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AFTER CANCER: STAYING IN THE MEDICAL SYSTEM. ONCOLOGIST
March 12, 2009
If I Was Treated by an Oncologist, Do I Still Need an Oncologist after Completion of My Treatments?
At least for a while, you need an oncologist to
• oversee your reevaluation
• advise you regarding the appropriateness of stopping treatment •advise you regarding follow-up (which tests and procedures need to be done when, where, and how)
• advise you regarding measures to prevent recurrent or new cancer or other medical problems.
•evaluate and treat any cancer-related and treatment-related complications, aftereffects, or side effects
• evaluate and treat early any future problems that may indicate recurrent problems with your cancer.
Will I Need to Be Followed by an Oncologist for the Rest of My Life?
Depending on your type of cancer and your personal cancer situation, after completion of cancer treatments you may need to be followed by your oncologist for a few more visits, a few more months, a few years, or the rest of your life.
If your oncologist advises that you no longer need to follow up with him or her, you are “dismissed.” This means that you now can do without the expertise of a cancer specialist involved in your routine care. Under these circumstances, your oncologist feels that follow-up with your internist or family practitioner will be just as good. Since you have to see him or her anyway for routine care unrelated to your history of cancer, it will be more convenient for you to see one doctor instead of two. Even if you are dismissed, your oncologist will keep your medical file and be available for questions, problems, or reevaluations at your request or if the need arises.
If you are involved in a clinical trial, you may need to proceed with follow-up with your oncologist for the rest of your life for the sake of monitoring and data collection. This follow-up will be nothing more than an inconvenience.
You can switch doctors at any time. If you feel the need to switch oncologists, now is a good time because
• your treatment is complete
• you need to be reevaluated anyway
•you are about to start a new phase of cancer follow-up
Why Would I Switch Oncologists Now?
There are a number of common reasons why you might feel the need to switch oncologists after completing your cancer treatments:
•Your oncologist is very far from your home.
•Your oncologist does not participate in your insurance plan, and your insurance will not cover your current oncologist’s bills.
•You were not comfortable, confident, or satisfied with your oncologist, despite sincere attempts to make it work during treatment. You can be going to the most famous, well-respected oncologist in the world for your type of cancer. If his or her style or personality makes it difficult for you to communicate your needs, then this oncologist is not the best person to be caring for you.
•You feel that your oncologist is not interested in your care now that your treatment is complete.
*97/32/5*
AFTER CANCER: POSTCANCER FATIGUE (SYMPTOM, CAUSE)
Is Postcancer Fatigue the Same As Chronic Fatigue or Chronic Fatigue Syndrome?
No. Postcancer fatigue is a symptom distinct from chronic fatigue and that seen in chronic fatigue syndrome. “Postcancer fatigue” applies only to weariness that occurs in people in remission following treatment, that is due to the prior cancer or its treatment, and that persists after all treatable causes of fatigue have been ruled out or been corrected.
In contrast, “chronic fatigue” is a term that describes a symptom but conveys nothing about its cause, course, or treatment. “Chronic fatigue syndrome,” still a somewhat controversial concept, is defined not only by its unique symptom complex but also by the supposed causative agents, the usual course it takes, and the treatment.
What Causes Postcancer Fatigue?
Although the exact mechanism remains unknown, the scientific community accepts the view that residual effects of radiation, chemotherapy, or other cancer therapy can cause fatigue long after the completion of treatment. Since the definition of postcancer fatigue demands that all treatable causes of tiredness have been ruled out or corrected, as-yet-unidentified changes or abnormalities are the probable culprits. Three possible causes are
•the circulation of fatigue-causing substances released by dead, dying, or repairing cells
• changes in the parts of the brain that affect energy level, changes caused by prior cancer or treatment
• the residual inefficiency of otherwise normal cells and organs (e.g., muscles may appear normal on examination and with diagnostic tests but may be functioning subnormally as a result of changes on the cellular level, detectable only with sophisticated research technology)
Fatigue is a nonspecific symptom. It is difficult, if not impossible, to determine which of the hard-to-quantify possible causes are playing a role. You may have been treated optimally for depression; yet some residual refractory depression (depression unresponsive to treatment) persists. Or you may have a high risk of recurrent cancer, and chronic subclinical anxiety (it is present, but there is little sign of it) may be contributing to your fatigue. We need further study of the mechanisms of this symptom. The hope is that research will lead to effective means of prevention, detection, and treatment of postcancer fatigue.
