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Modern medicine has developed solutions that allow cancer patients to live longer lives, but depression and anxiety often make these years painful and difficult. This book develops the techniques of behavior activation therapy into practical activities people recovering from cancer can use to recognize and overcome problems with depression and anxiety. Relieved from these two sources of emotional pain and limitation, readers of this book will be able to live life fully and apply their energy to the task of getting better.
Successes build on one another, creating a model for ever more positive feelings in the future. The key to success, though, is to keep focusing on engaging in enjoyable behaviors without getting bogged down by pain, frustration, and worry. Keeping on track is easy with the step-by-step approach offered in the book.
About the Author
Derek R. Hopko, Ph.D., is associate professor and associate department head in the Department of Psychology at The University of Tennessee. He graduated from West Virginia University and completed his residency and post-doctoral training at the University of Texas Medical School. His research and clinical interests focus on the behavioral assessment and treatment of mood and anxiety disorders. Hopko has strong interests in health psychology and conducts behavioral treatment outcome research with cancer patients diagnosed with clinical depression. He is a recipient of grant funding from both the National Institute of Mental Health and the National Cancer Institute, has authored some sixty peer-reviewed publications, and serves on the editorial board of five journals.
Carl W. Lejuez, Ph.D., is associate professor in the Department of Psychology and founding director of the Center for Addictions, Personality, and Emotion Research (CAPER) at the University of Maryland. He graduated from West Virginia University and completed his clinical internship at Brown Medical School. Lejuez's current clinical and research interests focus on the treatment of mood and addictive disorders. He has published more than ninety-five articles and book chapters, served as principal investigator for more than ten grants from the National Institute of Drug Abuse, and has received Young Investigator Awards from the American Psychological Association Division of Experimental Psychology.
Read an Excerpt
Your Cancer Experience
If you are reading this book, chances are that you may already know a great deal about cancer and how it works. However, there are also a significant number of cancer patients who make the decision to avoid learning about and thinking about their diagnosis. As this book progresses, we will address more specifically the concept of avoidance, that is, avoiding certain behaviors or thoughts, and why the human tendency to avoid can create problems. For the time being, realize that we are going to take a different path toward overcoming your anxiety and depression by approaching certain circumstances and behaviors, a process we will refer to as activation.
It is this mindset that will enable you to move forward in your life and to learn skills that will better allow you to cope with whatever difficult circumstances life throws in your direction. To head down this path of becoming activated, let's begin with the process of understanding the diagnosis of cancer. We'll include a time estimate for working through each chapter.
Time: Approximately One Week
What Is Cancer?
Although it may create some initial anxiety to read about cancer, the knowledge you gain may allow you to put things into a more helpful perspective and may prevent you from making faulty assumptions about yourself and your future. It may even help you and your loved ones to lead a healthier lifestyle, reducing the risk that your cancer will reoccur (if you are in remission). You may even find that some of your biggest fears are based more on a fear of the worst happening than on what is actually most likely to occur.
Even if you discover that some of your most significant fears or concerns are in fact justified or accurate, this experience may not be necessarily bad or undesirable. Instead, this will simply mean that you have become more educated about cancer. You can then process this new information and determine whether it changes how you view yourself, your values, and how you behave-and whether changes are needed in your life. If changes are desired, this self-help workbook will provide the assistance. So now, let's discuss cancer.
Cancer is not an uncommon medical diagnosis. Men and women, people from various ethnic and cultural backgrounds, and people of all ages are susceptible to developing cancer during the course of their lifetime. The American Cancer Society (2005) has printed the following information that helps highlight the impact of cancer in our society:
- The National Cancer Institute estimates that approximately ten million individuals with cancer are alive in the United States.
- Each year, approximately 1 to 1.5 million new cancer cases are diagnosed.
- Men may be at a slightly higher vulnerability to develop cancer.
- Over a lifetime, about 45 percent of all males will develop cancer.
- Over a lifetime, about 38 percent of all females will develop cancer.
- The most common form of cancer in men is prostate cancer.
- The most common form of cancer in women is breast cancer.
