The Health Blog

Sometimes doctors are given second chances, and it is possible that the belated recognition of the ‘teacher’ who was provoked in the doctor and nurse by the patient will make it possible to explore the ‘childish’ behaviour at the next visit.

Other feelings in the doctor can be seen to have developed in response to the patient. Irritability, anger and even a particular degree of sadness or despair become subjects of study. Indeed, the feelings may be projected from the patient, via the presenting doctor, into the group. For instance, unconscious aspects of the patient may be seen particularly clearly when her or his ambivalent feelings reveal themselves by a split in the feelings and sympathies of the group members themselves.

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Contraceptive consultations are favoured occasions for revealing overt or covert sexual problems. By attending for advice on birth control, patients are already revealing that part of them that is sexual, and the subject of difficulties with their sexual life can be broached with less difficulty (it is never easy). Doctors and

nurses concerned with giving contraceptive advice should be comfortable discussing sexual matters. They need to be skilful in their ability to receive and manage their patients’ confidences and to recognize when and how to refer those they are unable to help.

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Expectations of what will happen during consultations for family planning influence the choice between clinic or general practice, or between known or unfamiliar doctors.

Patients may attend a community family planning clinic because they have heard that patients have a ‘thorough examination’ there. On the first attendance the patient may look disappointed when she is told that the examination of that (sexual) part of her body – her genitals and breasts – can be left until later. She wants an examination of this part of her about which she has unspoken anxieties -perhaps doubts that it is ‘good enough’ to be shown to a partner, or that, untried, it may not function well enough, or might become out of control.

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A very anxious and distressed woman in her mid-30s came into a family planning clinic asking for postcoital contraception because of extramarital intercourse the night before. She explained that she was married to a long-distance lorry driver and they had three children. Four years previously her husband had undergone a vasectomy. Since then she had been surprised to find she could not allow sexual intercourse. She said she had never enjoyed it, but had assumed that things would improve once the fear of pregnancy was removed. Instead, she was devastated to find there was a marked deterioration. The doctor asked her why she thought this was so, and she said she had found it more exciting when there was a chance of pregnancy. Then she added that she did not think it was fair that her husband could now behave as he liked on his frequent absences from home, and that he need fear no repercussions now that he was sterile. The doctor asked if she had been distressed about her husband’s infidelity before the operation, and she said she had preferred not to think about it then. Although she had been angry, she had been so busy she had put it to the back of her mind. Recently, she had become frightened about her own lack of sexual feelings and she had drifted into a casual relationship with a friend, to see if she could respond to a fertile man.

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‘In general, Third World service programmes are primarily accountable to their governments and/or western donors who fund them.. They often have demographic rather than service priorities’ (International Women’s Health Coalition, 1986). Thus individual needs and the quality of the service are pushed down the list of priorities, and the acceptability of a method and greater security against pregnancy are considered more important. The service can become completely impersonal; for example, in Mexico it is policy that 90% of women who have a termination of pregnancy should have an IUD fitted. In Indonesia, poverty certificates have to be shown for access to some contraceptive services. Moroccan women queue in waiting halls without their underwear, to speed up throughput. It can be seen that the needs of women and the needs of the population can be at odds when resources are limited.

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Many women find that losing their hair from chemotherapy is the most disturbing thing that happens. (Talk with your oncologist about what to expect from your chemotherapy. Not all the drugs used cause the same degree of hair loss.) You should go to see someone who sells wigs while you still have your own hair so that there will be the best chance for a good match of color, texture, and style. Of course you may decide that you want to deal with hair loss by using hats, scarves, turbans, or a combination of all of these. Even when you are told that hair loss may or is likely to happen to you, it is still traumatic. Since this may begin to happen within the first three weeks of treatment, you will want to think about this as soon as you can. If you have a close friend or family member who can go with you to look at wigs, plan to go with her. As you decide on the type of wig to purchase, bear in mind that a synthetic or mixed fiber wig is not only less expensive but is also lighter, cooler, and more comfortable to wear.

Your doctor or nurse can give you an accurate guess as to when you might lose your hair. It is very predictable and depends on what chemotherapy drugs you are receiving. Some women find that their scalp becomes quite sore or tender a few days before the hair loss begins. This may not happen to you, but if it does, consider it a forty-eight-hour warning.

There is no way to make the actual experience of losing your hair anything less than a crisis. As hard as this is to imagine, it will be easier to bear once the hair is gone. The anticipation of the loss and the actual process of losing it are the worst. One strategy for when your hair begins to go is often very helpful for many people. You will know with certainty when this is happening; if you are wondering whether your hair is coming out, it is not. If you can muster the courage and determination to do so, consider having your hair buzzed and/or your head shaved. Many women find that their hairdresser is more than willing to meet them before or after hours at the salon or even to come to their home to do this. Your husband/friend/partner could also provide this service to you. Taking it off, all of it, puts you in control and gets you through it as quickly as possible. Once the hair is gone, you will start to adjust to your new bald head.

One woman whose hair came out in the early spring was enormously helped by her husband’s tender suggestion of putting clumps of hair in and near the bushes and trees in their yard. He said that birds would use the hair to build their nests, and this turned out to be true. In the fall, when the leaves were gone and the nests visible, she found several empty nests warmly and softly lined with her hair.

