Forgiveness and Health

Provided by Drew Angus, DMin
Director of Spiritual Outreach, Cancer Treatment Centers of America

 

Maryanne’s aging parents are still independent but they need more support than ever. Her Dad has a complicated health history including diabetes and a recent recurrence of cancer. Maryanne has three siblings who all live within an hour drive to their parents, however, Maryanne is the child who seems to always take her parents to the doctor and is in daily contact with them. Maryanne’s husband maintains her parent’s lawn and frequently does their home maintenance. Maryanne cooks three meals a week for her folks and stops by to check on them almost every day, all while managing her own household and working full time. In addition, Maryanne has recently gained added responsibilities with her daughter’s upcoming high school graduation. Recently, she asked her siblings if they could take over some of the duties of supporting their parents during the coming month. None of her siblings stepped up to the plate and each had excuses that did not seem valid. Once again, Maryanne was stretched thin with responsibilities and work that left her exhausted and angry. “I am disgusted with my siblings. Why do they have to be so selfish? I just need them to pull their weight and help Mom and Dad especially when I have so much on my plate already!”

During the course of any given day many of us get angry at least once. Something or more likely someone becomes a source of anger or frustration. There are a number of reasons why we get angry with people, but let me suggest a few of the m­ost common:

  • Injustice. We all have a sense of right and wrong and of what constitutes fair treatment. We know when wrong has been committed against us or someone we love, when people don’t do what they say they are going to do, when they don’t pull their weight, etc.
  • Hurt. The heart gets wounded. Most of us know what it feels like to be left out; overlooked, undervalued, put-down.
  • Fear. When there is a perceived threat to something that gives us a sense of identity or security.
  • Frustration. Everyone has a God-given need for significance and to leave a positive mark on the world. We want to see our work make a difference. Sometimes, roadblocks to moving toward our goals are people.

Sometimes we have a hard time letting things go.  We have the capacity to stew on offenses and sometimes develop deep pockets of resentment or lack of forgiveness that research shows actually hurts our health over time.

According to Seawell et al. in Pyschology and Health, “As a negative response to interpersonal offense that commonly involves grudge, resentment and revenge, lack of forgiveness has been consistently related to poorer health in published research.”

We know that those who do not forgive show an increase in sympathetic nervous system responses and release more stress hormones over a longer period that will in time affect their health and well-being. In other words, if I don’t forgive someone who has hurt me, the one who will suffer the most is me. So it is important for our friend Maryanne’s own health and well-being to be able to find forgiveness toward her siblings who have let her down.

So if it is so beneficial to forgive, why might Maryanne resist something that is good for her? Harboring an offense can actually feel good! History shows that one of the shadow sides of human nature is self-righteousness. If we are really honest sometimes we really enjoy feeling BETTER than someone else. If Maryanne forgives her siblings, she may sacrifice her sense of being `right’. When we hold onto a grudge it feels like we are in control although, in the long run, we end up being the ones controlled by the very offense that has hurt us to begin with. Another reason Maryanne might resist forgiving her siblings is the false notion that it means that she is letting them off the hook. It is difficult to accept that forgiveness does not perpetuate the hurt and injustices being done.

“Importantly, forgiveness is not condoning, excusing, denying, minimizing, or forgetting the wrong. It can occur without reconciliation, which requires the participation of both parties, if the person who caused the hurt is absent, deceased, or remains unsafe.” (Toussaint et al. Forgive to Live)

“Lack of forgiveness is like drinking poison and expecting the other person to die.” –Nelson Mandela

“Forgiveness can be defined as a freely made choice to give up revenge, resentment, or harsh judgements toward a person who caused a hurt, and to strive to respond with generosity, compassion, and kindness toward that person. It is a process that involves reducing negative responses and increasing positive responses toward the person who cause the hurt, across the realms of affect, cognition and behavior.” Loren Toussaint et al. (Toussaint et al. Forgive to Live)

Family therapist, Ruthanne Batstone, describes forgiveness as, “a willingness to absorb or pay the emotional debt for the offense and not seek revenge or payment in return. The offended person absorbs the price of emotional pain without seeking revenge.”

So if Maryanne forgives her siblings it is not a denial of the pain of their offense to her, rather it is an acknowledgement of the offense and a willingness to absorb the debt without repayment.

