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Posts Tagged ‘breast cancer’

Localized estrogen is not thought to be absorbed systemically, which means that blood estrogen levels remain in the menopausal range; if there is any absorption, it is scant. At that level, it does not increase risks of breast cancer. Unfortunately, the “prescribing information” (PI) for localized hormones is required to be the same as for all estrogens, although the risks are significantly different from those of systemic estrogens.

Last month, I attended the North American Menopause Society (NAMS) annual meeting, where I heard that a request has been filed with the FDA to amend the PI to fit more accurately what’s known about localized estrogen use.

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Breast cancer doesn’t really have much in common with sex. But I know it’s hard to be very interested in sex when you have cancer or are recovering from cancer treatments or are working to feel good about your body again after having had cancer.

However, anyone interested in staying vibrant and healthy (not to mention sexy) should be interested in the breakthrough research on breast cancer just announced in the journal Nature.

Turns out, genetic mutations caused by cancer and the unique genetic “fingerprint” they leave may be the new frontier for cancer treatment and could suggest treatments targeted to specific genetic mutations.

This research, which is the scientific equivalent of putting a man on the moon, is an outcome of the Cancer Genome Atlas, a federally funded study to map genetic changes caused by common cancers. Breast cancer is the third (after colon and lung cancer) to come under intense analysis, with several hundred researchers tracking the genetic changes caused by unmetastized tumors from 825 women.

As a result, four new subtypes of breast cancer based on 30 to 50 genetic mutation have been identified, which suggest new approaches to treatment and also explains why some one-size-fits-all treatments may not work.

“When treating breast cancer, we offer specific therapies that have been tested on large populations of cancer patients,” said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City in an article for HealthDay News. “…This research helps move us to the point where we will look at a tumor’s genetic makeup and tailor a specific treatment that will attack the tumor cells based on the tumor’s genetic fingerprint.”

This research may alter cancer treatments by

  • Basing treatment on the genetic signature of the cancer rather than its location in the body. For example, one of the less common but most deadly breast cancers is genetically very different from other breast cancers but very similar to ovarian cancer, suggesting that treatment for this breast cancer could also be similar to that for ovarian cancer.
  • Avoiding unnecessary, ineffective, and potentially harmful treatment. For example, one of the most common cancers, whose growth is fueled by estrogen, was routinely treated by an estrogen-blocking drug. The genetic study identified two different types of this common cancer, which suggests more targeted treatments. So, besides receiving appropriate treatment, cancer patients may also be able to avoid potentially harmful treatment. “Targeted therapies allow for more effective treatment of tumors, while minimizing the treatment of tumors with less effective therapies and their subsequent side effects,” said Dr.Bernik.
  • Suggesting new avenues for research. When these subtle genetic differences are identified, new research and treatments can begin. For example, some women with the same HER2-enriched gene respond to treatment by the drug Herceptin, and other women don’t. Now, ongoing clinical trials will try to identify the differences in the genetic makeup of the HER2 tumor that may explain the different responses to treatment.

While this research may be seismic for oncologists, it will be years before the laborious process of testing and approvals are complete and we begin to see the results on the ground and in our doctors’ offices.

Still, this affirms the need for informed, individual health decisions, weighing all factors, instead of applying one-size-fits-all thinking. And, taking the long view, this is great news for our daughters and granddaughters.

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“I cannot give you another regimen that has as many good health benefits as exercise. Hands down. Exercise improves life energy and sexual energy; your body image will improve. I can’t give you a better, free intervention.” So said psychologist Helen Coons in a recent speech to breast cancer survivors.

Any gentle exercise regimen during recovery is good. It helps ease many of the distressing symptoms of cancer treatment: insomnia, fatigue, weight gain, depression, poor body image, sexual dysfunction.

Yet, one of the best forms of exercise, according to several recent studies, is yoga.

Yoga combines gentle stretching and holding of various positions, which helps with balance, flexibility, and muscle tone. But it also involves a meditative component. The breath work in yoga “stimulates the parasympathetic nervous system and causes the body to relax and the blood pressure to drop,” says Maureen Ryan, sex therapist and nurse practitioner.

Yoga also encourages a sense of mindfulness—being aware of the moment and present to it. When the recent past is full of pain and the future is full of fear, “mindfulness brings people back to the present moment,” says Ms. Ryan. In one study of women with gynecological cancers who were experiencing difficulty with sex, the most helpful component of the experimental program was the practice of mindfulness.

Yoga is so effective because it exercises the body and calms the mind.

