Monday, April 08, 2019

"Breaking Bad" and Psychological Transformation After Cancer Diagnosis

In the very popular television series, Breaking Bad, the main character's personality begins to undergo a dramatic change after he receives a diagnosis of stage IV lung cancer.  Walter White is ostensibly a meek and mild high school chemistry teacher at the beginning of the series.  The cancer diagnosis seems to bring out parts of his character that were hitherto unexpressed and unknown either to Walter or to his wife. Slowly and shockingly over the course of the five seasons that the show aired, Walt's character displays increasingly ruthless and sociopathic thought patterns and behavior. By the end, Walt is finally able to admit to himself and his wife, that the reason he did all that he did (i.e. cooking extremely high quality methamphetamine and all of the murder and mayhem that ensued), was that it made him feel truly alive, in ways that he had never felt previously. We watch him sacrifice everything, including his relationships with his family and ultimately his life, in order to give expression to needs and feelings that had apparently been split off and dissociated, and which had as a consequence never been integrated into the other parts of his personality.  The cancer offered the excuse and the permission that Walt seemed to need, for his long held back frustration and rage to find a way out. It also seemed to free him to aggressively pursue his desire, something which he seemed unable to do before, resulting in his brilliance going largely unrecognized and unappreciated.

Although most cancer patients/survivors don't undergo the dramatic personality changes that happened to Walter White, they may begin to think and act differently as a result of their cancer experience.  With a new awareness of mortality and limits, a cancer survivor may begin doing things that she had always wanted to do but had been putting off, like a trip to an exotic destination, sky diving, painting, writing or some other creative pursuit. She may also reevaluate her friendships and decide to let go of the ones that pull her down more than they support her. Sometimes cancer survivors are also empowered to begin to address issues in their marriages or with their long time partners that have been simmering for a long time. I would never consider cancer a blessing, but it has the potential to bring matters into clearer focus. It sometimes gives us the permission we need to speak our minds, be more fully ourselves, and courageously follow our hearts desire.  

Friday, March 29, 2019

Can Breast Cancer Survivors Safely Take Estrogen or Hormone Replacement Therapy?

The answer according to Dr Avrum Bluming and Dr Carol Tavris in their (2018) book, Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer, is a resounding "yes." These authors make the case that it is safe for menopausal women to take estrogen either in the form of estrogen replacement therapy (ERT) for women who have undergone hysterectomies, or in the form of hormone replacement therapy (HRT), i.e. estrogen plus progesterone, for women who have not undergone hysterectomies. Furthermore they believe that HRT is a reasonable option for treating menopause-associated symptoms and improving quality of life even for breast cancer survivors. In asserting this, Bluming and Tavris are swimming against the medical tide. To back up their assertion, much of their book is devoted to a review of the available, scientific research including the Women's Health Initiative (WHI) study and the HABITS study (Hormonal Replacement Therapy after Breast Cancer - is it safe).

Regarding the 2002 WHI findings and reports, Bluming states that the finding that HRT increased the risk of breast cancer was not statistically significant. Furthermore the study's sample was not representative of healthy women - nearly half of the sample were current or past smokers, more than a third had been treated for high blood pressure, and 70 percent were seriously overweight or obese. By 2005, the WHI was saying that their findings show that women taking ERT actually had a decreased risk of breast cancer. 

In 2004 the HABITS study was stopped prematurely after only 434 women were enrolled, because after two years, 17.6% of the HRT group and only 7.7% of the non-HRT group developed new breast cancers. There were no new breast cancers in women taking estrogen alone and the increased risk for the women on HRT turned up only among those who were also taking tamoxifen. Despite their being significant problems with the design of this study including the lack of uniformity in the choice of hormone regimen, it was regarded as having lent significant weight to the WHI findings.

Bluming also cites the results of other research studies, including six that were done in the United States, in which treating breast cancer survivors with HRT did not increase their risk of recurrence of breast cancer when compared to matched control subjects. He conducted his own pilot study over a fourteen year period, in which he followed 248 women whom he had given HRT. His goal was to determine if these women showed an increased incidence of breast cancer recurrence in the same breast, developed cancer in the other breast, or developed breast cancer metastases elsewhere in the body. What he found is that they did not. A few did have a recurrence of breast cancer, but not at a rate higher than the comparable women who were not on HRT.  