*69/32/5*
AFTER CANCER: FEELINGS. READING THE OBITUARIES
What If I Feel Differently about Reading the Obituaries?
If you read the obituaries before your cancer diagnosis, reading them now is just the continuation of an old habit that satisfies certain needs for you. You may find the stories in the obituaries interesting. If you tend to check the age and cause of death, you are satisfying a somewhat morbid curiosity common to many people. It helps some to keep the perspective that life is short and not to be wasted.
If you never read the obituaries before your cancer diagnosis and now catch yourself reading them, it can be an uncomfortable, anxiety-provoking, and embarrassing self-revelation. Reading obituaries is a common behavior after cancer treatment, with many possible roots. Part of you wants to deny your recent brush with a life-threatening disease. To balance your denial and reach a realistic yet comfortable balance, you read the obituaries. This allows the other side of you to reassert that you are mortal and that many people do die of cancer. This process takes place on a subconscious level.
Seeing reports of others’ demise perhaps bolsters your sense of accomplishment when you are feeling low in other areas. “I survived. That is the important thing.” Or perhaps you still find it so hard to grasp the enormity of your cancer experience that you look to the obituaries for some sense of reality. This is similar to looking at the wreckage of a car after an accident, as if by looking at the crumpled metal you could understand the event.
Should I Avoid Reading the Obituaries?
Do not worry about it. Do not give yourself more anxiety by worrying about your behavior. You do not have to control everything. If you feel like reading obituaries, read them. If it bothers you to read them, turn the page. If you dwell on the obituaries and cannot stop thinking about death, get some professional help to sort out your fears and feelings.
*156/32/5*
AFTER CANCER: FEELINGS. DENIAL AND REPRESSION
What Is the Difference between Denial and Repression?
Denial is an abnormal refusal to acknowledge the known truth. If you refuse to believe that there is any reason to have follow-up or if you deny the presence of a new lump, you are said to be in denial.
Repression is the rejection of painful or frightening ideas from conscious thought. You may have a high chance of recurrence, but you are doing well now. You are said to be repressing thoughts of recurrence if, while you are enjoying an activity, you put out of your mind thoughts about potential future problems. You know and accept all the truths, but you do not let yourself think about them all the time.
Many people use the term “denial” when they are really referring to repression.
Is Denial Healthy?
Denial is unhealthy if it keeps you from doing the right thing. Denial that prevents you from taking steps to avoid or minimize problems is harmful. If you were treated for malignant melanoma (a type of skin cancer), and you continue to spend hours in the sun with your skin unprotected, you are denying your vulnerability. Consequently, you are missing one important and easy way to help keep yourself healthy. Using sunscreen does not mean that you are vulnerable and afraid; it means that you are taking control of your situation as much as possible.
Healthy denial can bring you physical and/or emotional comfort in painful or hopeless circumstances. The story of a young woman with aggressive cancer who was deteriorating rapidly illustrates how denial can be healthy. She was bald and jaundiced (yellow from liver failure). She had done everything possible to fight her cancer and had accepted that her death was near. She shared her sadness about dying. The interesting thing was that she always acted as if she looked wonderful, referring to her pretty skin and thick hair. She knew exactly what her situation was, but her physical appearance was so abhorrent to her that her mind protected her. Her denial did not change any of her decisions. It simply shielded her from the pain of acknowledging her physical deterioration and helped her to live fully within the severe constraints of her terminal condition.
Is Repression Healthy?
Repression can be a healthy, adaptive way of dealing with a painful reality. Repression can allow you to take steps to recover or stay healthy, while minimizing the negative impact of these actions.
