Cosmetics and Food

Life has settled into a groove. I swallow Tomoxifen in the evening and hope that it does its job of preventing estrogen from binding to the cells in my breast and causing another cancer. My breast is still swollen and despite reassurance from Sigal that the swelling is due to the radiation, the fear that there are other, more sinister, causes is ever present, occasionally leading to a minor anxiety attack. Its dimensions apropos the other, hopefully healthy, one reminds me that we should be careful what we wish for - I'd always wanted to be more buxom but my hope extended to both breasts sharing equal proportions; the devil is no doubt enjoying a prolonged snigger at my lopsidedness.

The hot flashes are still a major annoyance. Last month, I had an appointment with a gynecological endocrinologist with an unpronounceable name (Dr. Zlotsover. try it out loud) who prescribed a natural, over-the-counter remedy based on black cohosh. Black cohosh apparently improves the functionality of Tomoxifen and recoups bone mass lost as a result of taking Tomoxifen, However, according to several reputable sites I found on the internet, the jury is out on black cohosh - not only are there conflicting conclusions from the many clinical trials, but it might actually be contraindicated in breast cancer patients (http://ods.od.nih.gov/factsheets/BlackCohosh.asp). Apart from that, it doesn't seem to be helping - there are days when I feel that the flashes are less frequent and less intense but the next day, they're back, with increased vigor. However, it takes about six to eight weeks for the black cohosh to do the job, so I'll give it the benefit of the doubt.

In my quest for optimal health (having been so cruelly deprived of the illusion that that's what I had all these years the cancer was surreptitiously growing inside me), I've begun paying more attention to what I put on my body, not just in it. I've recently discovered a supermarket close to my office that sells organic vegetables and fruit alongside non-organic produce as well as rows of spices and herbs that claim health-inducing properties, every type of pasta on the planet, freshly-made bread with whole grains, goat's milk ice-cream, a soup bar, and so on and so on. The ambiance is rustic as establishments emphasising health tend to be, although the effect is somewhat marred by containers of Osem chicken soup powder at the entrance to the store. At the back, there is a shop selling all manner of toiletries that purportedly contain no harmful properties and were not tested on animals. In fact, the range of lotions, moisturizers, shampoos, conditioners, deoderants, etc. is overwhelming, as indeed are the prices. But who wouldn't hand over a few more shekels to promote good health!

The question is, does it? The market is cashing in on the current obsession with good health. (There's a furniture store near my office called Green Furniture, as if to deny that their furniture is depleting the rain forests. On the other hand, the proprietor's family name could well be Green.) How much of it is a scam? Do we assume that the labels on products are telling all the truth? Is the literature telling us to avoid products with sodium lauryl sulfate, propylene glycol and petrolatum based on substantiated proof that these substances, even if they don’t cause cancer, are harmful to our bodies in other ways? Is the absence of harmful ingredients from the packaging sufficient indication that the listed ingredients are indeed good for you, or at least, will not cause you any harm? How is a simple consumer with no training in pharmaceuticals or chemistry supposed to make intelligent decisions?

The sales assistants project an air of knowledge about their products and are seemingly sincere in their belief that the products are not harmful but that's what they have been trained to do. Notwithstanding the sincerity of the manufacturers and sales staff, the possibility that some substance hitherto believed to be harmless could become toxic in combination with other substances cannot be precluded. These questions might seem obsessional but I find it hard to accept the superiority of a product, a food or a belief just because people with persuasive skills tell me to.

In spite of the questions and doubts, I've decided to to err on the side of conventional wisdom and buy the toxin-free products gradually, choosing those that suit me, and phasing out those containing ingredients identified as harmful. And if these products are indeed all they are purported to be, I hope that my current habit of mixing them - such as the healthy, pomegranate-smelling shampoo with the unhealthy conditioner, and vice versa - will not cost me any brownie points.

The Cancer Notebook by Julia Chiappetta provides a pretty full breakdown of which cosmetic ingredients to avoid - in fact, it contains quite a lot of useful information; highly recommended.

Scepticism also describes my approach to what I put in my body. Every morning, Nachum and I down a glass of green magma, a bright-green powder smelling of grass, mixed with water (http://www.greenfoods.com/products/green_magma.html). Based on barley grass, this tasteless mixture lays claim to promoting good health by supporting cardiovascular function and supplying the body with a generous dollop of antioxidants. Efforts to locate independent research on the efficacy of green magma proved fruitless but I was directed to http://www.greenfoods.com/news/#1 by the manufacturers of Green Foods. My conclusion was that so long as it does no harm, the worst that can happen is that it does no good. In the meantime, I wrote to Sloan Kettering to ask if they had ever conducted research on green magma, but apart from an auto-generated acknowledgement, I have not yet heard from them.

