Managing the psychological impact of breast cancer

Psychologist Dr Geraldine Meechan takes us through the different emotional phases of breast cancer treatment and recovery and provides tips on how to manage the stress and anxiety.

When a woman is diagnosed with breast cancer, it is common and normal to experience a range of emotions including shock, fear, sadness, anger and guilt. Indeed, many women say that, from the time of initial diagnosis, through treatment and even post-treatment, they feel that they are on an emotional rollercoaster with the challenges and changes they face. It’s important to acknowledge that from that initial diagnosis, a process of adjustment and grieving begins as women experience loss, change and at times, isolation.

Surgery

For most women, surgery is the first part of treatment for breast cancer. After the initial diagnosis, decisions about what type of surgery (for example partial or full mastectomy) and options for breast reconstruction are necessary. Common emotions at this time are fear about dying, having surgery and distress about going to hospital and leaving children.

Post-surgery, feeling frightened about results and the next stage of treatment are typical reactions. A woman may have to adjust to ongoing symptoms, for example, pain and psychological issues arise such as feeling a loss of control, independence and facing an uncertain future. Loss of control and independence are particularly challenging for some women as they are used to working, running a household and juggling a full and busy life. To suddenly have to slow down and ask for help or stop usual activities is a huge shift in a woman’s life.

Chemotherapy

As women go through chemotherapy, they often experience anxiety and depression. Some anxiety is about the fear of needles used in chemotherapy treatment and having ongoing blood tests during treatment. Low mood can arise with having to manage symptoms such as nausea, vomiting, hair loss and fatigue. Some woman describe losing their hair as the most distressing part of their breast cancer treatment – their hair is a key part of their identity and this loss can also impact on their sexual and intimate relationships. Problems with memory, concentration and problem solving are common during chemotherapy and can continue once treatment has finished.

For younger women undergoing chemotherapy, grief is commonly experienced in relation to the loss of their fertility and the opportunity to parent.

Radiotherapy

Women typically experience fatigue during radiotherapy. Feelings of fatigue accumulate as radiotherapy progresses and it is important to balance doing what you can with periods of rest.

Some women say that as they near the end of this treatment, they begin to feel very vulnerable as the frequency of contact with health professionals involved in their care decreases. They acknowledge that despite the challenges of treatment and medical intervention, it has been reassuring to have this intense focus on and support for their health.

Hormonal Treatment

For many women, hormonal treatment is necessary. Dealing with the side-effects, such as hot flushes, nausea, weight gain and vaginal discharge, is an ongoing challenge. Some women describe that their fear about the future is triggered each day as they take their hormonal medication – essentially the medication serves as a daily reminder of the impact of their illness and treatment.

Post-Treatment

Some women cope well through treatment and then at the end, they experience a range of psychological issues and strong emotions. Fear of recurrence is very common and results in daily worry and anxiety. Often this is a time when the full impact of what they have been through surfaces and grief can escalate. Women talk about a sense of loss in terms of dignity, control, confidence, relationships, employment and a secure future.

Fatigue is one of the most common long-term effects of treatment. Women are often surprised that many months after they have finished treatment they continue to experience fatigue.  Planning for regular rest periods is important for managing ongoing fatigue.

Being identified as a “breast cancer survivor” is a term that some women object to. A different way of thinking about life post-treatment is as a “thriver”. Some women reflect on their experience and begin to perceive the impact of their diagnosis and treatment in positive ways. For some, their diagnosis has enhanced relationships, deepened their appreciation for life and increased their sense of resilience. Sometimes women describe their diagnosis as a “wake-up call” to make changes in their life, such as focusing on what is truly important to them, clarifying their priorities and making lifestyle changes.

Body Image and Sexuality

From initial diagnosis, through treatment and post-treatment, a range of issues are experienced in relation to body image and sexuality. Women often say that their perception of their body is changed, for example, they see themselves as disfigured as a result of surgery. The breasts, for some women, are part of their self-concept – they identify their breasts with their sense of being a woman and their sexuality, and others also acknowledge the importance their breasts have had in breastfeeding.

Common issues are a reduction in sexual desire and sexual pleasure, anxiety about sexual performance and pain during intercourse. Some women return to sexual activity in spite of these issues for many reasons – wanting to achieve a sense of normalcy again, recognizing the importance of expressing affection and maintaining intimacy. Another reason is because they fear abandonment by their partner if they express a lack of sexual desire or need more time to adjust to the impact of their diagnosis and treatment.

Relationships

A breast cancer diagnosis impacts on relationships with partners, family and friends. A woman’s role within her family and network of friends typically changes as she needs to adjust her usual routine and responsibilities.

Communication can often breakdown between partners and the impact on intimate relationships, as discussed above, can be particularly distressing. Often women reflect on the fact that their diagnosis has revealed to them who their true friends are – as long-term friends and some family members suddenly do not make contact and new friendships are formed with people who step up and show incredible support and understanding.

