Choosing To Live

by Barbara Joseph

I. My Story

It was in the early morning in the Spring of 1991, just after breast-feeding, that I noticed it. Oliver was eight weeks old and my breasts were empty, yet a huge mass was still there and it was rock-hard. I could not pretend I was engorged with milk. I had to face the terrifying truth. As a physician who had felt many similar masses, I recognized the likelihood that it was a malignancy. My life was about to drastically change and I was profoundly afraid. Deep inside I knew it was the beginning of a journey to claim the unexplored parts of my soul.

I grew up in Brooklyn. Like many an adolescent during the late sixties and early seventies, I rebelled: antiwar protest rallies, Woodstock, hitchhiking across the country; I also took a year off from my studies to live in Israel and backpack in Europe. When at last I was ready to get on with my life, I resumed studies at Brooklyn College, applied and was accepted to Downstate Medical College, and completed an obstetrics and gynecology residency at Rutgers. I had been practicing obstetrics and gynecology for six years in Fairfield County, Connecticut and had three children when I was diagnosed with advanced breast cancer. At that moment my ordinary world came to an end. Never again would I take my life for granted.

All the tests that ensued were mere formalities. From the start, I knew my life was in danger. The sonogram said the mass was solid -- bad news. The biopsy said it was cancer -- even worse. Like so many other women, while still reeling from thediagnosis, I was given conflicting opinions regarding the treatment. My medical oncologist suggested chemotherapy before surgery (neoadjuvant chemotherapy); at a regional cancer center I was advised to have a radical mastectomy and lymph node dissection followed by chemotherapy; at another major cancer center I was given a variety of more radical chemotherapy protocols from which to choose, including bone marrow transplant.

In an effort to get a consensus that made sense to me, I sought an opinion from Dr. Susan Love, whose book, Dr. Susan Love's Breast Book, I had received from a grateful patient prior to my diagnosis. Warmly and without hesitation, Dr. Love opened a door in me called "recovery is possible," a door that must be opened for anyone who has given up or has gotten the message that recovery is unlikely. Placing no undue emphasis on the stage of my disease, together we outlined a number of treatment options and the possible outcomes, each leading to further crossroads in decision-making. One road led here, one there, and one, I was greatly relieved to learn, led to a complete healing. I decided on neoadjuvant chemotherapy; further decisions would be based on its effects. In addition to selecting choices within the conventional medical model, I worked actively toward a holistic response by creating a breast-healthy recovery diet, treating my body respectfully by balancing rest and exercise, assuming absolute responsibility for my feelings, seeking my greater purpose in life, and always hoping, a necessary component of healing.

In some ways life had prepared me for this catastrophe. It was already part of my nature to go beyond the conventional, to pick the road less traveled, and to ultimately rely upon myself to make choices. Now, my life was at stake. Illness is a crisis of the soul as well as one of the body. My hectic lifestyle and occupation as an obstetrician-gynecologist had allowed little time to take care of my own physical, emotional, and spiritual needs or even to reflect upon them. When the shockwaves of the diagnosis subsided, I knew that in order to heal the very fabric of my life would have to change. The treatment for this disease is not simply the recommended combination of surgery, radiation, and chemotherapy. For myself and for those who choose to be transformed by the experience of cancer, there is the life before cancer and then there is the life we create after cancer.

In the months that followed, I began an enormous amount of psychological work. My long-buried memories of my own mother's untimely death from cancer surfaced; I was frozen with the thought that I would reenact her demise. She had passed away when I was almost eleven, and it had taken most of my adult life to come to terms with the shame and emptiness that I connected with her death. Our shattered family had been so devastated that no one would speak of it. And as the old wound opened, my healing began. My pain was deep, dark, and boundless. Yet in the depths of my despair there was a spark within that allowed me to maintain my own identity and forge my own story.

In my darkest moments I refused to give up. It no longer mattered whether I would live or die. I knew I was to become a warrior and my children would always remember me engaged, rising to meet the challenge. My mother's silent death and her inability to take part in her own healing had pointed me in the opposite direction. I knew my life depended on speaking out and participating in my healing. The essence of healing is finding that light within the blackness, making order out of chaos, and enabling empowerment to emerge from fear. As Jews have learned throughout history, no matter how little control we may have over circumstances, even in the most terrible of times, we can choose how we will respond. In our choosing we can regain our power, so much so that we may even overcome the most threatening physical conditions.

And so it was with me. One Friday evening in October 1991, after six months of neoadjuvant chemotherapy, followed by a lumpectomy, I received the lumpectomy results. No residual tumor was identified. I DID IT! And to this day, I am free of cancer.

II. Heal Thyself

In 1995, 32 percent of cancers in women were breast cancer; 18 percent of female cancer deaths were attributable to this disease, accounting for 183,000 new diagnoses and 46,000 deaths nationwide. When a disease is reported to affect 1 in 8 women, it is an epidemic.

We can confront this epidemic and do the healing work by taking the following steps.