How do we find the power to forgive? “Forgive us our trespasses as we forgive those who trespass against us.” This beautiful quote is familiar to many and is taken from Jesus prayer from the Sermon on the Mount. One way to forgive is to remember our own humanity and frailty which will help us develop compassion towards others, even those who have hurt us. All of us who are loved well are also known well and that means we are not loved because we are perfect, but rather loved `warts and all’. If we meditate long enough on being loved by God with others even with our imperfections, it will create the space in our hearts to do likewise and to ‘forgive those who have trespassed against us.”

At Cancer Treatment Centers of America®, we see many people who live with cancer and their caregivers who, like Maryanne, carry immense responsibilities. Our desire is to minimize their stress and optimize their health and well-being by offering forgiveness education ­­­as one of many modalities to integrated health and healing.

Scriptural wisdom gives two possible responses to an offense by another. Sometimes you go to the person and talk about the offense, especially if it is needed to keep the relationship free of resentment and for the sake of loving the offender well. Sometimes you overlook the offense if you are able to absorb the debt without resentment and it is a more minor offense. Part of living in any relationship, any community is “patience, bearing with each other in love” (Eph 4:2). So we often need wisdom and discernment to know whether we let an offense go or talk to the person about it. When trying to decide, the guiding principle is LOVE.

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It’s Complicated: Our Relationship with Food

By Renee Pieroth, RD, CSO, LDN and Lauren Clanet, RD, LDN

food

As Valentine’s Day approaches, how is your relationship with food?

Overeating

Try mindful eating. When eating slowly, we give our bodies time to recognize when we are full.  Try resting your fork/spoon on your plate between each bite or holding your utensil with your opposite hand.  These simple yet effective tips force us to focus on the meal itself, not the amount of food being consumed.

Busy Schedule

Consider planning and preparing a week’s worth of meals on one day.  By preparing your meals in advance, you save yourself additional time at the end of each workday. There is no need to stop at a fast food restaurant on the way home from work because you know your homemade, nutritious meal is already waiting for you at home.

Skipping Meals

Carry balanced, healthy snacks with you to overcome missing a meal. We tend to overeat later in the day if we skip a meal, which can also slow down our metabolism and lead to weight gain. Consider snacking on mixed nuts, an apple with peanut butter or a granola bar.

Fad Diets

Do what is best for you. Following an [organic/gluten-free/lactose-free/low-fat/insert-other-diet-name-here] is not appropriate for everyone. If you’re considering a change, contact your personal doctor or dietitian to discuss if a diet is necessary and which one may be best for you and your needs.

 

In general, try thinking about food in terms of nutritional benefits. Food is life, so choose food that soothes your mind, body and soul. Focus on moderation and balance, as opposed to what you “shouldn’t eat.”

Love your body.  Love yourself.  Love your relationship with food.

Ask the Doctor: Breast Surgery and Reconstruction

Dr. Christine Hannaway is a General Surgeon located in Seaford, DE.  She is a member of the Nanticoke Physician Network and practices at Nanticoke Memorial Hospital.  Dr. Hannaway also serves as the Physician Liaison for the Committee on Cancer at Nanticoke Memorial.

Q: How do I make the decision with my doctor to have a mastectomy or lumpectomy?

Many variables come into play when making this decision.  The primary factor will be your cancer diagnosis and predicted aggressiveness of the tumor.  For most early stage breast cancers, mastectomy or lumpectomy can provide equivalent outcomes for prognosis and lifetime risk of recurrence.  However, lumpectomy will require the addition of radiation therapy for invasive cancer diagnoses.  Other factors that may influence your final decision are your lymph node status, your age, your breast size, your desire for reconstruction, and what regimen of adjuvant therapy you will require after surgery.

Understanding each of these variables and discussing them with your surgeon, oncologists and plastic surgeon is the best way to make a decision you are comfortable with.   
Q: What can I expect as recovery time after a lumpectomy vs. mastectomy? How long will I be out of work? How long before I can shower? Drive? Exercise?