I have begun to eat with abandon and in the last few months, have gained around seven kgs, which makes me feel clumsy and uncomfortable. Having eaten according to the rules for so long and yet falling foul of cancer, I have thrown caution to the winds and, although our fridge now contains goats' dairy products, I have eaten cows' dairy products that were high in fat, aware that dairy foods cause mucus in the body and that cancer cells thrive on mucus. I have eaten cookies and cakes, aware that cancer cells thrive on refined sugars. On the other hand, Nachum has been making me a weekly portion of soup of carrots, yams and squash because I was advised to eat orange food.

In the battery of tests scheduled over the next few weeks, I've included a dietician to help me streamline my eating habits. She will no doubt dispense advice based on current conventional wisdom.

Panic

It’s a known condition of human nature that we appreciate what we have only when we’re faced with losing it. I’ve spent so much time bemoaning the lack of well-being that characterized my life BC (before cancer) that I failed to notice a gradual process whereby a facsimile of that well-being was developing in its place.

And then, that was shattered.

I’d become aware that my bra was pressing against my flesh, especially on the left side, but put it down to having put on weight. During the week, however, I realized that my breast was swollen. I remembered it had swelled during radiation but I’d had a vague notion that it had settled down to its normal dimensions some time over the last two months, since completing therapy. But now, my breast obtruded whenever my left arm brushed against my side, a situation that was not reflected on my right side. By the time I became agitated enough to call Hannah, my old companion, the churning stomach, was back.

Hannah told me to contact the surgeon. She said that the swelling could be due to the radiation, but it scared me that she could entertain any other possibility. (It’s unclear to me why she suggested I contact the surgeon instead of Dr. Sarid, my oncologist. She said that she didn’t know Sarid’s schedule for Wednesday, when he would be at the hospital, but I still wonder why she couldn’t have made an emergency appointment for me.)

Genuinely alarmed now, I tried to contact Dr. Sigal Librant and left a message on her voicemail. Next I made an emergency appointment to see her on Thursday afternoon (made possible by Nachum running to the doctor to obtain an emergency referral).

By the afternoon, I had calmed down. I’d surfed the net and spoken to Sally, my granddaughters’ former nanny, whose young daughter is a cancer survivor. It seemed that even months after radiation therapy, the breast can remain swollen. My problem was that I couldn’t remember if it had ever returned to its original smaller proportions.

I remained relatively calm until Wednesday evening when I noticed small black spots on the aureole around my nipple. Thursday morning, I ran a search for inflammatory breast cancer or IBC and what I read sent me into an unprecedented realm of panic (http://www.mayoclinic.com/health/inflammatory-breast-cancer/DS00632). My symptoms met some of those of IBC, although they could just as well be related to the effects of radiation. IBC is rated as Stage 3B or Stage 4 if it has metastasized, and survival rates are low. I believed with my whole being that the fight was over and that I was now facing death.

We reached the clinic early and when Sigal arrived, she told me that she’d heard my voicemail message only that afternoon. She examined me, told me the swelling was indeed due to the radiation but that I had one of the best recoveries she’d seen, that the black spots were pigmentation, also from the radiation, and that I certainly was not suffering from IBC.

I wondered, and still wonder, why I wasn’t immediately lifted out of my sense of doom by a feeling of relief. I think it’s because I’d given up. I had cried with uncontrolled hysteria, I’d screamed with fright at the horror of imminent death, I'd rued the time I hadn’t spent feeling grateful for my life as a cancer survivor. Mentally, I had gone to the brink of the abyss and it took a while to step away from it. How fragile my ability to cope with it all is and how wonderful life is when I can.

The next day I drank in the beauty of the world, and was back to complaining to Nachum, dispenser of indispensable TLC during that horrible period, about his driving.

How Am I Physically?

I'm tired. I don't know if I'm tired because radiation destroyed some of my cells and my body has to work overtime to recreate them, or I'm tired because we're in a transitional season and I'm working long hours. Everything becomes cancer-centric even when a connection to it is farfetched.

I sometimes forget that I still have limited use of my left arm. This is the arm from whose armpit 15 lymph nodes were extracted and although I'm getting some sensation back - for example, I can feel myself applying deoderant - an area of my upper arm is still numb. Sometimes, such as when I stab my electronic card at the parking entrance at work, I overreach and then my arm hurts. I've been told not to lift anything heavy in this arm, including weights. For the rest of my life, blood tests, injections and anything involving the active use of an arm and its contents must be done from my right arm. I wonder how much more time will pass before I get full feeling back.