Coping with children’s reactions to the diagnosis, can also be difficult. Women are often scared about their prognosis and telling their children about what is happening is difficult, as is coping with children’s reactions when they do talk with them. Try to keep the same routine for children as much as possible as this gives them a sense of normalcy and security.

How you can cope

There are many ways to cope with the range of emotions and issues that are experienced from diagnosis, through treatment and post-treatment.

Sometimes women say that they feel a strong pressure to remain positive through their experience – this pressure can come from family, friends and work colleagues. What are perceived as negative emotions such as sadness and anger are normal in the context of breast cancer and it is important to express them rather than suppressing them in a bid to remain totally positive.

Helpful ways to cope can be in talking to a friend, or a counsellor or psychologist. Attending a support group to hear how others have coped and share your experience can be beneficial and empowering. Online support groups are also an option, especially for rural women who may not have a local support group to attend. Writing down your feelings and thoughts or blogging are also good ways to cope.

A counsellor or psychologist can not only offer you supportive counselling, but also support you with different types of therapy. For example, cognitive behavioural therapy is particularly effective for anxiety and depression. Women often discuss that seeing a counsellor or psychologist was helpful as the therapist was someone who was not a close relative or friend and they could talk openly with them and not be worried about burdening them. Learning skills such as relaxation, mindfulness and working with imagery can also be extremely helpful.

Below are a range of strategies that you can use to cope. Not all of them may seem right for you – that’s ok – think about what you need and work with the concept of self-care as an ongoing process for your well-being. Some strategies may be useful at particular times compared to others; some you may begin with and see as a key to your self-care and coping well.

• Keep your attention focused on the present - do something that will make you feel good each day – this will give you a feeling of maintaining and/or regaining control in your life.
• Include rest and relaxation times in your day.
• Eat as well as you can 
• Exercise if you can – gentle to moderate exercise can actually reduce fatigue.
• Listen to music you enjoy, meditate.
• Read for pleasure – not just books focusing on cancer.
• When possible, spend time with supportive people.
• If you feel tired, try to a) Set small, manageable goals, b) focus on what you can do, rather than what you cannot, c) reduce stress

• Keep a journal - writing down your thoughts and feelings can help relax your mind and enable you to make sense of what is happening.

• Say “no” to non essentials – ask yourself - does it have to be done now? done by me? 

• Accept offers of help.  

• “Putting your day to rest” – you may want to use this technique at the end of the day, some time before bed, to allow a time to reflect -  acknowledge what you achieved for the day; consider your plans for the next day.

•   Accept you will have good and not-so-good days.

• If you have children, talk to them about what is happening. 

How Family and Friends can support you and look after themselves too

When a family member or friend is diagnosed with breast cancer, there are many way you can support them. Sitting with them and listening without trying to offer solutions can be particularly helpful. You may also want to suggest they seek professional counselling or find out about local support groups.

Partners

The partners of women diagnosed with breast cancer often experience similar emotional reactions such as shock and fear. Talking with your partner about what you are both experiencing is vital for keeping communication open between you both. Conversely, it’s ok to “take time out from cancer” – do something socially and agree that you won’t talk about cancer during that time.

It is important to acknowledge that you cannot cover all the support that is needed - asking for help from other family members and friends is a key strategy. So, think about giving people jobs – for example, work out a roster of drivers for radiotherapy appointments. Look at what organisations such as the Cancer Society, offer in terms of information, education talks, counselling, support groups and nursing support.

Your own self-care also has to be considered. Treatment for breast cancer can take many months and while a natural reaction is that you want to support your partner 150%, you need to look after yourself in the process. Some partners set up a regular “time-out” for themselves – for example, exercise or having a coffee with a friend. Professional counselling may also be beneficial for you too or attending a support group.

Family and Friends

As previously mentioned, often women find that long-term friends and some family members suddenly do not make contact with them. Sometimes friends and family members do not know what to say or hearing about the breast cancer diagnosis triggers their own fears about cancer and they react by avoidance. If you hear about a friend’s diagnosis make contact and acknowledge what has happened with “I’m sorry to hear about your diagnosis”.

Other things to say are: “What would you find useful for me to help you with?” or “What’s the best day for me to……eg. take the kids for the afternoon?”.

Practical help can make a big difference, so think about:

• Making meals
• Going to appointments and taking notes
• Driving to appointments
• Taking children for an afternoon or overnight
• Doing the grocery shopping and household chores

The rollercoaster analogy is very appropriate given the “highs” and “lows” of breast cancer diagnosis, treatment and life post-treatment for women, their partners, family and friends. Adjusting to the challenges and changes is ongoing and there are many useful coping strategies to consider to ease that process of adjustment.