Women: Listen to and know your body. It is often the case that the woman herself discovers a breast lump. I detected mine not during a formal examination but in the course of everyday living. Examine your breasts regularly during your menstrual cycle and at all other times. Do so with love and respect for your body.

Understand the limitations of mammography in early detection. Despite the raging controversies about when and if to get mammography, tumor cell dynamics indicate that most breast cancers have been around for six to eight years prior to achieving a size that would even be detectable by mammography. So what we refer to as early detection is not really early at all. As a culture we need to give far more attention to preventing breast cancer in the first place rather than detecting it and treating it after the fact.

Get informed about treatment, and treat the whole person. Breast cancer is a multifactorial disease whose causes are weighted differently in every woman. We have an incomplete understanding of its natural history, which compounds the difficulties in making treatment decisions. Breast cancer is best thought of as a systemic disease. Utilizing this model, local therapies, i.e. surgery and radiation -- the therapies directed solely at the breast -- become less important, because the breast lumps themselves are not life-threatening: metastatic breast cancer is. The therapy chosen to deal with the breast lump should be the least destructive/disfiguring to a woman as possible, while accomplishing the goal of eradicating disease. More extensive breast surgery generally has no better cure rates than more conservative surgeries. A recent review of national statistics on breast cancer surgery has shown that mastectomies are performed more frequently in certain regions of the country, reflecting regional physician preferences. So be sure to get second opinions. In choosing surgical therapy, a woman and her physician must take into account the size and location of the tumor, the size of her breasts, and her preferences.

Radiation therapy does not alter short- or long-term breast cancer survival rates. The Early Breast Cancer Trialist's Collaborative Group confirmed that radiotherapy did not affect ten-year survival. Its usefulness is only in the reduction of local recurrence. Women who smoke are at greater risk to the harmful effects of radiation. Breast cancer patients treated with radiation and chemotherapy are at a much higher risk of treatment-induced leukemia than those who receive chemotherapy alone. We need to be well-informed about the risks and benefits of treatments before we agree to them. Since 1975 the number of breast cancer patients receiving chemotherapy has increased 300 percent. Mortality statistics do not reflect a proportionate benefit. In 1988 the National Cancer Institute took the stand that all women with breast cancer should have chemotherapy primarily because of our lack of understanding regarding this disease. We need to address the whole body in breast cancer treatment, not by accepting a blanket recommendation for chemotherapy but by attending to body, mind, and spirit.

Early disease is not what we think it is. Even early stage breast cancer can spread -- if only microscopically -- and so it is imperative to treat more than just the breasts. Cancer does not necessarily progress in an orderly, step-by-step fashion. If this were not the case, then why would 20 percent of women with Stage 1 disease die of metastatic cancer? Why wouldn't they be cured by surgery alone?

Foods to Embrace, Foods to Avoid: In 1982 the National Academy of Sciences reported that 60 percent of cancers in women are associated with long-term eating habits. Not enough has been done to get this message across.

Nutrition is an essential component in cancer therapy. In the New York Times (May 17, 1997), Jane Brody reported that "several studies point to the protective value of eating lots of fruits and vegetables, which are rich sources of nutrients and plant chemicals that in laboratory studies impeded the development of cancer."

My Breast Health Food Pyramid outlines the diet that was part of my recovery. The most vital elements in the diet are those at the pyramid base: whole grains (rice, corn, millet, oats, barley, pastas, and breads) which are minimally processed and retain their naturally high fiber. Next on the pyramid are fruits, legumes, nuts and seeds, and vegetables and sea vegetables, which contain an incredible array of vitamins, minerals, antioxidants, and immune enhancing powers. Third are soy foods (including tofu, soy milk, soy sauce), which contain phytoestrogens that modulate excess estrogen stimulation. Women in countries where the consumption of soy foods is high have significantly lower breast cancer rates than American women.

Consuming oils that contain essential fatty acids such as flaxseed on a daily basis is also important. Fish and eggs can be eaten weekly; meats and poultry monthly; and alcohol, sweets, and dairy very rarely. It is important to eliminate refined sugars and partially hydrogenated oils, as well as chemicalized and highly refined foods. It is best to eat organically grown foods which are richer in minerals and do not contain the chemical residues which require detoxification in the body. Some of these pesticides are classified as xenoestrogens, that is, they can attach to estrogen receptors and stimulate the growth of estrogen sensitive tissues such as the breast. Research continues on the role these and other chemicals play in the breast cancer equation; in the meantime they are best avoided.

Shopping, preparing, and consuming healthful foods can be a daily rite of passage that slows us down and nourishes both body and soul. Just as Sabbath observance can make our ordinary lives more sacred, so too can food preparation become a healing ritual that imbues daily life with meaning. Often I am up in the quiet of the early morning washing, cutting, and chopping my vegetables, the God-given food that is also my medicine.