Fear of recurrence can be a debilitating problem, destroying your quality of life even when things are going well. Understanding and sharing this fear will diminish it, but not make it disappear completely. Repression of any remaining fear will free you to live your life most fully. Effective repression enables you to minimize your fear of recurrence between checkups, but it does not misguide you into believing you no longer need them or can ignore symptoms. Repression allows you to forget when it is safe to forget.
Repression is a dynamic process. When you are due for a checkup or develop a worrisome symptom, you will be less able to repress your fears. Accept the anxiety as part of a mechanism that is working well.
Repression is a healthy way of coping with physical and emotional pain as long as it does not prevent you from doing the right thing.
As you can see, repression and denial can be good or bad, adaptive or maladaptive, depending on how they are used. Repression is not inherently good or bad, any more than a drug is inherently good or bad; it depends on how it is used.
*129/32/5*
AFTER CANCER: VACCINATION. PNEUMONIA SHOT. FLU VACCINE
Why Is the Timing of Vaccination Important?
The timing of the administration of vaccines is important for several reasons:
•Your body must be able to mount an immune response to the vaccine in order for it to be effective. If a vaccine is given too soon after cancer therapy, your body may not mount an effective response.
• It takes a few weeks after vaccination to build up immunity. If you are vaccinated just prior to exposure to the illness, your body may not have had enough time to build an effective immunity.
•The resultant immunity lasts for a specified length of time. For short-lived vaccine-induced immunity, the timing of the administration of the vaccine should be such that your peak immunity will occur at the expected time of exposure to illness. If you are vaccinated too early before exposure, your immunity may have waned and become less effective when you need it.
Do I Need a Pneumonia Shot?
The pneumonia vaccine is a safe and effective vaccine that helps build your immunity to the most common cause of pneumonia, the pneumococcus. You are a candidate for the pneumonia vaccine if you
•are sixty-five or older
• have diabetes
• have chronic lung disease
•are taking drugs that suppress your immune system
• have multiple myeloma
If you are in close contact with those who need the pneumonia vaccine (flatmates, children, other close associates) ask your doctor about also getting vaccinated. This will minimize the chance that a contact person will bring the infection to a person at risk.
Receiving the pneumonia vaccine does not guarantee that you will never get pneumonia. It merely offers some protection against the most common cause of pneumonia. You can still develop pneumonia from one of the many other causes of pneumonia not covered by the vaccine.
Do I Need a Flu Vaccine?
In general, it is a good idea to minimize your chance of getting sick, including catching the flu (influenza). After cancer treatment, there are additional physical and emotional benefits to preventing illness such as influenza. If you do not have a history of egg allergy or some other reason for not taking it, you should probably receive the flu vaccine. Discuss with your doctor the risks to you of influenza.
When large numbers of people receive the flu vaccine, it is effective in decreasing the overall incidence and severity of flu in the group. But many factors determine how effective the flu vaccine is for each individual. Taking the flu vaccine does not guarantee that you will not get the flu.
The flu vaccine is given every autumn, around April, to those who need it. It is also available to people who simply hope to avoid the inconvenience of the flu (workers and homemakers for whom a few days “out of commission” would be a hardship).
Flu vaccines protect for only one season. You need to be revaccinated in every year in which you wish to boost your immunity to influenza.
*103/32/5*
GROWING OLD – PHYSICAL CONDITION
March 11, 2009
Growing old affects different people in different ways, at different times, and with different degrees of severity. Old people are no longer as physically efficient as when they were younger. An old person’s senses are less acute: for example, his hearing decreases, and he can hear high-pitched notes less easily. The disability increases with age so that some degree of deafness affects 5 per cent of men aged 50, and 25 per cent of men aged 70. The diminished ability to hear can be embarrassing, but hearing-aids help considerably. Alex Comfort has pointed out in his splendid book A Good Age that the cheapest hearing-aid is a piece of string, one end of which is put in your ear, the other in your breast pocket! If you wear this, people talk more slowly and clearly!