I've put on weight. Initially, I put on weight because I tend to overeat but I should've been smart and lost a few kilos before beginning the Tomoxifen. Now my jeans pinch around the waist and the thighs. I don't know if there's any point in even trying to diet.

I have hot flushes. When I stopped taking HRT, I began to get a few hot flushes a day. They didn't last more than a minute or two and were more or less bearable, even those that left a faint line of sweat on my upper lip. It was, after all, summer and there were times when I didn't know if I was having a flush or it was just damned hot. A hot flush, for those who have never had one, begins in the depths of the body and spreads itself all over while concomitantly increasing in intensity. It has been referred to as 'cooking from the inside'. I think their frequency has increased since I began to take Tomoxifen - a spot check over the last four hours shows I was getting one every hour on the hour for the first three and the fourth one a mere 50 minutes later. If it gets worse than this I'll be dressing for summer in the depths of winter.

Musings

I have been a hypochondriac since childhood. Whatever ghastly illness of the week I was suffering from, the inevitable panic was sometimes allayed by a visit to a doctor, where more often than not I felt like an idiot, or it just dissipated with time as I found that I had no real symptoms and I was still alive. As I matured, I found that although I was still apt to take on board the most rare and deadly disease possible, I was far more sanguine about my state of health. In fact, I suspect there was an element of 'it can't happen to me', because until then, it hadn't.

Now I find that, in common with almost every cancer patient I know, anything that is even slightly awry is cause for panic. A little over a month ago I watched with horror the appearance and daily growth of a mole-like object on my leg. It started as a small, white bump that morphed from a pale pink to a darkish brown. I was convinced that my body was breaking out in melanomas but people who should know what a melanoma looks like put my mind at rest. The mole or whatever it was, darkened, hardened and has since disappeared. But this is the way it is - an unexpected twinge where there had never been a twinge before, a bout of gas, fatigue, a pimple, all become the focus of a fear that my cancer is manifesting itself in a new and dangerous way.

Liron (my erstwhile psychologist) had asked me to assign a number to my anxiety level on a scale of one to 10, (10 high) and I'd said four, which is probably why he decided I wasn't really in need of his ministrations. However, those moments when I feel something amiss, my anxiety levels are off the chart.

I watched carefully for side effects from the Tomoxifen and sure enough, just under a week after beginning with half a pill, I suddenly had a vaginal discharge. As the leaflet accompanying the medication clearly states that in the event of a discharge, stop taking the medicine immediately and call a doctor, I went into panic overload. I don't know Sarid's number so I called Hannah, who didn't seem very concerned - she just told me to go to the gynecologist. There was no recurrence and, a few days later when I kept my appointment, the gynecologist's examination calmed me down completely. It was nice going back to the old days when a visit to a doctor ended with a clean bill of health. I'm resolved to steer clear of unfamiliar toilets. A few days later, the day after I began taking the pill whole, I woke up with pain from mid-buttock all the way down my leg. Again, the leaflet sent me into a cold panic because it seemed I was having a bad reaction in my pelvic region. However, an hour or so later, the pain was gone and it hasn't yet returned. Either my body was having an initial response to the medicine - or we simply need to buy a better mattress.

Art of Living

I'd been looking forward to this course, which was conducted within the framework of research, and was open to anyone who had contracted breast cancer within the last five years. Art of Living appears to be an international organization - launched by one Sri Sri Ravi Shenkar - with the usual claims of reducing stress, increasing awareness, and promoting better health, energy, personal and global peace. A number of courses on its effect on cancer patients was concurrently underway in Jerusalem and Tel Aviv. (See http://www.artofliving.org/)

The course I attended consisted of 16 women, the trainer, Dafna, and two additional women whose presence was not totally clear - I think they were there to help us perform the exercises or tend to someone in case of distress. The women were of all ages, some shockingly young, from different walks of life. Our common denominator was that we had all suffered breast cancer, ranging from the minimally treated for early stage cancer (one woman's lump had been only 0.5 cm., less than half the size of mine) to those who'd gone through the hell of chemotherapy. One young woman revealed she'd had a recurrence.

Following the initial meeting, I was struck by the impact of that seemingly innocuous statement - we'd all had breast cancer. My diagnosis and ensuing treatment had been so very dramatic and I have been totally focused on my feelings, my treatment, my health care practitioners. As I have moved through the process to recovery, I have immersed myself in learning about the disease and its remedies, exchanging stories with women who shared the process with me, and riding the emotional roller coaster of trauma, fear, panic, despair and acceptance. It had been, it still is, a very personal, intense and all-encompassing experience.