On average total recovery time is two to three months with either procedure. If you have an axillary dissection instead of sentinel node, your recovery may be on the longer side. Depending on the type of work you do, expect to be out a minimum of two weeks, more if you need to use your upper body a lot. Driving is restricted at any time you are still using narcotic pain medication. Your ability to fully move your arm on the side of your surgery will also restrict your driving. You may shower as soon as 48 hours after your surgery.If your surgeon placed drains under your skin, you will have to wait until these are removed before showering. Exercising is encouraged immediately after surgery but should be tailored to where you are in your healing stage. Walking, climbing stairs, doing simple activities of daily living can be started right away. You want to avoid high impact exercise for the first few weeks to minimize trauma to your breast or mastectomy site. After two weeks, you will be given special exercise instructions to follow which help you recover range of motion and strength in your arm and chest. 

Q: How long after surgery until I can start chemotherapy or radiation?

The determining factor for starting adjuvant therapy is the healing of your incisions and which order of treatment your oncologist has recommended. With normal wound healing, you may start chemo between 2 and 4 weeks post-op. If you will be treated with hormone receptor antagonists only, your therapy can start even sooner. Radiation therapy usually starts 4-6 weeks post-op. If you have any problems with your wound, treatment will be delayed until these have resolved. Your oncologist and radiation oncologist will be able to outline your treatment schedule in more detail.

Q: What can I do to make myself more comfortable after surgery?

You want to invest in a comfortable post-mastectomy garment regardless if you are having a lumpectomy or mastectomy. These tend to fit like camisoles but open full length in the front. They may have special pockets for your drains. And many will come with different size inserts to pad and fill the area where you had your surgery. These garments are expensive, ranging between $50 and $100; however a portion of the cost may be covered by your insurance. Ask them and be sure to get a prescription for the garment from your surgeon. Area specialty lingerie shops offer these garments for sale. Other good alternatives are zipper front athletic bras or soft full-coverage wireless bras with front closures. Bring your garment and soft slip on clothes to the hospital. Your nurses can help you get dressed that first time. 

One of the most difficult times for any woman with breast cancer is that first time you see yourself after surgery. I encourage my patients to have a good support network in place ahead of time. A close friend, sister, daughter or mother who can be available for you at this time. In addition to your loved ones, reach out to your community through your church, hospital cancer support groups, and the community. Many of these people want to help you. And some may even be women who have already conquered the many challenges you will face, such as the Peer Mentors available through the DBCC.
Q: Should I have surgery and breast reconstruction at the same time?

Whether a woman chooses breast reconstruction depends on the type of surgery she is having as well as her personal preferences. Most commonly, a woman elects reconstruction following a mastectomy, either immediately or delayed. Sometimes a woman may have smaller sized breasts and if choosing a lumpectomy, she may find her breasts to be asymmetrical after healing. In this case, reconstruction might be desired to correct the size difference. This too can be done immediately or in a delayed fashion.  Your choice of when to have the reconstruction will depend on whether you need radiation therapy and your plastic surgeon’s preference for timing of reconstruction relative to your cancer treatment. The type of reconstruction, implant versus tissue transfer, will also influence the timing thus it is important to discuss your reconstruction options with a plastic surgeon early while you are discussing surgical and medical treatment options with your cancer care team.    

Ask the Doctor: Survivorship Care

Dr. Sawhney
Written by Rishi Sawhney, MD, Medical Director of the Bayhealth Cancer Institute and a member of Bayhealth Hematology/Oncology Associates.
Who is a breast cancer survivor? 
Any woman or man diagnosed with breast cancer.  The issue of cancer survivorship encompasses physical, psychosocial and spiritual aspects at all stages of the cancer journey.  You are a survivor from the day you are diagnosed. 
Why is survivorship care important?
According to the American Cancer Society, there are now more than 13.7 million cancer survivors in the United States. Of these, there are nearly 3 million breast cancer survivors, comprising 41% of all female cancer survivors. Current predictions estimate there will be 18 million Americans living with a history of cancer by the year 2022.