- For both genders, lung, colorectal, and skin cancers are the next most common types of cancer.
- Cancer is the second leading cause of death in the United States, exceeded only by heart disease.
- The five-year survival rate for all cancers combined is 62 percent.
Cells are the basic structural units that are essential to all living things. Each of us has trillions of cells in our bodies that allow us to function in different ways. These cells allow for breathing, digesting food, thinking, talking, walking, and many other human behaviors. Normal healthy cells generally perform all of these functions. These normal cells have the ability to reproduce themselves by dividing, a process referred to as mitosis. One cell will become two, two will become four, and so the story goes. This division of normal and healthy cells occurs in a regulated manner.
Throughout the body, cells continually divide and form new cells to supply the material for growth or to replace worn-out or injured cells. For example, when you cut your finger, certain cells divide rapidly until the tissue is healed and the skin is repaired. They will then go back to their normal rate of division. However, some cells may stop functioning or behaving as they should, may serve no useful purpose in the body, and may become cancerous or malignant. Cancer cells divide in a haphazard manner that is very different from the normal process. Scientists have recently made great advances toward understanding the different pathways that cells may use to become cancerous that involve different genetic alterations. Some genetic changes result in:
- The speeding up of cell growth
- The removal of genes that normally help to slow cell growth
- Cells continuing to live even when they are damaged or deranged
- Cancer cells being nourished by healthy cells and tissue
- Decreased immune system functioning and inability to destroy cancer cells
So, while cells normally will replicate themselves and create identical copies, occasionally the cells make mistakes. These mistakes are caused by mutations. A mutation refers to any change in the DNA of a cell. Mutations may be caused by mistakes during cell division, or they may be caused by exposure to DNA-damaging agents in the environment. When mutations occur, it is common for these mutated cells to be "killed off" by healthy cells. Healthy cells have internal mechanisms in place so that mutated or dangerous cells are not allowed to completely develop.
Unfortunately, sometimes these internal mechanisms are faulty, mutated cells are not contained, and they begin to reproduce rapidly. The result is that they typically pile up into a nonstructured mass or tumor. These tumors may be benign or malignant (cancerous). Benign tumors can divide and grow out of control, just like malignant tumors. However, malignant tumors also are capable of something unique.
These cells can move to different parts of the body where they normally don't live and grow rapidly out of control. They may destroy the part of the body in which they originate and then spread to other parts where they start new growth and cause more destruction (called metastasis). Although benign tumors may grow quite large, they do not spread to other parts of the body. Frequently they are completely enclosed in a protective capsule of tissue and do not pose danger to human life like malignant tumors. In spite of cancer often being referred to as a single condition, it actually consists of more than a hundred different diseases. All of these diseases are characterized by uncontrolled growth and spread of abnormal cells.
It's also important to note that cancer can develop in many places in the body and may behave quite differently depending on where it began. Breast cancer, for example, has different characteristics than liver cancer. Cancer originating in one body organ takes its characteristics with it even if it spreads to another part of the body. For example, metastatic breast cancer in the liver continues to behave like breast cancer when viewed under a microscope, and it continues to look like a cancer that originated in the breast.
Staging refers to the process of describing the extent or spread of cancer from the site of origin. Staging is generally the result of a comprehensive assessment that might include a detailed medical history, physical examination, mammogram, blood tests, bone scans, or a CAT scan or MRI. The American Joint Committee on Cancer (AJCC; Singletary and Greene 2003) has established specific guidelines for a staging system. According to this system, three important elements are considered in determining your cancer stage: tumor (T), nodes (N), and metastasis (M). In each instance you are allocated a score, with lower scores suggestive of a less advanced cancer. Your T score may range from 0 to 4 and is based on the size of the tumor. Your N score may range from 0 to 3, depending on the extent to which cancer has spread to lymph nodes. A score of N0 indicates that cancer has not spread to lymph nodes while a score of N3 indicates that cancer has spread to many lymph nodes. Your M score is either 0 or 1, where M0 indicates your cancer has not metastasized to other parts of the body and M1 indicates that it has spread to other organs.