Most research stopped after the WHI results were published, but some investigators continue to evaluate existing studies. In 2006, Dr. Pelin Batur and her colleagues at the Cleveland Clinic published a review of fifteen studies totaling 1,416 breast cancer survivors using HRT compared with a cumulative control group totaling 1,998 patients. The majority of the women in the HRT group began using HRT between two and five years following their diagnosis. On the average, they remained on HRT for three years. Compared to the control group, the women on HRT had a 10 percent decreased chance of recurrence of breast cancer and a slightly reduced mortality rate from cancer and other causes.

We know that hormone therapy for menopausal women has enormous benefits including protection against heart attacks, strokes, bone fractures, diabetes, colon cancer, depression and Alzheimer's disease. According to Dr. Harriet Hall, by the 1990's, the evidence indicated that estrogen reduced the risk of heart disease by 40-50%, hip fractures by 50%, colon cancer by 50%, and Alzheimer’s by 35%. With benefits like these and research results like the ones cited in the Bluming/Tavris book, it's clear that the question of treating menopausal women with hormones needs to be revisited. Additional carefully designed and controlled large scale studies are needed to determine as precisely as possible, what the risks of taking hormone therapy are, for whom and under what circumstances.

Unfortunately most members of our medical community seem to believe that this issue is settled. It may take a lot of women and a lot of physicians bringing up the topic of hormone therapy with their physicians, colleagues and friends to get the matter reopened. Go for it ladies! The quality of women's lives depends on it!

Bluming, A. & Tavris, C. Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer

Hall, Harriet. 09/04/2018 blog post in Science Based          

Wednesday, August 29, 2018

iBreastExam - A Cheaper and Less Stressful Prescreening Tool for Breast Cancer

          Two researchers, Mihir Shah and Matthew Campisi have developed a new prescreening tool for breast cancer detection at Drexel University's School of Biomedical Engineering, Science and Health Systems in Philadelphia. This new tool is called the iBreastExam (iBE) and it uses a new ceramic sensor technology to detect subtle variations in breast tissue. It is a battery operated, hand-held machine that can provide results after only a few minutes via a mobile app. Other advantages of the iBE are that it's cheaper than a mammogram, painless, involves no radiation and can be done by a trained female health care worker in five minutes anywhere.  

          In 2016, a study [1] performed by a group of researchers at the Perelman School of Medicine at the University of Pennsylvania showed that iBE demonstrated acceptable sensitivity and specificity in a cohort of patients who had already had a positive breast exam or an abnormal screening mammogram. This was a study designed to validate the iBE's ability to detect lesions.  These researchers state that mammography and ultrasonography demonstrate sensitivity rates of 85-88% and 93-97% for a population of known detectable findings. The iBE in this population demonstrated a comparable sensitivity of 85.7%. Furthermore the iBE meets the threshold of a pre-screening device when compared to the current prescreening tool, i.e. a clinical breast exam, which has a sensitivity of only 50-60%. 

           In this study cohort, the iBE was able to detect all but two of the malignancies, both of which were less than 1 cm in size which is an important threshold for a prescreening device. Directly comparing the sensitivity of cancer detection demonstrates that both the iBE (83%) and the mammogram (91%) are reliable tools to identify patients with cancer. While the sensitivity of cancer detection is lower, the specificity of iBE (74%) surpasses that of mammography (51%) showing that the iBE is better than mammography at not falsely identifying patients with cancer ( i.e. false positives). For this reason and the fact that the iBE is painless, quick and easy to undergo, and doesn't involve radiation, it appears to be a screening tool that won't trigger undue anxiety and stress in patients. In addition its modest cost relative to other screening tests should make it very attractive to insurance companies and medical providers, especially those in economically deprived areas. 

1. Broach et al. World Journal of Surgical Oncology (2016) 14:277.

Wednesday, March 08, 2017

Evidence Of A Correlation Between Depression and Anxiety and Cancer Mortality

     On January 25, 2017, The BMJ, a respected British scientific journal, published the results of a research study in which the unpublished data from 16 prospective cohort studies initiated between 1994 and 2008 were pooled to examine the role of psychological distress (anxiety and depression) as a potential predictor of site specific cancer mortality. The participants in this research, 163,363 men and women, 16 years of age or older at the time of study induction, make up nationally representative samples drawn from health surveys for England and Scotland. Participants were initially free of a cancer diagnosis, and were asked to fill out questionnaires with items that were designed to capture symptoms of depression and anxiety over the previous four weeks. According to the study's authors, these questionnaires are widely used in population research and have been validated against standardized psychiatric interviews.