Your sight changes as you grow older, and your ability to focus easily decreases. These changes can be compensated by wearing spectacles. It is wise to have your sight checked periodically to detect the onset of glaucoma, or of incipient cataract, which occur increasingly with age and which are easily treated. As you grow older, your sense of smell diminishes, and your teeth tend to be less firmly fixed. Your hair becomes grey and, at a later age, white, due to a loss of the pigment cells. The time when this change occurs is genetically determined, as is baldness.
*351/16/1*
HOMOSEXUALS AND HETEROSEXUALS
The survey showed that those men who accepted their homosexuality, and who were least concerned about society’s reaction to them, were least likely to have psychological problems such as depression, alienation, loneliness, and guilt. By contrast those few homosexual men who believed homosexuality was a ‘mental disease’ had the most problems.
However, contrary to the current medical belief, the majority of homosexual men were as normal psychologically as the majority of heterosexual men. Psychiatrists have noted the high degree of psychological disturbance in the homosexual men they see, either because the man has consulted them, or because the police have sought an opinion about a homosexual they have arrested. Dr Weinberg’s study rejected this psychiatric view, pointing out that most of the homosexual men surveyed were well adjusted. This statement applied particularly to those men who had a stable relationship or who had ‘come out’ and openly admitted their homosexuality.
*305/16/1*
IMPOTENCE – CONCLUSION
To remove the fears, to make the man an active participant, and to establish communication, the couple undergo a course of training. They learn about their problems in discussions with therapists, and they do sexual exercises. The therapist stresses that the ability to have an erection is as natural as any other physiological process -eating, breathing, or urinating – and that a man will respond by having an erection if the stimuli are the right ones and if the fear of failure is eliminated.
The exercises (which were described in Chapter 
and the discussions with the therapist are needed for the cure of impotence. It is also essential for the man to have a medical examination to make sure there is no physical cause.
Using these techniques more than 60 per cent of impotent men will be cured. In the future, other techniques may reinforce the ability of sexual therapists in curing a most distressing male sexual dysfunction.
*259/16/1*
PREMATURE EJACULATION – TYPICAL EXAMPLE
During his life nearly every man finds that at times he ejaculates very quickly. This is normal. Stress, a particularly exciting erotic encounter, or tension may result in premature ejaculation, which ceases when the particular stimulus ceases. It is only when a man consistently ejaculates too quickly that he has a real sexual dysfunction.
A typical example of this pattern of sexual disability is shown by the case of John.
As the affair developed, John and his girl began petting and this got heavier. They were both inexperienced and both tense. Sometimes after intense kissing, John fondled the girl’s breasts while she rubbed his erect penis, through his unzipped trousers. Because both were concerned about the consequences of sexual intercourse, the next step, as sexual tensions rose, was for John to lie upon her, his clothes relatively in place, and to mime sexual intercourse, without any attempt at vaginal penetration. As the purpose of this, both for John and for his partner, was to obtain a rapid release of sexual tension, John was quickly stimulated to ejaculation by the mock-sexual intercourse. He was learning a pattern of sexual behaviour, namely that once his penis was in his partner’s vagina, ejaculation was expected to occur at once.
*212/16/1*
THE BARREN MAN – INFERTILE MARRIAGE
When it was realized that a man might be the cause of an infertile marriage, it became obvious that his semen needed to be analysed more exactly. Before this time doctors had not examined the man. Instead, they had instructed the woman to arrange to have sexual intercourse, and to attend about six hours later. The doctor examined the woman’s vagina and took a sample of the secretions found around her cervix, which he looked at through a microscope. If he saw any spermatozoa, the man was exonerated as the cause of the infertility.
The ‘post-coital’ test is still made, but has only limited value. Far more information is obtained by examining a specimen of a man’s seminal fluid. This can be obtained by asking the man to masturbate or by suggesting he has sexual intercourse, making sure that before he ejaculates, he withdraws his penis from the woman’s vagina and comes into a dry wide-mouthed container, such as a small jam jar. The specimen is then taken, within two hours, to a laboratory so that the seminal fluid can be analysed. The alternative method is to produce the specimen by masturbation in the laboratory, a procedure many men find difficult to achieve.
*165/16/1*
