Monday, November 17, 2008

Cancer Survivors: Take the "package" deal!

I have been following the research for many years led by psychologist Barbara Andersen, PhD who has been leading the Stress and Immunity Breast Cancer Project at The Ohio State University's Comprehensive Cancer Center. She has been following a group of 227 breast cancer survivors with stage II or stage III disease observing various outcomes in the women who had intensive group education on various coping strategies and support after diagnosis compared to a control group who did not receive this additional intervention.

Soon after diagnosis, half of the 227 participants were randomized into the intervention group, which met weekly in groups of 8 to 12 with a clinical psychologist. During these weekly sessions participants learned progressive muscle relaxation for stress reduction, problem solving for common difficulties (such as fatigue), how to find support from family and friends, health behavior change tips for exercise and diet, and finally, how to deal with treatment side effects plus keep up with medical treatment and follow-up. After four months of weekly sessions, participants then met monthly for eight months. Earlier published research articles demonstrated that, compared with the assessment only arm, the intervention group improved across all of these outcomes, plus immune system indicators were also enhanced.

What this new study demonstrates is the best evidence to date that a psychologist-led intervention program that teaches multiple strategies for coping with the changes and challenges after a breast cancer diagnosis improves overall health and quality of life and also increases the chances of longer survival. The women in the intervention group, which by now have been followed for 7-13 years with an average of 11 years, reduced their risk of breast cancer recurrence by 45% and reduced their risk of dying of breast cancer by 56%.

This study will be published in the December 15, 2008 issue of Cancer. The abstract is available to read on-line.

There are many important points about this study:
(1) Focusing the study on those women with stage II and stage III breast cancer helps to define additional strategies for improving outcomes for the largest group of breast cancer patients. Studies that include stage I and/or stage IV diagnoses are very difficult to interpret and apply to general clinical practice.

(2) Even for women who did die from breast cancer, those in the intervention group lived longer than those who received the appropriate medical care and were simply psychologically assessed at various points after diagnosis. (an average of 6.1 years versus 4.8 years)

(3) Participants in the intervention group also has a lower chance of dying from causes other than breast cancer, such as heart disease or other cancers. Again, even among those women who did die of other causes, the ones who were in the intervention group lived for an average of 6 years versus 5 years compared to those in the assessment only group.

(4) This study was actually designed to study recurrence and survival in contrast to the older studies published in the 1980-90's which observed some survival advantages in patients receiving psychological intervention but those earlier studies had multiple research design flaws and thus could not be considered strong evidence that such therapy would improve survival.

(5) While the researchers found that patients in the intervention group who had the greatest reductions in distress and physical symptoms were those who practiced progressive muscle relaxation most frequently, the intervention group clearly received a "package" of strategies for coping with the multiple challenges patients face following a cancer diagnosis, including information and support regarding lifestyle changes such as diet and exercise for improving overall health. An intervention and approach of this type should no longer be considered "complementary" medicine but represents "integrated" medical care and should be included for all patients as a component of comprehensive cancer care.

(6) The other important point of this research for patients to use for a take-home lesson is don't wait until life becomes unmanageable to seek out stress reduction information and support along with other lifestyle changes and coping techniques to get you through what may be the most stressful event of your life. Seek out support such as this study provides EARLY after diagnosis. Get your medical options chosen and then take on the other challenges. You are in charge of the biggest fight of your life, for your life, and it will take more (much more!) than surgery, radiation, and/or chemotherapy to achieve wholeness and wellness after cancer.

The enhanced longevity data from this study is very, very important, however quality of life outcomes such as improved mood, decreased fatigue, or better sleep are equally important outcomes. No cancer survivor I know would ever consider research to be "soft" or unimportant if it showed an intervention improved many aspects of quality of life, i.e, real life. In fact, there are situations where it could even be argued by any reasonable person that a longer but miserable or difficult life may not have been worth the effort and multiple costs of undergoing cancer therapy.

I titled this post "Take the package deal!" Unfortunately, it will be the unusual cancer center that has such an extensive education and support program for all of their patients included as an automatic part of the cancer care offered at that center. However, nearly every single cancer center I have visited offers many types of support programs for their patients. In addition, the American Cancer Society offers a program called I Can Cope and many communities have support organizations such as Gilda's Club or The Wellness Community that offer multiple types of support classes as a few examples of support available.