The stress of our fast-paced daily lives, the drain that cancer treatment puts on our detoxification systems, and the difficulty in getting all the vitamins and minerals we need from our diets make supplements a sensible addition to a healing program. Important antioxidants to include are Vitamin C, Vitamin E, beta carotene, zinc, selenium, N-acetyl cycsteine, and Co enzyme Q-10. Fortifying myself with a healthy diet and supplements allowed me to go through the conventional treatments with minimal toxicity, no significant hair loss, and good energy levels.

Learn to Nurture Yourself. In 1989 Dr. David Spiegel published a landmark study in Lancet comparing two groups of women with metastatic breast cancer. Those women who were part of supportive group therapy lived on average twice as long as the other women (all the women received the same medical therapies). This is one of many studies giving scientific validation to the physiology of hope, nurturance, and support.

When I was first diagnosed, I did not see the connection between my life as physician, mother, daughter, and woman and the development of breast cancer. My medical education failed to address the deeper meaning of illness and my fragmented Jewish upbringing had left me only vaguely aware of the interconnectedness of mind, body, and spirit.

The emotional component in the development of disease and in healing became quite clear as I began my recovery. An ECaP workshop (the Exceptional Cancer Patients foundation created by Dr. Bernie Siegel) I attended early in the course of my illness inspired me to view my life in a new way. Yes, we are all mortal; therefore, the question is not whether we will die but how we will choose to live. And with this realization -- the celebration of life -- that is central to Judaism, I began to live for the first time in my life.

Through the ECaP foundation I met my therapist, Tullia Forlani Kidde, who was as helpful to me in recreating my new way of life as the treatments were for extending it. Just as we need to replace convenience/junk food with a new way of eating (i.e., wholesome food), so too do we need to replace emotionally unhealthy ways of living with new ways of relating -- prioritizing self-care and relating to others from a position of self-knowledge and strength. In Tullia's support group I found a place to share the turmoil of a life-threatening illness -- and a place to laugh.

Living in the moment lies at the heart of healing. In the early days of my recovery, after my work was complete and I had finished my evening meditation, I went into the rooms of my sleeping children and breathed the sweet soft air around them; it was an elixir. They nurtured me by night as I nurtured them by day. I began to create a new life, a life of caring about myself for the first time, of allowing myself to take pleasure in the moments of my life. I was glad to be alive and grateful for the opportunity to heal. Moment by moment, day by day, I chose life.

In our society women too often are consumed with being the nurturers. They give and give, and at some point there is no more to give. Women with breast cancer need to be especially aware of this dynamic; they need to learn how to receive and how to give to themselves.

Religion and Prayer: Shema Yisrael Adonai Elohenu, Adonai, Echad. In the early days of my illness, I lived with a constant awareness of my own mortality. While this may sound as if I lived in fear, it was actually quite the opposite; the awareness gave rise to an acute enhancement of life and I was often filled, almost to bursting, with love. Shema Yisrael Adonai Elohenu, Adonai, Echad. In the morning this prayer would come to me, and while I showered I would sing it aloud. Prayer is potent; it connects us with our higher Self, with the divinity within and without. Shema Yisrael Adonai Elohenu, Adonai, Echad. I was filled with gratitude for my life, my intelligence, my intuition, and the love of my three children -- all providing me with the opportunity to overcome my challenge.

Move Your Body. Dozens of studies have shown that regular, vigorous exercise enhances the immune system and decreases the risk of cancer. Recent research at the University of Southern California found that four or more hours of exercise per week during the reproductive years cut the risk of breast cancer by 60 percent. More exercise, however, is not necessarily better. It is important to find a balance between exertion and rest. Sometimes the body is crying for rest and we may push too hard. Learn to listen to your body's messages.

It is best to participate in a variety of sports and exercises that encourage flexibility, strength, and endurance. Brisk walking, jogging, weight training, aerobics, dancing, swimming, biking, and yoga are all possibilities. Not only will they help protect you from disease; they will improve your state of mind.

III. Conclusion: The Essentials of a Healing Program

Healing is a full-time commitment. If your intention is to transform your life in the process of recovering from breast cancer, you must be willing to put forth the effort. Your energy output needs to be organized and prioritized around this crisis.

Strength of body and mind will assist you in your journey. Rest will conserve your strength for healing. Clean food and water will allow your body to do the work. Meditation, visualizations, and affirmations will enlist your mind in the service of your greater purpose.

Let love into your life: love yourself and where you are in your recovery, love the adversity that awakens you to your fighting spirit, love your Creative Power and become attuned to it, love those around you who are there to help you learn the lessons of your life.

While our vulnerability is frightening, it is also authentic and empowering. As Jews we have always dealt with the threat of annihilation. At times we have no control over our lives beyond our choice of response. If there is a gift in cancer, it is in opening us up to the preciousness of life in the moment. Healing takes place only in the present. So celebrate life -- L'chaim.

Barbara Joseph, M.D., the author of My Healing from Breast Cancer (Keats Publishing, New Canaan, CT), is affiliated with The Center for Women's Health in Stamford, CT and is a member of Temple Israel, Westport, CT.

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