A small but significant study found that several weeks of Restorative Yoga, which involves gentle poses, usually with support from pillows and other props, reduced depression by 50 percent in women with cancer. (All had breast cancer; about one-third were still in treatment.)

Another larger study focused on the effect of two types of yoga—Hatha Yoga and Restorative Yoga—on cancer survivors who were having difficulty sleeping, a common problem for survivors and one that isn’t easily alleviated with medication.

Half the group attended 75-minute yoga classes twice a week and also practiced yoga at home. At the end of a month, this group was sleeping better with less medication than the control group. The group also reported less fatigue during the day.

In yet another study, breast cancer survivors reported better body image and less self-consciousness. After doing yoga for two months both at home and in group sessions, these women also had less pain, better muscle tone, more flexibility, and greater weight loss than a control group that had just exercised minimally for 30 minutes a week.

In fact, yoga is seen to be so effective in recovery that several top cancer centers, such as Memorial Sloan-Kettering and Stanford Cancer Center, provide their own yoga classes to patients.

Any form of exercise is helpful, but evidence suggests that the kind of mind-body regimen that yoga offers is particularly effective. Yoga classes are also easy to find—most communities offer them, and they are affordable.

Besides, anything that reduces depression, increases energy, improves body image, and reduces pain has to be good for sex, too.

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Here is the second part of our talk with Mary Jo Rapini, a therapist who specializes in intimacy counseling (the first part focused on the mind). She often receives referrals from oncologists who have treated women and men for cancers that, post-treatment, require a re-thinking, re-learning, re-framing of their intimate life. Says Mary Jo:

When a couple is referred to me, it’s usually because the cancer part of their life is now under control. That is, they have their diagnosis, understand staging, and have been receiving treatments, with some evidence that treatments are working. Until that point, survival is the critical concern for most couples.

This time of diagnosis and sheer survival can actually bring couples closer — they realize that what they used to argue about is petty. On the other hand, really bad relationships will many times get worse. Women who are sick might ask themselves what they’re doing, what happened in their relationship. When that’s the case, my first step is figuring out the emotional environment. Where is this couple now, at this moment in time?

When we do come around to talking about intimacy in the relationship, my first concern is with pain. Painful sex is a really common problem for survivors. Low energy is another problem. People receiving treatments or recovering from extensive treatments have very low stores of energy.

Women recovering from surgery and radiation for any kind of cancer, including breast or uterine cancers, may be adjusting to new losses and scars that affect body image, sensation, mobility, or all three.

And while thinking about restoring sexuality may be pretty far from her mind, the truth is that reengaging with a lover has been shown to really help with recovery. Sex is very healthy—for our bodies and our minds—and a loving intimacy is certainly one of the best things we have to live for.

Get help. Your intimate life may have been perfect your whole lives, your relationship sound, your commitment to one another unshakable, but still a good counselor can give you things to think about, assignments and exercises that can help you to re-engage after harrowing course of treatment. Consider it a gift to yourselves, a reward for surviving.

Planning is everything. Spontaneous sex was great when you were teenagers, but now things are different. Intimacy is best now when it is anticipated and planned. Choose a day of the week when nothing much else is going on. Choose a time in that day when you are likely to have less pain. Be sure you have an hour of pain medication in your body before engaging in cuddling and caressing.

Set a new goal. Sexuality is often so goal-oriented we forget that sex is good for more than just orgasm. When orgasm is difficult to reach—for either of you—why not take it off the table and enjoy the benefits of sexual intimacy without it? Massaging erogenous zones is extremely pleasurable—provided there is no pain—whether we achieve orgasm or not. It still circulates blood, increases healthy hormone production, and helps couples bond to one another. Set a new goal: bonding and intimacy. Use that vibrator to make one another purr, and let purring be enough for a while.

Become a prop master. Pillows, pillows, pillows. If you spend any time in a hospital, you will notice that nurses really know how to use pillows to prop people into comfort in bed. Well, we can use them too, to prop us into comfortable positions for intimate caressing and lovemaking. We may not have needed them before surgeries or treatment, but may really need them now, when a slight change in position or angle may make a huge difference in comfort and painless lovemaking.

Patient exploration is the key. Most of us don’t know how our bodies will respond to treatment. Our mileage varies. So patiently exploring how treatment may have changed our sense of touch and taste and smell, in addition to pain and pleasure—this takes time. Be a scientist about it. Experiment, experiment, with all the patience of a field biologist!

Use a light touch. When we get chemo, our skin can become very sensitive. Chemo changes the epidermis of the skin. Our sense of touch shifts. That’s where things like feathers, mitts, and lotions become so important as tools for exploration, because your body is different on chemo. Figuring out those changes is the work ahead for both of you.