So right now, my real message to all those with a cancer diagnosis is to SEEK the "package" deal, which includes information and strategies from many types of oncology team members (social workers, psychologists, dietitians, nurses, chaplains, etc) for stress management and lifestyle alterations (diet, exercise, smoking cessation), spirituality, and counseling for the many problems that often surface with such a stressful life event.

In fact, don't wait, but make some phone calls to find out what support is available in your area, and then run, walk, bike, skate, jog or even skip on over to get started. The rest of your life is waiting!!

Heartfelt thanks to Dr. Andersen, her colleagues, and all her funding sources for believing in and supporting this research of critical importance to all cancer survivors.

Diana Dyer, MS, RD


Stuart said...

Dear Ms. Dyer, sorry if you've addressed this topic elsewhere. I am wondering what I should feed my wife. She will be returning Thursday from the hospital where she had her stomach removed due to an early stage stomach cancer. She has announced to me that she expects me to cook for her "for a while." My problem is compounded by the fact I am living in Japan and my wife is Japanese. My Japanese is too poor to understand the advice I get from the hospital staff. Judging by what she has been getting in the hospital, her diet is very boring, consisting of mushy rice, miso soup and tofu. Are there any good sources of recipes for stomachless people that will alleviate weightloss and make sure they get enough vitamins? I am a little worried about my wife's psyche, too. She used to be a strong, take charge type of woman, something that was vital for our relationship to succeed here in Japan (my Japanese is okay for teaching kids, but not taking on the bureaucrats). Now my wife plays helpless, doesn't want to return to her job and even refuses to cook (she doesn't like my Western-style cooking). I have always done all the housecleaning, dish washing and laundry. Now I must cook too and I am worried my cooking will make her sick. Thanks for your advice.


Diana Dyer said...

Thanks for visiting my blog and supporting your wife during this challenging time for her. Hopefully, you and your wife will receive nutritional counseling and support before she leaves the hospital.

Does the hospital offer translators so that you can more effectively communicate and understand discussions with the medical staff? Do you and your wife have a bilingual friend or relative that could help with translations in this important situation?

Nutritional recommendations for a diet after stomach surgery (gastrectomy) are designed to maintain optimal nutrient intake, minimize weight loss and "dumping syndrome", which is a variety of symptoms that happens when the body no longer has the reservoir to hold food and liquids until they are ready to move to the small intestine. General guidelines to avoid dumping syndrome include the following:
• Eat 6 or more small meals a day
• Eat slowly and chew all foods thoroughly
• Sit upright while eating
• If you experience nausea, vomiting or diarrhea when consuming high-sugar foods, avoid or limit the following: Kool-aid, Juice, Soda, Ensure, Boost, cakes, pies, candy, doughnuts, cookies, fruits cooked or canned with sugar, honey, jams, jellies
• Limit fluid consumption at meals. Drink liquids 30–60 minutes either before or after meals
• Eat a protein containing food with each meal. High protein foods include the following:
–Eggs, meat, poultry, fish, lunch meat, nuts, milk, yogurt, cottage cheese, cheese, peanut butter, dried beans, lentils, tofu
• Choose high-fiber foods when possible. These include:
–Whole wheat bread, whole wheat pasta, fresh fruits and vegetables, beans (black, brown, pinto, kidney, garbanzo), fiber-fortified cereal

If she has difficulty maintaining her weight, she may need to drink a nutritional supplement for extra calories. She can try low-sugar over-the-counter supplements. These include no-sugar added Carnation Instant Breakfast, sugar-free
Nutrishakes or Glucerna weight loss shakes (I don't know what is available in Japan).

These guidelines come from an excellent article more fully describing the nutritional concerns following gastric surgery, which can be accessed at the following web site:

Hopefully your wife has a very good prognosis from her early stage cancer and will be followed by a medical team that monitors the potential nutritional complications often experienced by patients who have such an extensive surgery.

In addition, she may benefit from meeting other women who have had cancer and recovered or talking to a health care professional such as a social worker, psychologist, or spiritual advisor about her concerns. Every person's path to wholeness and wellness (including renewed self-confidence) after such a significant life event will take time and support.

Your wife is fortunate to have you on her team. I send all my best wishes for health, healing, and hope.

Diana Dyer, MS, RD