The 16 women assembled in the room with the Indian ambiance and yoga mats, could have been anyone you see in street, the mall, driving to work - and yet, each and every one of us has lived through the same drama. It's almost surreal to contemplate that we all experienced the same gamut of emotions; the anxiety punctuated with intermittent hope waiting for results, the horror, fear, panic, despair and tears on receiving the devastating diagnosis, the bewilderment of submitting our bodies to the various machines, the resilience needed to confront the fear.

The course was exhausting. We filled out forms, learned to breathe in different rhythms (we learned to recognise each rhythm by its Sanskrit name), we looked into each other's eyes, we informed each other when we arrived on the planet and how long we intend to stay here, sang a song to an alien god, shared our feelings, and thankfully lay down on the mats to sleep as soon as we could complete the requisite breathing exercise. We drank a lot of water. Strangely, the subject of cancer was almost a stranger in the room, rarely becoming a topic of our interchanges.

We did this every evening from 7.00 to 10.00 from Sunday until Thursday - I got home every night after 11.00 - and again on Friday morning and the following Sunday evening. Despite two major sources of tension in my life at this time, I felt quite relaxed during the whole period I was attending the course but I'm not sure how much was due to the exercises or to tiredness from the sheer relentlessness of the schedule. I have failed to keep promises I made to myself to continue the breathing exercises at home or at work, but there is an open invitation to attend a session every Saturday and, for the next five weeks at least, on Friday morning.

I asked Dafna what happens physiologically when we breathe in different rhythms. Surely there is a purpose in taking long, drawn breaths as compared to short, panty ones. She insists it cleans the system, but cannot say how or why. Whenever I ask questions such as these, a common response is Why do I want to know. Seems to me a more relevant question would be, why would I not want to know.

Hiatus

The period between the cessation of treatment and my appointment with the oncologist was, despite predictions to the contrary, almost tranquil. With no treatments to undergo and no medication to remind me of what I'd had, I was almost able to enjoy the illusion that life was returning to normal.

I returned to work on October 16, after Rosh HaShana. I approached the day with a sense of heaviness, resenting the need to fling myself back into the pressure of a profession that I'm becoming increasingly less enthusiastic about. Although I work in a small company, most of my colleagues don't seem to know about my cancer and just assumed I'd been off on a carefree vacation for three weeks. By Monday, I was feeling better about being back, the workload not being particularly onerous. My boss, who had shown patience and understanding while I was undergoing treatment, seemed to expect me pick up where I'd left off pre-cancer as if I'd suffered nothing more than a particularly nasty bout of flu that had now passed. The CEO, who'd regaled with me with horror stories of the cancer experiences of a close friend of his, told me that he'd almost called to convince me not to take time off during the radiation treatments, for my sake, he averred, not the company's. I told him that the emotional as well as the physical effort of traveling daily to the hospital had taken its toll and I had been correct in taking the time off. All in all, my employers have been supportive and considerate.

I'd contacted the 1 in 9 organization a few weeks earlier and the very sympathetic and knowledgeable volunteer I'd spoken to had told me that many women have an emotional crisis during the month-long period between the end of treatment and their next visit to the doctor. I remember the period between learning I wouldn't have to undergo chemotherapy and beginning my radiation treatments as being emotionally difficult because for the first time since receiving the devastating news of my cancer, I was faced with downtime - no test results to wait for, no appointments to keep, just timeout for contemplation. The lack of action forced me to confront my mortality and go to the next stage emotionally, Now, during this longer, one-month hiatus, I found, unlike that earlier time, I began the day with a smile, which I more or less maintained until flaking out in front of the TV at around 9.00 in the evening, waking up around 11.00 in time to go to bed.

Medication Begins

I've allowed a whole month to go by without updating this blog, not because nothing happened in October, but because I didn't have the time or the mental energy to sit down and write it.

At 10.10 am on 10 / 10, I had my third appointment with Dr. Sarid, my oncologist and, as expected, he prescribed Tomoxifen.

Tomixifen is the medication of choice for hormonal-receptor positive cancer treatment. It received FDA approval in 1978 and its role is to block estrogen from binding to its receptors in the breast. There are some unpleasant and even life-threatening side-effects and I was curious to know why I wasn't being given Arimidex, which the informative lady at the 1 in 9 organization had told me is generally prescribed for post-menopausal women, such as myself. Arimidex is an aromatase inhibitor that prevents the conversion of steroids produced by the adrenal gland into estrogen and it has its own set of unpleasant but not necessarily life-threatening side-effects; however, it is thought to be superior to Tomoxifen in terms of preventing recurrence.