After these individual scores are formulated, they are combined to determine your stage of cancer (stage 0 to 4). Stage 0 indicates a less severe form of cancer, such as lobular carcinoma in situ or ductal carcinoma in situ (forms of breast cancer). By comparison, stage 4 cancer is the most severe stage and indicates that cancer has metastasized to other parts of the body. It is important to remember that even stage 4 cancer does not necessitate that death is soon to follow or that you're without treatment options. Every day, new and exciting developments are occurring in cancer research that are helping to treat the illness and save lives.
Risk Factors for Developing Cancer
You may be wondering why you developed cancer. You may feel anxious, depressed, scared, lonely, and even angry. The reality is that anyone can develop cancer and for a variety of different reasons. In truth, cancer researchers are aware of many factors that are linked with cancer but do not agree very much on the precise cause of cancer. In only a minority of cases can medical professionals actually pinpoint the exact cause of cancer. Instead, it is useful to look at specific risk factors. In general, you become more likely to develop cancer as you get older. Almost 80 percent of cancer diagnoses occur after the age of fifty-five.
Ethnicity also seems to play a role in the development of cancer. For example, white women are most likely to develop breast cancer, followed by African Americans, Asian Americans, Hispanics, and Native Americans. In the case of prostate cancer, on the other hand, African Americans are at greatest risk, followed by white, Hispanic, Asian American, and Native American men.
In addition to age and ethnicity, genetic factors definitely play a role in whether someone develops cancer. About 5 to 10 percent of cancers are believed to be hereditary in the sense that an inherited gene increases vulnerability to certain types of cancer. For example, all human beings have what are referred to as BRCA1 and BRCA2 genes. These genes are present in all cells in our body. If one of these genes has mutated, there is an increased likelihood of developing breast cancer. Instead of about a 13 percent risk of developing breast cancer (if you don't have the mutated gene), the risk extends to between 50 and 85 percent. Blood tests can be done to determine if individuals have this mutation, as well as other genetic abnormalities that may be associated with cancer.
In addition to a genetic component, cancer may be caused by other factors that include hormones, eating habits, tobacco, chemicals, radiation, and infectious organisms. Hormones are active regulatory chemical substances that are formed in one part of the body (glands) and carried by the blood to other parts of the body, where the hormone will have an affect on cell functioning. Although there are many hormones in the human body, a few hormones in particular seem related to the development of cancer. These are our reproductive hormones, referred to as estrogen, progesterone, and testosterone.
All hormones are essential to human life, and all healthy cells require hormones for support. However, it has been demonstrated that cancer cells are also dependent on these hormones. For example, the longer women are exposed to hormones (estrogen and progesterone), the greater their risk of developing breast cancer. So, the risk of acquiring breast cancer increases when women begin menstruation at younger ages or stop menstruating later. The older women are when they have their first child, the greater the risk. Women who have never given birth to a child are at increased risk. Researchers also believe that the longer women breastfeed, the lower the likelihood of their getting breast cancer (Lipworth, Bailey, and Trichopoulos 2000). For men, prostate cancer is more likely to develop and grow with increased exposure to testosterone and related hormones called androgens. As you will see in the next section, certain cancer treatments have been developed that reduce levels of these hormones in the body and may help to kill cancer cells.
Eating habits also may play a role in the development of some forms of cancer, and it is estimated that about one-third of cancer deaths may be directly attributable to dietary factors. These factors are outlined here and in greater detail on the National Cancer Institute website (cancer.gov/). In particular, diets high in fat intake have been associated with breast, colon, and prostate cancer and possibly pancreatic and ovarian cancer. Although it appears that total fat intake is more important than the type of fat (saturated, polysaturated) in terms of who develops breast and colon cancer, there also are a couple of studies that indicate saturated fats may be particularly associated with breast and colon cancer risk (Howe et al. 1990; Willett et al. 1990). So what dietary behaviors are associated with reduced cancer risk or recurrence?