Some of the chemos are so toxic any intercourse would be too rough on fragile tissues. That’s a good time to think about a different form of expression, beyond intercourse. Find new ways to connect.

Wetness now, more than ever. Most women can’t handle intercourse during treatment. Chemotherapy can be very drying, and our skin, our vaginal tissues, are just too fragile. But if you are going to try intercourse during treatment, lubrication is extremely important. Try a lube that has a trace of silicone. I especially like Liquid Silk and Yes for this purpose. A little bit of silicone can give that lube sticking power. Too much is hard for a dry vagina to clear on its own.

Slow down. Pretend you are new lovers, virgins, even. Go very slowly. Be prepared to relearn everything about to make love to each other. Kissing can change. Taste can change. Relax, take interest, explore, report, and learn.

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“Not everything that is faced can be changed, but nothing can be changed until it is faced.”     –James Baldwin

We’ve been hearing from many women who are receiving treatments for various forms of cancer: What about us, they ask. Post-menopause is one thing, but what about post-cancer treatment? Or mid-treatment? How do we maintain intimacy when we are going through chemo or radiation or when surgery has changed our bodies and the way we feel about them?

We sat down to discuss these very difficult questions with our pal and counselor, Mary Jo Rapini. Her practice gathers couples referred before, during, and after cancer treatment to talk about sexuality and intimacy and how to maintain physical expressions of love when we are sick. This is a big subject, with many possible angles, so we will break it down into two pieces: the mind and the body.

Here’s part of what Mary Jo told us:

I see lots of women with breast, ovarian, and uterine cancer in my practice. I ask to see her first, before meeting with the couple together. Women have a strong protective instinct; they will put up walls when they get sick, in part to protect themselves, but also to protect their loved ones, to avoid burdening them. I will coach her to share this crisis. That protective sense turns out to be too distancing. Whatever she is going through, whatever she decides for her course of treatment, the people who love her are in it with her. Their world is changing too, and it’s important to respect that and bring them along on the journey, consult with them. It’s important to have a team in this fight.

When a couple comes to me mid-treatment or post-treatment, they walk through the door with the goal to restore their sex life. The first thing I do is to slow them down, to hit the reset button. I give them a list of things to think about that goes like this:

  1. Focus on the positive.
  2. Take intercourse off the table until you have the energy for it, but don’t stop thinking about sex. Don’t stifle your own sexual thoughts out of guilt. Tell your partner, I still really desire you and wish I could make love to you.
  3. Remember sex is more than intercourse.
  4. Discuss your fears of the cancer.
  5. Consider buying your partner something sexy or feminine that will help her feel like a woman.
  6. Be a good listener and let her set the pace.

My focus for couples at this important time is to feel pleasure and relaxion first, before working on feeling excited. Excitement is exhausting, and exhaustion can lead to failure and frustration. I ask them to just flat out remove the goals of intercourse and orgasm from the picture. I promise we will get to these, eventually, but for now, let’s not worry about it.

I had an aneurysm that nearly cost me my life. For me, orgasms changed a lot. For one thing, they made my head ache. With a clip on arteries in my brain, and my blood flow trying to figure out a new path—orgasm took a lot out of me. Sex didn’t give me the energetic feeling I used to have. Instead, orgasms robbed me of energy for the rest of the day. A lot of my cancer patients tell me that intimacy tires them, so planning is important.

A recovering cancer patient has to plan how she will spend the little energy she has on home and health and relationships. This is a very important adjustment, especially if a couple has always enjoyed a spontaneous sex life in the past.

I prescribe a lot of hand-holding and hugging. We know the importance of hugging now, how it builds and maintains bonds for us. Most men will tell me that when their partner is sick, this is what they miss more than anything. The worst thing people can do when they can’t have sex is to withhold all touch. When a couple only touches as a pre-cursor to sex, touch can be loaded with expectations, and we need to break through that. We need to experience touch as a pleasure in itself.

During treatment, during chemo and radiation, just take intercourse off the table, but replace it with lots and lots of touch. Hand holding, back scratching, feather-brushing, rubbing hair, petting. Have fun touching, kissing, necking, without the worry of failure. Just revel in closeness.

Once you’ve gotten this connection really going, add water. Because water is relaxing. Shower together. Or take a bubble bath (but stay away from very strong scents). Light candles, bring in soft music. Focus on enjoying each other. Wash each other. Especially, wash each other’s feet. When something feels especially good, say so.

