"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.  

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.

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.

Sexuality And Breast Cancer Treatment

There are many ways in which standard breast cancer treatments affect a woman's sexuality, both in the short and long term.  The removal of even part of a breast (lumpectomy), let alone the complete removal of one or both breasts, represents a loss and a change in a part of the body that is loaded with sensitive nerve endings and very involved in sexual arousal.  Having only a lump removed along with surrounding tissue, can involve severing nerves that were very involved in producing physical sensation in that area. In addition, the alteration in physical appearance caused by breast surgery, may cause a woman to experience herself as less womanly and less sexually desirable. As if that is not enough to process, females who undergo chemotherapy, will usually be thrown into menopause, with all of the changes that entails, such as fatigue, possibly severe hot flashes and decreased vaginal lubrication. Being jolted into menopause via chemotherapy is a very different physical and psychological experience than the experience of a natural and gradual cessation of menses occurring over a period of years. Adding to the menopausal effects of chemotherapy, drugs like tamoxifen and aromatase inhibitors are routinely prescribed to further reduce and suppress estrogen. Sex can become painful, and the walls of the vagina can atrophy and become very thin and dry. Vaginal yeast infections and urinary tract infections are also more likely to occur. (For more information on this, see Dr. Michael Krychman's blog post http://community.breastcancer.org/blog/sex-matters-vaginal-dryness/.)

The good news is that breast cancer survivors are still very capable of experiencing sexual desire and sexual pleasure. However, due to all of the physiological changes induced by breast cancer treatment, women often come to feel that they need to become acquainted all over again with who they are as sexual beings. This realization may come as a surprise, since oncologists often glide over these sexual sideeffects, in their zeal to rid the body of cancer, and because psycho/sexual/emotional aspects of cancer treatment are complex and outside of their area of expertise and comfort. It is important for cancer survivors and psychotherapists who work with them, to understand that along with physical and emotional healing, time and patience may be required for patients to uncover the sexual trauma related to the treatment, and to discover who they now are as sexual beings. Living in the realm of "the new normal", cancer survivors may need to learn what works now for them sexually.  For example, where and for how long they want to be touched in order to achieve sexual arousal and gratification, may be different from before cancer treatment. Partners of cancer survivors also need to be educated that what was pleasing and stimulating before the treatment, may be different now, and that their partners' bodies may not function in the same way.