First, increasing dietary fiber can substantially reduce your risk of cancer, particularly colon cancer and perhaps breast, rectal, and stomach cancer (Howe et al. 1990). Second, in geographic regions where fruit and vegetable intake is highest, cancer risk is lowest. Fruits and vegetables and their associated vitamins seem important for reducing the risk of most cancers, particularly cancers of the respiratory and digestive tracts. Of the many vitamins and minerals, carotenoids and vitamins A and C may be most essential in reducing cancer risk. Foods rich in carotenoids include carrots, cantaloupe, sweet potatoes, broccoli, and spinach.
Finally, there is some indication that certain food additives or methods of preserving food (such as pickling, smoking, or curing) may be associated with some forms of cancer, particularly stomach cancer. So whether you have been diagnosed and treated for cancer, are trying to lead a healthier lifestyle to prevent cancer reoccurrence, or are simply concerned about other family members, a diet including fruits, grains, and other vegetables can go a long way toward improving both physical and mental health.
It is probably no surprise that tobacco products increase the likelihood of developing cancer. In fact, cigarette smoking is believed to cause about one-third of cancer-related deaths and is the leading cause of lung, oral, and esophageal cancer (National Cancer Institute 2007). Amazingly, tobacco products contain thousands of chemical agents that include about seventy carcinogens, or substances that have been demonstrated as causing cancer. Included on this list are substances such as acetylene, ammonia, arsenic, carbon monoxide, methanol, and formaldehyde. Whether smoking causes cancer will depend on such factors as how long you have smoked, the number of cigarettes smoked per day, how much of the cigarette you smoke, and how deeply you inhale. Our suggestion is to not smoke at all, and if you do, please take advantage of the many treatment options that are available to you. Rate of death from cancer is double among individuals who smoke compared with those who do not (National Cancer Institute 2007).
A number of cancer-causing chemicals have been identified, including benzene, asbestos, lead, hexavalent chromium, chlorinated hydrocarbons, and over fifty other toxic agents (International Agency for Research of Cancer 1987). Benzene is a flammable gas that is evident in cigarette smoke whereas asbestos is common in insulation, roofing shingles, tiles, and many other products. Lead exposure also is quite common, and in years past, lead was a component of gasoline. Lead is still found in much of the house paint used prior to 1980. Tap water that runs through old lead pipes may also be contaminated with lead. Other exposures can occur through contact with various cosmetics, ceramics, and bullets. Lead exposure typically occurs by swallowing or inhaling, and although the available research is still somewhat inconclusive, lead exposure has been associated with cancers of the lung, brain, stomach, and kidneys. Finally, various other chemicals may be associated with cancer development, including less-commonly encountered herbicides such as Agent Orange (an herbicide used by the military during the Vietnam war), as well as more-frequently experienced products such as lawn pesticides and herbicides.
Although the research is highly inconclusive, there are even some data to suggest heavy exposure to fluoride in your drinking water may cause cancer. As chemicals are everywhere, including the air we breathe and the water and food we digest, completely eliminating exposure is highly unlikely. Being aware of the association of chemicals and cancer, however, can help us avoid higher risk situations.
Both natural and human-made radiation can increase cancer risk. The most obvious source of natural radiation is the sun. Excessive and unprotected exposure to the ultraviolet (UV) radiation of the sun is considered the most significant risk factor in developing skin cancer (National Cancer Institute 2007). Skin cancer is in fact one of the most common forms of cancer in the United States, and the American Cancer Society predicts that in the next year, approximately one million Americans will be diagnosed with skin cancer, with about 6 percent being diagnosed with melanoma, the most deadly form of skin cancer. In addition to sun-related cosmic radiation, and less studied as it pertains to cancer, radioactive material is found naturally in the soil, water, and vegetation.
Human-made radiation can be experienced via exposure to tobacco, television, medical X-rays, and smoke detectors. Outside of tobacco, the cancer-causing effects of these objects are largely unstudied, though it seems unlikely that excessive television watching or frequent walks by your home smoke detectors would be carcinogenic! On the other hand, high doses of radiation also may be human made. For example, the radiation experienced by inhabitants of Hiroshima and Nagasaki following the dropping of atomic bombs in 1945 was associated with an increased risk of developing cancer. Similarly, experts predict that one of the long-term effects of the Chernobyl disaster will be a slightly increased rate of cancer in years to come (Cardis et al. 2006).