     The results of this pooling of unpublished data are interesting. They showed that those with the most psychological distress (depression and anxiety), had a higher rate of death from selected cancers than those with the lowest psychological distress. This was after adjusting for other known risk factors such as adverse health behaviors and reverse causality (it is well known that a diagnosis of cancer can give rise to psychological distress so these authors attempted to control for this by excluding participants with self reported cancer malignancy at study entry). The most consistently robust effects were evident for cancer of the colorectum, prostate, pancreas, esophagus and for leukemia.

     These authors state that their findings could be important in advancing understanding of the role of psychological distress in cancer etiology and cancer progression. They go on to explain that psychological distress could be considered along with other factors such as smoking and obesity to develop an algorithm that would have predictive utility for common cancer presentations such as colorectal, breast and prostate cancer.

     Among the limitations of this study cited by the authors is that the assessment of psychological distress with the instrument that they used, referred to the preceding four week period. A short bout of depression or anxiety is highly unlikely to be relevant to cancer etiology, but the authors state that there is evidence that rates of recurrence are high for psychological distress. Therefore they state that a single administration of a distress inventory seems to capture cases of long term depression and anxiety. Nevertheless, if serial assessments of depression and anxiety had been done over a period of time, that would lend more credence to the findings.

     The results of this study suggest associations between depression and anxiety and cancer mortality, and lend support to the idea that psychological distress could have some predictive capacity for the occurrence and lethality of some types of cancer. It is important to note that further research is required to clarify the extent to which each of the associations between psychological distress and cancer are likely to be causal and to examining the precise mechanisms by which they exert their influence. We would need to investigate exactly how depression and anxiety affect cancer. For example, how much of any effect that we see is related to poor lifestyle choices that a depressed person might make, such as compliance with treatment screenings or treatment regimens. Alternatively, we need to learn how much of the impact of psychological distress is associated with biological mechanisms, such as prolonged inflammatory responses.

Friday, March 20, 2015

Using Viruses to Cure Cancer - Getting The Word Out

On March 6th, just two weeks ago, an HBO television program called Vice aired a documentary about how viruses, some of which used to kill human beings in large numbers, are now being utilized to treat and actually cure cancer.  Major cancer research centers such as The Mayo Clinic in Minnesota, MD Anderson Cancer Center in Houston, Texas and The University of Pennsylvania in Philadelphia, are conducting groundbreaking trials with cancer patients using genetically modified viruses such as the common cold virus, the measles virus and the HIV virus. According to the physicians involved in these trials, we are on the verge of a major breakthrough in cancer treatment. As the maker of this documentary states, it is important to get the word out about this so that these technologies can be fast tracked and be made available to anyone who needs them.

Dr. John Bell at the Center for Innovative Cancer Research in Ottawa, Canada, is credited with being the first to discover that viruses can actually attack cancer cells without harming the healthy cells around them.  One of the most successful series of ongoing trials has been happening at The Children's Hospital of Philadelphia under the auspices of Dr. Carl June. Dr. June and his colleagues have for about the last four years, been using the HIV virus to treat leukemia in children whose cancer had progressed to the point where other standard cancer therapies were no longer of any use. In these trials, genetically engineered HIV is being used to reprogram the t-cells in the patients' bodies, so that the patients' immune systems can tell the difference between the cancer cells and normals cells, and begin to attack the cancer cells. In this documentary, Dr. June informs us that so far, thirty-nine children have participated, and ninety percent have experienced complete remission with no remaining trace of their cancer. Most seem to be staying in remission for several years. He goes on to tell us that this particular treatment is "probably going to be available and FDA approved in 2016", and that using modified viruses to treat cancer represents "a true paradigm shift".

There are about 300 kinds of cancer. Which viruses attack which cancers most effectively? There is still a lot of research that needs to happen to answer this question. At the Mayo Clinic, they are reengineering the measles virus, and then using it to treat bone cancers.  At MD Anderson, they are treating glioblastomas or brain cancers with a modified common cold virus and patients who had no hope are going into remission.