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Radiation therapy, following lumpectomy, is given five days a week for approximately six and a half weeks. The specific schedule of your treatment will be discussed with your radiation oncologist and nurse. If you are also getting chemotherapy, radiation may be administered at various points:

* Prior to chemotherapy

* Following chemotherapy

* “Sandwiched” in the middle of chemotherapy

* Concurrently with chemotherapy

* Recent studies have indicated the value of radiation for some women who have had mastectomies. If this is suggested to you, it will probably be at the end of your other treatments. You may have more trouble with skin burning when the radiation is directed at your chest wall rather than at a breast.

Most women find their radiation treatments to be relatively uneventful. It can be tiring to make a daily trip to the hospital, and it certainly is a daily reminder of what has happened to you. It may also require a major psychological shift to think of radiation as life-giving, instead of as an encounter to be avoided whenever possible.

In Hester’s clinical practice, she has encountered some women who have a very difficult time psychologically during radiation therapy. Again, for most women, these treatments are quite manageable and sometimes more of an inconvenience than anything else. However, Hester believes that two groups of women may have real trouble during these weeks:

* Women who have a childhood history of sexual abuse

* Women whose primary coping mechanism is avoidance

Women in the first group may have a strong reaction to having to lie prone and still while a large and powerful object is suspended over them. These feelings may be intense but confusing, as they come from semiconscious or unconscious memory. If you know that you have a history of sexual abuse, it would be wise to talk over these feelings and your planned treatment with an experienced oncology social worker or other mental heath clinician. Unless you choose to do so, you do not need to tell your medical team of your history. You can simply say that this treatment is difficult for you and that, therefore, you will require a little extra time and attention.

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We have heard college age and adult sons and daughters of mothers with breast cancer describe the fear of being excluded from the real situation at home and their anger when they discover that certain details have indeed been kept from them during their absence in order to spare them unnecessary worry. We have also known many who opt to maintain some distance and separation from what is happening at home. As is the case with their younger siblings, most college age and young adult children will do fine as long as they are given honest information and the chance to participate or not, as they choose.

Some adult children may try a combination of different coping mechanisms, sometimes fully engaging in social situations, sometimes retreating and withdrawing from peers, except those who also have a parent struggling with a life-threatening disease. At other times, these young adults might find solace in rituals that provide comfort; some are based in conventional religious practices and others are less traditional in origin. Still other adult children might display different forms of rebellion, such as a predilection for unusual risk-taking activities.

Having a mother (or father) who goes through cancer is likely to impact significantly how a young person thinks about, and shapes, major life decisions. The extent to which this medical crisis affects the maturing children depends on whether or not the cancer treatment succeeds in vaulting the patient into remission. In most cases when the treatment is, or appears to be, successful, the children go on about their business. Obviously, when a family is not so fortunate, and the patient’s condition worsens, the effect is profoundly different.

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Some husbands have told us they were surprised that from the very beginning they felt they were unimportant to the doctors and other caregivers trying to help their wives. Some of them had a difficult time getting used to the fact that for the duration of their wives’ treatment, the doctors attending their wives, as well as the entire hospital staff, were focused completely on their wives’ well-being and did not ever acknowledge the husbands’ needs. This is, of course, uncomfortable and unfortunate. Full attention and support is often focused on the patient, and to some extent, this is completely appropriate. Husbands/partners may need to look elsewhere to find support for themselves. It is not really reasonable at this time to lean on your wife. She needs to lean on you. Husbands/partners need to talk with their own family (perhaps siblings or parents) and friends.

Husbands/partners often experience a total sense of loss of control from the first minute of the diagnosis. Events unfurl extremely fast. Appointments are often made for tests and for surgeries without any attempt to consult with them in any meaningful way. This, too, is less than ideal, but the realities of busy hospitals are that appointments are made without much consideration of anyone’s schedule. The emphasis is on getting the patient what he/she needs as quickly as possible. In most cases, the husbands had confidence in the doctors helping their wives, and they trusted the doctors’ judgment and were content to stay in the shadows. However, some husbands want to emphasize the point that if you or your partner feel that something is wrong with the way the diagnosis is being made or the treatment is being planned, you must reassert some measure of control and press the doctors for further explanations. In the rare case that you feel something is very wrong, you must discuss your feelings with your husband and get a second opinion. You both must feel comfortable with the physicians you ultimately choose. Remember, however, that you are the patient. If you don’t have confidence in the doctor, find another one that you trust. Don’t allow yourselves to be stampeded by the medical establishment.

In all likelihood, some member of your family will have an especially hard time coming to grips with your illness. It may be one of your children or it may be your mother or father. A partner can provide immeasurable help by spending time with this child or with whoever most needs extra attention.

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You need a sympathetic ear and advice about how to deal with several issues simultaneously: your own feelings and those of other family members, including perhaps your parents, siblings, children, and friends. You may not feel up to the emotional requirements of dealing with so many people all at once. Both you and your partner may need advice about how best to inform family and friends; your clergy member should be able to help you sort this out and may also connect you to leaders within your community who stand willing to organize other members to help you in the weeks and months ahead.

You and your partner will most likely want to have your intense, almost overwhelming feelings validated by your religious leader. She should respond to your concerns by saying either “I know how you feel” (only if she truly does from personal experience) or “I can imagine how you must be feeling.” Most people we know resent the presumption of another person assuming s/he knows how you feel—even a professional clergy or physician—unless s/he has actually lived through a similar crisis. Even professional training does not entitle other people to assume that they really know how you are feeling; the truth is that, unless they have had the same experience themselves (either personally or through an immediate family member or close relative), they really do not know what you are going through.

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