Finally, because viruses can invade and alter the genetic material of cells, infectious organisms such as viruses may contribute to the development of some forms of cancer. For example, the hepatitis B virus is linked with liver cancer, and liver cancer is most commonly found in those countries with the highest rates of the hepatitis B virus (China, Japan). The T-cell leukemia virus, similar in many ways to the HIV virus, has been associated with Kaposi's sarcoma. In addition to Kaposi's sarcoma, the three types of cancer most often associated with viral and bacterial infections are cervical, liver, and gastric cancer (National Cancer Institute 2007). It is important to remember, however, that in most cases of viral or bacterial infection, cancer doesn't typically develop. Therefore, infection is seen as a risk factor that is likely combined in a complex manner with the other risk factors outlined in this section.
Perhaps the best way to sum things up is to say that cancer develops gradually as a result of one's environment, lifestyle, and heredity. About 80 percent of all cancers are in some way related to tobacco, dietary habits, and to a lesser degree, exposure to radiation or cancer-causing agents (carcinogens) in the environment (American Cancer Society 2006). Although many risk factors can be avoided, other (genetic) factors are unavoidable. We should be mindful of these risk factors and remember that whether we have been diagnosed and treated for cancer or whether we are free of cancer, we can further protect ourselves by avoiding these risk factors when feasible.
EXERCISE: WHERE DID YOUR CANCER COME FROM?
In this exercise, we will present you with a few questions. Please consider each question and write down your thoughts. Feel free to write in full sentences or simply jot down your thoughts. The important thing is that you get the opportunity to start thinking about these issues.
If you are reading this book, chances are you have either undergone treatment for cancer, are preparing to go through treatment, or have not yet decided on a treatment. In all cases, especially with respect to the last two circumstances, understanding your options and what to expect during treatment can prepare you to make informed decisions and also help you to cope with the process. Again, increased awareness can help you to overcome some feelings of anxiety and depression that you may have about acquiring cancer and being treated for the illness.
Depending on the type of cancer you have been diagnosed with, different treatment options may be more or less likely. Additionally, many individuals are likely to have been or will be involved in diagnosing and treating your cancer. In diagnosing your cancer, your primary care physician may have been very involved. A radiologist, who specializes in the use of diagnostic tests like mammography, ultrasound, and other types of X-rays, also probably played a role. Finally, following a biopsy, or removal of tissue to determine whether cancer cells are present, a pathologist, or person who specializes in examining tissue samples, determined whether cells were cancerous and the stage of cancer development. In treating your cancer, several other medical professionals might have been or could be involved. These include a medical oncologist, who will describe the process of treatment options such as chemotherapy and hormone therapy, help you decide what may work best in your situation, and provide follow-up care after your treatment. A surgical oncologist will be involved in conducting the biopsy, educating you about recent advances in surgical techniques, and performing the surgery to remove cancer from your body. A radiation oncologist may be in charge of your radiation treatments and may also educate you about this process and what to expect over time.
Depending on the type of cancer you are being treated for, a plastic surgeon may be involved with reconstructive surgery. Finally, many other important individuals will be involved with treatment, including nurses, staff, physical therapists, and mental health professionals, such as the authors of this book. In general, cancer treatment may include the following: surgery, radiation therapy, chemotherapy, hormonal therapy, and immunotherapy (American Cancer Society 2005).
Surgery is the oldest treatment for cancer, and most individuals will undergo some type of surgery to remove cancerous tumors. There are many different kinds of surgery. Preventive or prophylactic surgery is done to remove tissue that is not yet cancerous but is at high risk for becoming malignant. Precancerous polyps might be removed in such a way, and breast mastectomy (removal) might be indicated if a woman is at particularly high risk (genetically) for acquiring breast cancer. As indicated earlier, surgery also may be conducted for diagnostic purposes, as in removing tissue through biopsy to determine whether cancerous cells are present.