View the entire VICE documentary here:

Friday, March 13, 2015

Treating Posttraumatic Stress in BRCA Survivors

In an earlier post, I described how breast cancer survivors are often the victims of posttraumatic stress, and frequently display many of the signs and symptoms that are associated with that psychological diagnosis. Things like heightened anxiety, hypervigilance, a change in outlook on life, negative beliefs and expectations about herself or her body, and a change in risk-taking behaviors may be present not just during treatment, but also after treatment has ended.

Now I am going to describe how psychodynamic psychotherapy can help with the disturbing PTSD symptoms that survivors may be experiencing. In addition to discussing problematic symptoms and how the survivor is coping with them, the psychotherapist will work on understanding and appreciating the significance to the client of not only having had breast cancer, but also of each of the treatment interventions to which she was exposed. Today's mainstream cancer treatments, i.e. surgery, radiation, and chemotherapy all act as powerful triggers of complex emotions and earlier traumatic experiences. It is crucial to understand how each breast cancer patient mentally engaged with each of them. Every woman’s breast cancer journey is unique, and is a function of not just her encounters with her medical providers, medical interventions and our health care system, but also of her earlier life experiences. How we engage with the present is always influenced by what we experienced in the past.

It is vital that the psychotherapist assist the client in uncovering and comprehending the psychological meaning to her of what she has been through. For example, what did each treatment modality symbolize to this particular client? Did the chemotherapy represent something positive that was going to destroy cancer cells and restore health, or did it feel like an evil intruder that was wreaking havoc throughout her body? Did the accompanying loss of hair, a well-known side-effect of chemotherapy cause the patient to feel less attractive to her spouse or to potential romantic/sexual partners? Was it experienced as the destruction of an important symbol of femininity? Did it feel like a potent connection to an early attachment figure was destroyed?  Perhaps an early caregiver who expressed love by fixing and combing her hair? Did it have both of these meanings as well as others?

How did all of the physiological and cognitive effects of the treatments (fatigue, nausea, memory loss, loss of mental sharpness etc.) affect things like self-esteem, perception of a benign world, sense of bodily vulnerability, or the person’s sense of their future possibilities?

In order to effectively treat symptoms like depression, anxiety and insomnia over the long term, it is often crucial that psychological meanings be patiently explored, in the context of a safe, psychotherapeutic relationship in which trust and mutual respect have been established and are being carefully nurtured.

Sunday, March 08, 2015

Posttraumatic Stress – A Frequent Consequence of Breast Cancer Diagnosis and Treatment

Given the limited state of our current medical knowledge, a diagnosis of breast cancer followed by extensive cancer treatment usually constitutes a prolonged trauma. Therefore when breast cancer survivors appear in psychotherapists' offices, they are likely to be suffering from some degree of post-traumatic stress even if their reasons for seeking treatment seem to be unrelated to their cancer experiences.

Patients, their families and their medical providers may be unaware that it is not unusual for survivors to continue to experience things like irritability, difficulty concentrating, trouble getting a good night's sleep or heightened anxiety for some time after breast cancer treatment has ended. An increased sense of vulnerability is also a very common aftereffect of cancer treatment even when the cancer was caught at an early stage, and patients are told at the end of their treatment that they are cancer-free.

Survivors may display ways of coping that are typical for persons who have experienced trauma. They may for example, become hypervigilant with respect to cancer. Every time they have a new ache or pain that does not have an obvious cause, they may begin to think that the cancer has returned and experience acute emotional distress. Similarly every time they hear that a food, a product or something else in the environment may be correlated with an increased risk of cancer, they may immediately try to avoid that substance. This is of course, a common and reasonable way that humans try to increase their sense of control and decrease their level of free-floating anxiety. However in today’s news/media environment, research study results are often reported without the media outlet taking the time to determine which of the studies have been well designed and which are merely preliminary or speculative. One media outlet after another may pick up and report the same story without ever investigating the actual significance of a study’s results, yielding to the pressure of our twenty-four hour news cycle. It is easy to see how a person who is trying to reduce her exposure to environmental toxins can end up feeling more stressed and overwhelmed.

Posttraumatic stress symptoms are often part of “the new normal”, a phrase that has been adopted by oncologists to describe how their patients are different after cancer treatment from how they were before cancer treatment. These symptoms often make up a significant part of “the new normal” and they can linger for a long time. Fortunately psychotherapists now know a lot about how to identify and treat them, so that survivors can obtain relief and an increased sense of control over their lives.