Dr. Sarid explained that Arimidex is very expensive and is not included in the basket of services in the first two and a half years of recovery from cancer. If I survive the first two and half years, I can expect to then be prescribed Arimidex, always presuming that it won't have been dropped entirely by then. Regardless of the cost, I wanted to know which medication was more likely to keep me alive. He said that in some cases, when the cancer was more advanced than mine, he recommends that the patient undertake the burden of paying for Arimidex. He seemed so convinced that I am going to survive that he was almost dismissive in asserting that Tomixifen is good enough for me. He wasn't receptive to the idea that I seek a second opinion, which the 1 in 9 lady had recommended. I managed to ask a few more questions before deferring to the feeling that I was taking up time he should be spending on other patients. I am now on a schedule of 3-monthly checkups. Perhaps at my appointment in January, I'll be able to ask another few questions. Prior to that, I'll need to have a blood test, a mammogram, ultra sound and check my bone mass.

Still feeling uneasy about the medication, I went to talk to Hannah, the nurse, and asked her if she thought I should get a second opinion and if so, what should I do if it differs from that of Dr. Sarid. She reminded me that Arimidex has been around for only about five years, compared to the decades that Tomoxifen has been in circulation, and that the long-term effects of Arimidex have still not been determined. Say no more - Tomixifen it is. She suggested I begin slowly, taking a quarter of a pill for two weeks, then half a pill for two weeks and working my way up to a full pill in a month in order to give my body time to adapt to it. In cases where there is a extremely unpleasant reaction to Tomoxifen, Kupat Holim (health fund) might be persuaded to switch funding to Arimidex.

In the end, I found that the pill itself is so small, chopping it into quarters is more trouble than it's worth. I began with half a pill which I took in the evening for two weeks. A few days ago, I began taking the pill whole.

Self-Pity or What?

I've become aware of a new phenomenon. Occasionally, and not preceded by any particular thought or event, my throat fills and my eyes well with unshed tears. Is this self-pity? Or perhaps it's a rush of gratitude that I discovered my cancer at an early stage and have a good chance of surviving it.

The tears don't fall and the moment passes.

No More Therapy

Last Thursday (September 20), I had my fourth and final session with Liron the psychologist. Although the sessions were slated to continue for three months, I could only agree with Liron that my anxiety was mainly under control and that the turmoil I’d felt that had caused me to seek psychological help in the first place was settling into broad acceptance of my fate. I guess there are patients who are unable to ‘hold’ their anxiety - as Liron put it, cupping his hands to indicate how anxiety metaphorically nestles - as well as I seem to be doing and therefore need his services more than I do. Also, if my fears and anxiety threaten to overwhelm me, I have several other options. In October, I’ll be beginning a yoga course called the Art of Living which has been adapted especially for breast cancer patients. (I understand that the difference between this course and the standard one is that we breathe more!) I’ve also made contact with the 1 in 9 organization and hopefully will be joining a support group very soon. I meditate and once a month have a session with Eran.

So the opportunity to plumb the depths of my sub-conscious and discover if there is anything there that contributed to my cancer is unavailable for now. Clearly, if I knew what thoughts and perceptions I have buried there, they would no longer be in my sub-conscious. I do think that the theory of flooding the mind with positive messages (I will survive, I am unique, and so on) to neutralize any sub-conscious negativity is seriously flawed. Any messages of this type would set up residence in my conscious mind rather than dislodge the contents of my unconscious mind.

But what if my sub-conscious is harboring massively positive, life affirming thoughts? I remember one afternoon in the waiting area for Accelerator 4 how one young woman was describing how her treatment was extended because the machine broke down so often and the thought that immediately leapt into my mind was, Well, that won’t happen to me! Of course it did, the very next day, and it hadn’t been repaired in time for my treatment the day after either. However faulty they might be, why would I want to expel such perceptions from my sub-conscious where all they are doing is making me happy and optimistic?

No More Radiation

Today I had my final radiation treatment. Out of a set of eight booster treatments, three had to be deferred because of a breakdown in the accelerator, bringing my last treatment right up to erev Rosh HaShana, a fitting start to the new year. Any cancer cells lurking anywhere in the vicinity of my breast should have been thoroughly nuked and expunged after the 33 treatments, leaving me, it is hoped, completely cancer-free. That’s the plan.

The angry-looking redness of my breast has now morphed into a rather nice tan color, with only slight redness around the scar, under which the lump, the original cause of all this trouble, was located. I was lucky that, unlike some women, I suffered no pain, no blistering or burns.

My next appointment with the oncologist is on October 10. On Sunday evening, on my first day back at work, I’ll be attending a meeting of participants in a yoga course for breast cancer patients called Art of Living.