When you are in treatment for cancer, self exploration is really important. Experiment with self touch, especially where you have had surgery. Touching helps you deal with grief of loss and letting go. If you have lost a breast, you need to feel that void and be able to grieve it. Whether to include your partner in this exploration is entirely your choice, but it can very helpful for both you and your partner to join in this exploration and support you in your grief.

With any kind of an illness, the ill person asks, “Who am I now?” A serious illness changes the self, sometimes just a bit, but often profoundly. And if one self in a couple changes, then it follows that the couple’s sense of couplehood changes. Talk together about the changes you experience and notice.

A healthy partner often feels guilty about wanting sex; he knows a sick partner doesn’t have energy for sex. The healthy partner is a caretaker and not a lover right now. Talking about that is very helpful and important. Getting a counselor to talk with both or either of you during this time of adjustment can be the best investment you’ve ever made.

If you are sick, don’t underestimate your lover. We are all pretty good at putting our sexual needs on the shelf, as long as we feel loved. The most helpful way to show your love is through touch. Touching can make talking more available. Some things you hate to tell your partner. But if you are touching them while you talk, there are moments when the communication is so authentic, you will find you can say anything. And that is the sound of real intimacy.

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Without doubt, breast cancer is a game-changer, altering every area of life and relationships. At first, amid the flurry of medical decisions, surgery, chemo, and recovery, you don’t have the time or energy to think about sex. But then… how do you make your way when all the furniture is rearranged? When your body, your emotions, your self-image and feeling of security, and your relationship with your partner are so permanently changed?

For a while, sex is understandably the last thing on your mind. Your chest is a surgical site; chemotherapy and radiation may make you nauseous, bloated, and incredibly fatigued; it may induce menopause if you haven’t already made that passage. Cancer survivors frequently experience depression as well. It’s important to know that if you don’t feel like sex for a period of time, you don’t have to go there. Focus on getting well first, say the experts, without completely shutting the door to intimacy. You can still love and support each other in small ways—holding hands, taking a walk, reading in bed together—to keep the coals alive during this period of stress and anxiety.

Your partner is under a lot of pressure, too, and is probably struggling to find purchase on the slippery slope of this crisis, uncertain about how to support you, and how or when to approach the sticky wicket of sex. Your partner may be waiting for you to make the first move, or be afraid of hurting you.

It might be helpful for both of you (or just your partner) to talk with your doctor or a counselor. Forthright, open communication about sex (or any other issue) can make the difference between feeling your way in the dark alone or shining a light on a difficult path. The most challenging situations can be overcome with honest dialog and the willingness to seek help and information.

Over time, as you begin to heal, you face the inevitable hurdle: resuming your sexual life. How will your partner respond to the way you look; for that matter, how do you feel about your changed body? Your incision site may still be tender or you may be undergoing reconstructive surgery. Chemotherapy may have brought on menopausal symptoms. Maybe you’re not sure you feel like having sex at all, and you certainly don’t feel very sexy.

First, take it slow. You (and your partner) have been through a prolonged, life-threatening crisis. In addition, you’ve lost an important erogenous zone. Unless your doctors have been able to spare your nipples and their nerve endings, you probably can’t feel anything in an area that used to be erotic and arousing.

You and your partner need to become acquainted with your new body. You may have lost your breast(s), but other parts—neck, shoulders, ears—may become more sensitive. Your first foray into sex could be an exercise in gradually raising your awareness of sensation rather than worrying about intercourse.

Try simply touching each other. Leave the genitals out for now. Talk about what feels good. Or—don’t talk at all, just be together, touching each other. Slowly, in this session or the next, add genital exploration and move on to intercourse when it feels comfortable. Sex will be different—and not necessarily for the worse.

Experts say that you don’t have to “love your scars.” If you’re uncomfortable letting your partner see you naked, wear sexy lingerie. On the other hand, your partner may be able to reassure you that you are as loved as you ever were, and that’s incredibly affirming.

Second, assemble your tool kit. This should include lubricants to make penetration easier and sex more pleasurable. Maybe experiment with toys; try massage oils. Experiment with positions that are comfortable. Lying on the affected side may be painful, for example. You may prefer being on top or on your knees with your partner behind you. Since so much is different anyway, why not shake up the routine? Be sure to discuss any problems or questions about sex with your doctor. A solution may be easier than you think.

In a blog about sex after having had both breasts prophylactically removed, one young woman likens the experience of resuming sex with her husband to a second adolescence—shy, awkward, fumbling, uncertain. “But like adolescence, this is a phase I will grow out of. I will become more comfortable with my body and my husband will too.… But all of this is uncharted territory, and I’m trying to do what feels right to me. Each of us will recover our sexuality at her own pace, and this is the (frank) truth about mine.”

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