As many survivors have learned, completion of treatment does not necessarily mark the end of the cancer experience.  Breast cancer survivors are at an increased risk of certain physical, mental, and emotional side effects, many of which can be prevented or drastically reduced with early detection and intervention.  Furthermore, survivors may be at risk for future relapse of their original breast cancer, and will benefit from regular surveillance by their medical team.
What kinds of late side effects may a breast cancer survivor be at risk for?
Recent studies have indicated that some therapies are linked to increased risks of specific long-term side effects for which a patient should be monitored:

    Heart complications. For those having received radiation therapy to the chest, specific chemotherapeutic or targeted agents (i.e. Adriamycin, Herceptin).
    Learning or memory difficulties. High doses of radiation to the brain or treatment with some chemotherapy agents can lead to learning, memory, or attention difficulties. This issue is currently under extensive study.
    Second cancers. Cancer survivors are at an increased risk of developing a second cancer, the type of which largely depends on the specific therapy received for the initial cancer. Some chemotherapy agents may slightly increase the risk of developing hematologic (blood) cancers such as leukemia.
    Bone, joint, and muscle issues.Osteoporosis (reduced bone density) is more common among breast cancer survivors than in the general population. Prior or continued treatment with aromatase inhibitors, steroids, or chemotherapy and low levels of activity—all may contribute to an increased risk of developing osteoporosis.
    Hormonal changes.Chemotherapy can damage the ovaries in premenopausal women resulting in early menopause, osteoporosis, hot flashes, infertility, and sexual dysfunction. Treatment with aromatase inhibitors or selective estrogen modulators such as tamoxifen can also cause mood swings, weight fluctuations and affect energy levels.
    Fatigue. Approximately one-third of cancer survivors report fatigue. The underlying cause of fatigue among these patients is often not known, although lifestyle management and nutritional support can help combat fatigue.
 
    Effects of surgery. Women who have undergone a lumpectomy  or mastectomy may experience emotions related to femininity or sexuality due to the disfigurement caused by the surgery, whereas women who have had extensive lymph node removal in one area (lymphadenectomy) may experience significant swelling or pain of the limb to which the removed lymph nodes provided drainage.
Fortunately, with monitoring and intervention (the earlier the better), many of these side effects, whether short-term or long-term, can be effectively dealt with so that survivors can live their lives without these issues. In addition, as research and treatment continue to improve, radiation therapy is becoming more precise, so the cancer cells are targeted while sparing healthy surrounding tissue from its effects. Chemotherapy agents that are associated with increased risk of long-term side effects or second cancers are also being used less and substituted with other agents that are just as effective and not associated with such side effects.
How should I be monitored for potential recurrence of my cancer?
National practice guidelines have been issued by the American Society of Clinical Oncology (ASCO).  Routine followup care should include:
  • Regular visits with your doctor every 3-6 months for the first three years, and then every 6-12 months thereafter
  • Annual mammography
  • Breast self examination
  • Regular gynecologic examination
  • Genetic counseling evaluation (if applicable based upon personal or family history)
  • Reporting any new relevant symptoms to your doctor (new breast lump, rash, nipple discharge, bone pain, chest pain, breathing problems, persistent headaches, etc.)
Note, the following tests are NOT currently recommended on a routine basis for surveillance: bone scan, CT scan, PET scan, breast MRI, or laboratory studies including tumor markers.
Exercising is an important part of care

What else can I do to help in my care?

Ask the Doctor: What’s a Breast Ultrasound?

Ask the Doctor with Dr. Jacqueline Napoletano, MD

Breast Ultrasound uses high frequency sound waves. The sound waves travel through tissues (in the breast that is fibroglandular, fat, cysts, and tumors) and bounce off boundaries to produce an image. Ultrasound does not use radiation.

Ultrasound is an adjunctive test, used in addition to mammography, not a replacement for mammography.


Indications for breast ultrasound include: 

  1. Characterization of masses as a cyst or solid mass. 
  2. Characterization of solid masses for low or high probability of malignancy.
  3. Evaluation of a palpable finding (breast lump).
  4. Evaluation of a breast density or mammographic finding. 
  5. Evaluation of nipple discharge.
  6. To guide in breast biopsies.
  7. Potential use in screening in dense breast following a mammogram. 

About Dr. Napoletano

Dr. Napoletano received her Doctor of Medicine in 1989 from the Temple University School of Medicine. She currently serves as a Diagnostic Radiologist and Director of Breast Imaging at the Breast Center at the Helen F. Graham Cancer Center, Christiana Care Health System. She is a Delaware Breast Cancer Coalition (DBCC) Board Member and sits on the advisory committee for the Christiana Care Health System Center of Excellence for Women.

