatter shade also might help. If eyebrow or eyelash loss is experienced, there are some tricks to camouflage those areas until natural brows and lashes return. Eye shadow, brow color, and mascara, applied in certain ways, can also provide pleasing results. Some important things to remember: cleanliness is essential. Never, ever share cosmetics or skin care products with anyone. That includes brushes, sponges, and other tools used to apply these products. Try to avoid putting fingers into jars and bottles. Using cotton-tip swabs or something similar helps to keep bacteria out of products. Check with your physician before using any products (including perfume or deodorant) on treated areas. If any irritation or discomfort is experienced, products should be discontinued. It is important to advise the physician if any skin changes are noticed. Wigs, hairpieces, and scarves are fashionable, fun and effective options in dealing with any hair loss. Saving a lock of hair prior to beginning treatments is a good idea so that the color can be matched later if necessary. Many women find that their own hairstylist is willing to cut and fit wigs. Scarves come in a variety of sizes and materials, and there are several good how-to books available describing the many ways they can be worn. A special program -- Look Good, Feel Better -- is sponsored by the American Cancer Society and the National Cosmetology Association, and the Cosmetic, Toiletry, and Fragrance Association. Trained volunteers use step-by-step instructions through a hands-on routine of skin care and make-up application based on an individual's special needs and preferences. The program includes all the information covered in this section and samples of appropriate beauty care products are provided at no cost. Information on wigs and scarves is also available through the Look Good, Feel Better program. Special sessions may also be arranged to address specific needs. For further information on Look Good, Feel Better sessions and other related resources, contact the local American Cancer Society Office at 434-978-7423. Contributed by Mary Ann Clark, American Cancer Society: Look Good, Feel Better Volunteer
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| Chapter 3
Resources
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Now that you know about the many options you have for finding information and taking care of yourself, this last section provides local resources so you can follow-up on any suggestions in this book that might be helpful. If you can't find what you are looking for in the first phone call, remember to continue to ask questions until you get the answers you need. Some women who have been diagnosed with breast cancer find it helpful to gather as much information as possible about their disease and its treatment. Learning more about your situation may help you feel more in control and provide a sense of taking charge. Many patients diagnosed with breast cancer today are given choices for treatment, and well informed patients may feel more comfortable in this decision making process. The University of Virginia's Breast Resource Center offers the most current information on cancer detection and treatment. A growing reference library includes information on current practices in detection, treatment, and breast reconstruction. The Shared Decision Making Program, an interactive video, is available to help women make decisions about their breast cancer treatment. The library also provides access to the internet and resources to help guide you through the many websites pertaining to breast cancer. Health professionals are available to answer questions and will assist you in finding the information you need. The Breast Cancer Education Series is a one day program held twice a year for patients, their friends and family members. Provided by members of the Breast Team, it provides current information on treatment, nutrition, genetics, hormones, and other topics. Ongoing breast cancer support groups are also available at the University of Virginia. You won't want to miss the Getting Stronger exercise class and video for women who have had cancer. The free class is offered once a week in the Cancer Center and provides appropriate exercises for women recovering from breast surgery. A video is also available free of charge to cancer patients and will enable you to exercise at home when it is convenient for you. It includes two parts; one for getting started right after surgery, and a second, more advanced part. Ramona's Room is an excellent resource for people whose appearance my be altered by therapy. Named in honor of a breast cancer patient, Ramona's Room provides a place where you can find wigs, turbans, hats, and scarves to help you deal with hair loss. For more information about classes or other information, contact the Breast Resource Center at 243-6015. Contributed by Diane D. Cole, M.P.H., UVa Cancer Center's Education Coordinator
Cancer Patient Support Service Studies have shown that the most successful way to treat cancer, or any other illness, is by treating the whole person. Patients come to us with many concerns and many personal resources. If we can accentuate the use of personal resources while minimizing the concerns weighing on a patient's mind, coping with cancer becomes easier. A part of the medical team available to patients at the University of Virginia is the Psychosocial Team. This is a team of professionals made up of psychologists, social workers, chaplains, and educators. Each of these resources is available to cancer patients to help with the variety of counseling needs that arise during diagnosis, treatment and the follow-up period. Support groups and special programs are offered to give the full range of services that help support patients and families.