Curative surgery is intended to remove malignant tumors that are isolated in specific areas of the body. This surgery often is used in conjunction with other treatments such as radiation therapy and chemotherapy to increase the likelihood of completely destroying cancerous cells.
On the other hand, palliative surgery is not used in a curative sense, but more to deal with complications arising from an advanced cancer. For example, in the situation of a patient with advanced metastatic cancer, if a large rectal tumor is preventing the person from being able to use the restroom, surgical procedures might be used to provide relief, though the person would not be without cancer following surgery.
Supportive surgery might be used to facilitate cancer treatment, such as the insertion of a catheter port to assist in the administration of chemotherapy. In such cases as breast reconstruction following a mastectomy, reconstructive surgery may be used to restore a person's appearance.
Finally, in many other circumstances, alternative forms of surgery such as laser surgery (cervix, larynx, rectum skin cancer), cryosurgery (cervix, prostate), electrosurgery (skin, mouth cancer), and Moh's surgery (skin cancer) may be indicated (American Cancer Society 2006).
Radiation therapy (or radiotherapy) is an approach to treating cancer that involves the use of radiation to destroy cancer cells. Radiation therapy may involve the use of a number of radioactive elements that include cobalt, iodine, phosphorus, and cesium. During radiation therapy, radiation is directly targeted at a region of the body where cancer cells are present. A stream of high-energy waves are directed at cancer cells and have the effect of damaging their DNA so that the cells can no longer reproduce. Radiation therapy may be external in the sense that a machine can administer it, or internal, where radioactive material is implanted within or near a tumor.
If you are receiving external radiation, the typical course of treatment will be about five days per week for several weeks. Although radiotherapy is useful for destroying cancerous cells, some healthy cells can also be damaged with this process, including cells in the hair follicles and skin. This is why certain side effects of radiation therapy may occur, many of which depend on the dose and schedule of radiation. Among these side effects are hair loss, skin lesions or skin shedding, nausea, vomiting, fatigue, and increased susceptibility to infection.
Depending on the type and stage of cancer development, radiation may be the only form of treatment for your cancer or may be a component of a more comprehensive treatment that includes other interventions discussed in this section. Radiation therapy is considered an effective form of cancer intervention and has been used on a number of different cancer types, including breast cancer, colon cancer, Hodgkin's disease, kidney cancer, oral cancer, prostate cancer, and skin cancer.
Unlike surgery and radiation therapies, which are considered localized interventions, chemotherapy is a systemic treatment: that is, one that is used to reach all parts of the body. Chemotherapy is really the use of a combination of different drugs to prevent cancerous cells from returning and to destroy malignant cells that may have traveled to different parts of the body. About half of all individuals diagnosed with cancer will receive some form of chemotherapy.
Chemotherapy may be given through intravenous administration (most common), intramuscularly, or via orally ingested pills. Chemotherapy is a cyclical treatment, which means that individuals who undergo this therapy will have periods where they are being treated that will be followed by longer recovery periods.
The side effects of chemotherapy are in many ways similar to those of radiation therapy and include appetite loss, nausea, vomiting, hair loss, and mouth sores. Loss of fertility and thrombocytopenia (a low platelet count) also may be possible outcomes. The seriousness of side effects will depend on the type of medications used, the dosage, and the duration of treatment. The significance of these side effects usually diminishes as one moves further into the recovery period between treatments. As with radiation therapy, chemotherapy is used to treat a variety of cancer types.
[ End of excerpt ]
Table of Contents
Your Cancer Experience
Understanding Avoidance in Your Life
Behavioral Activation Treatment for Cancer (BAT-C)
Treatment and Medication Management
Becoming an Effective Problem Solver
Getting a More Restful Nightâ€(tm)s Sleep
Assertiveness and Social-Skills Training
Relaxation, Mindfulness, and Self-Hypnosis
Maintaining Treatment Gains and Preventing Relapse