Ask the Doctor: Breast Cancer Risk Factors

DBCC talks with Dr. Jacqueline Napoletano, MD. Dr. Napoletano received her Doctor of Medicine in 1989 from the Temple University School of Medicine. She currently serves as a Diagnostic Radiologist and Director of Breast Imaging at the Breast Center at the Helen F. Graham Cancer Center, Christiana Care Health System. She is a Delaware Breast Cancer Coalition (DBCC) Board Member and sits on the advisory committee for the Christiana Care Health System Center of Excellence for Women.

Excluding skin cancer, breast cancer is the most frequently diagnosed malignancy among American women. About 1 in 8 U.S. women will develop invasive breast cancer over the course of her lifetime. A man’s lifetime risk of breast cancer is about 1 in 1,000.

Breast cancer is the second leading cause of cancer mortality.

Relevant risk factors:
  1. Being female
  2. Growing older. Incidence increases with age (for women age 50 and older – 375 per 100,000 compared with women under age 50 – 42.5 per 100,000). However, because women under the age of 50 represent about 73% of the female population, 23% of all breast cancers are diagnosed in women under the age of 50. 
  3. Personal history of breast cancer and prior breast biopsies with certain benign diagnoses such at atypia, atypical ductal hyperplasia, lobular neoplasia, and juvenile papillomatosis. 
  4. Family history of breast cancer involving a first degree relative. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 15% of women who get breast cancer have a family member diagnosed with it. 85% of breast cancers occur in women who have no family history of breast cancer. 
  5. BRCA1 and BRCA2 gene mutations–found in approximately 5-20% of the total percentage of breast and ovarian cancers.
  6. History of chest wall exposure to high dose radiation (such as with prior treatment for lymphoma). 
  7. Other factors implicated with breast cancer risk: early menarche, late menopause, late first-term pregnancy, nulliparity (no full-term pregnancies), postmenopausal obesity, and hormone replacement therapy.
Breast cancer mortality rates (death rates) have declined an average of 2.3% per year between 1990 and 2005. These decreases are thought to be the result of treatment advances, earlier detection through screening and increased awareness.

Ask the Doctor: What about Breast MRI?

Ask the Doctor with Dr. Jacqueline Napoletano, MD


Magnetic resonance imaging (MRI) uses strong magnetic fields and radio waves to produce a very precise image of the breast. MRI uses no radiation.

MRI is an adjunctive test, performed in addition to mammography and not a replacement for mammography.

In 2007, an expert panel reported new recommendations for the use of MRI screening for women at increased risk for breast cancer. The panel recommended annual screening using MRI in addition to mammography for women at high lifetime risk (20-25% or greater). Women at a moderately increased risk (15%-20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening. MRI screening is not recommended for women whose lifetime risk is less than 15%.

Indications for breast MRI include:

  1. Screening in patients with a high risk of developing breast cancer (20-25% lifetime risk of breast cancer, such as women who carry the BRCA1, BRCA2 genes and women with prior chest wall radiation (such as in treatment for lymphoma).
  2. In some patients with a new diagnosis of breast cancer. This is controversial as MRI in this case has potential benefits (such as finding additional cancer in the same breast or the opposite breast) but also has risks (such as leading to more biopsies that are not cancerous and also increases a woman’s chance of having a mastectomy).
  3. Assess a patient’s response to chemotherapy.
  4. Determine what is scar tissue versus a recurrence of cancer at site of prior surgery.
  5. Evaluation for rupture in silicone breast implants.

Since breast MRI can lead to additional biopsies, the decision to have a breast MRI should be made after discussion of the benefits and the risks with your doctor.

About Dr. Napoletano

Dr. Napoletano received her Doctor of Medicine in 1989 from the Temple University School of Medicine. She currently serves as a Diagnostic Radiologist and Director of Breast Imaging at the Breast Center at the Helen F. Graham Cancer Center, Christiana Care Health System. She is a Delaware Breast Cancer Coalition (DBCC) Board Member and sits on the advisory committee for the Christiana Care Health System Center of Excellence for Women.