The Patient Support Services of the University of Virginia Cancer Center is a place where the creative support is expressed. Patients and families coming to the clinic are greeted by caring volunteers who offer refreshments and a warm smile. Should a patient have a particular need, the volunteers open the avenues of communications to the psychosocial services, the physicians and other health professionals, as well as community resources. Each year, a Reunion welcomes patient currently and formerly treated for cancer in an afternoon of celebration and stories. Whether someone has a practical need, such as a place to stay or help with understanding bills, or a more subtle need like a kind listening ear, the Patient Support Services are available and excited to be a part of healing and hope. For more information on this program please call the University of Virginia Cancer Center Patient Support Services at (434) 924-2477. Contributed by Susan Goins-Eplee, M.Div., UVa Cancer Cancer Chaplain and Cancer Patient Support Service Coordinator Reach to Recovery is a free American Cancer Society rehabilitation program for individuals who have had breast cancer. Trained volunteers will visit you to provide emotional support and also to supply you with an information packet. A referral for visitation is made by the your physician to the American Cancer Society office, and the volunteer contacts you to arrange a convenient time to visit. Visits are usually made while you are in the hospital. But if you have been discharged from the hospital, an appropriate location can be arranged later. Volunteers will also schedule visits prior to surgery, while you are still in the decision making period, should you wish to discuss your upcoming surgery. All Reach to Recovery volunteers have had breast cancer and some type of breast surgery (a lumpectomy, mastectomy, and\or reconstruction) at least one year prior to having been carefully selected as a volunteer. They have also been approved by two physicians as well as an American Cancer Society's Virginia Division Coordinator. Each volunteer must attend training sessions led by qualified Reach to Recovery volunteers, and be assisted by volunteers on several visits before being certified to make visits alone. During the visit, the volunteer will give you a kit containing a temporary breast form, information regarding hand and arm care, exercises, sample letters for loved ones (men and children - if needed), and a list of local stores where breast prosthesis can be purchased. A temporary breast form will be given to mastectomy patients to wear until they are able to purchase a permanent form. With the many new approaches to the treatment of breast cancer, you are matched according to specific needs with a volunteer who has had similar radiation, chemotherapy, reconstruction, or other treatment. The information provided will help you gradually return to a normal lifestyle physically and emotionally. You are encouraged to ask questions that are of concern. You will be given the name and phone number of your particular volunteer should you wish to raise additional questions later in the recovery period. After the visit, you will also receive a follow-up card or call by the volunteer to check your progress. There may be a spouse, significant other, or family member who feel upset and are unable to talk about their concerns to their loved ones. You may suggest that he talk with your volunteer's spouse. Call the local American Cancer Society at 434-978-7423 for support in dealing with breast cancer concerns, and a volunteer will be contacted to assist in whatever way is appropriate. American Cancer Society Resources
Other resources: 2. Wigs are available at no charge. 3. Brochures include:
Contributed by Mary Jane Morris, Coordinator, ACS Reach to Recovery Program
Prosthesis, Clothing, Wigs, and Cosmetics Charlottesville
Richmond
Communicating Your Health Care Choices - In 1990, Congress passed the Patient Self-Determination Act. It requires health care institutions to tell patients and the people in their communities about their rights under Virginia law to make decisions about their medical care. These rights include the right to accept or refuse care and the right to make advance directives about their care. How Do I Exercise My Health Care Rights? Under Virginia law, every human being of adult years and sound mind has a right to determine what shall be done with his own body. Doctors help their patient to exercise this right when they give information about medical treatment they are recommending. When you agree to the recommended treatment, you have given your informed consent. You also have the right to refuse the recommended treatment. What Happens If I Cannot Give My Consent? Many people worry about what would happen if, due to mental, physical or emotional problems, they are unable to tell their doctor whether they want or don't want recommended medical treatment. Under Virginia law, adults may sign documents that make their choices about treatment known to their doctor or family in advance, or that will name someone they trust to make these decisions for them at such times. These documents are known as advance directives. Virginia law allows two types of advance directives - the Natural Death Act declaration, sometimes called a living will and the durable power of attorney for health care, also called a health care proxy. What Is a Natural Death Act Declaration or Living Will? The Virginia Natural Death Act is a state law that allows an individual to sign a document that tells people how to care for them if they ever have a terminal condition and are unable to make decisions for themselves. This document is called a declaration; it is often referred to as a living will. There are two basic types of living wills: In one type, individuals decide in advance whether they want doctors to perform on their behalf what the law calls life-prolonging procedures, and they put their decision in writing. In the other type, the individual names someone else to make that decision for them. If any individual has signed one of these living wills, they should be sure that their doctor has a copy so that if they ever suffer from a terminal condition and can not make treatment decisions for themselves, the doctor will know what to do or who to ask, as the case may be. Copies of a Health Care Proxy and a Living Will Declaration can be found on the next f | |||||||||||||||||||||||||||||||||||||||
