Читать книгу The Lovin' Ain't Over for Women with Cancer - Ralph Alterowitz - Страница 21

Understanding how best to achieve the most satisfactory sexual experience after therapy can only occur when a woman and her partner know the effects of the therapy. Broadly speaking, the three major treatments for any cancer are surgery, radiation, and chemotherapy. Each individual being treated for cancer requires one or more of these treatment types (modalities) and may have a host of options to choose from within each modality, depending on the type of cancer and the stage at which the cancer is discovered. (Stage refers to the progression of the disease, from totally localized to diffuse or metastatic.)

Cancer and cancer therapy cause changes in the four Ps: an individual’s physical, physiological, and psychological makeup, and in the partner. The term physiological refers to the functioning of the body and its processes. For example, if a therapy affects an organ that produces a hormone, production of that hormone may increase or decrease, and various parts of the body will reflect such changes.

Table 1 shows the major modes of cancer therapy that may be discussed with a patient: surgery, radiation, or chemotherapy. The oncologist may recommend one or several in combination as being most appropriate, given the nature of the disease, its stage and other factors. The fourth column, Other, notes hormone therapy, as well as less widely used medically accepted therapies such as cryoablation and high-temperature ultrasound.

Surgery causes the most dramatic physical effects. Change in physical appearance is a major effect of breast surgery. Partial or total loss of sensation in the breast often also results. Surgery for gynecological and other pelvic cancers may cause changes in genital sensations, and may even make some types of sexual activity difficult or impossible. The majority of pelvic cancers concern the female organs - the uterus, ovaries, cervix, and vagina - but other pelvic cancers occur in the colon, small intestine, anal area and bladder. Treatment for abdominal and pelvic cancers affects nerves that go to the genital area, so that sensitivity in that area can be affected.

In addition to physical changes that are often observable, second-order effects include physiological and psychological changes. As shown in Table 1, surgery for breast cancer can be a mastectomy (the technical term for breast removal), which may or may not include surgically removing the lymph nodes on that side of the torso and under the arm, or a lumpectomy, in which only the cancerous tumor and some surrounding tissue is removed. Mastectomy (without immediate reconstruction) generally leaves a flat area with a scar where the surgeon sewed the skin together. Usually, the outcome of a lumpectomy is a scar much like a large dimple.

In both instances, nerves in the breast area must be cut to remove the diseased tissue. However, a mastectomy results in totally severing all nerves to the breast. The nerves cannot be replaced and will not regenerate to provide the previous extent of sensation. In the case of a lumpectomy, some of the nerves remain intact. The extent of the neural network that remains depends on the location and the size of the tumor.

The psychological impact of a mastectomy is due to the loss of a breast, the body’s resulting asymmetry, the scarring, and the loss of sensation in the area. Although the physical appearance of a lumpectomy may be merely a dimple-like depression, some women are psychologically affected.

Appearing symmetrical is a major reason why many women who have single-side mastectomies opt for reconstruction or an implant. However, reconstruction does not provide restoration of sensation, and will still leave scars that may at times cause discomfort. In addition, the scar capsule around the implant can contract, causing pain and hardening of the implant.

Given these facts and the numerous other possible complications of reconstructive surgery, it is scarcely surprising that many women, especially those who are older and/or in very secure, supportive relationships at the time of surgery, simply opt to wear external prostheses (breast forms) inside pocketed mastectomy bras to achieve a natural appearance when clothed. Good-quality mastectomy bras are both attractive and comfortable, and modern prostheses, especially those made of silicone, are comfortable to wear and quite similar to natural breasts in weight, size, and density. Just like real breasts, they come in a wide range of sizes. Their cost is often covered by insurance, including Medicare.

Some women with breast cancer may also be at increased risk for developing cancer in organs in the female reproductive tract. A prophylactic hysterectomy (removal of the uterus) or oophorectomy (removal of the ovaries) is sometimes performed when the woman has an altered gene related to breast cancer. Nerve damage, common during pelvic surgery, results in diminished genital sensitivity. The same is true for surgical treatment for colon and other abdominal and pelvic cancers. Surgery may be so extensive as to preclude intercourse. However, a woman may still have orgasms with stimulation of the clitoris.

Surgeries for gynecological and colon cancers usually affect nerves in the genital and rectal area. As a result, sensitivity may vary considerably, depending on the type of surgery, extent of disease, and skill of the surgeon. Women may experience a decrease in sensual responsiveness in some areas, and, by contrast, exhibit heightened responsiveness in other areas.

Radiation therapy, also known as radiotherapy, may be the primary or adjunct therapy (therapy to assist the primary, or first line, of therapy) to treat a cancer. The two main types of radiotherapy are external beam radiation and internal radiation therapy, also known as brachytherapy. Both are usually performed on an outpatient basis.

External beam radiation is provided by a machine that directs a beam of energy to the area of the body where the cancer is located. External beam radiation therapy itself is not painful and does not cause the person undergoing treatment to become a radiation source after leaving the radiation clinic. In the 1990s, external beam radiation to treat cancer covered a broad area of the body. That approach has since been replaced by more focused techniques such as 3-D conformal beam radiation therapy and Intensity-Modulated Radiation Therapy (IMRT). IMRT is a more focused type of external radiation, which spares the tissue and organs surrounding the diseased area. Typically, the woman receives radiation therapy five days a week for six or seven weeks.

Brachytherapy, the internal type of radiation therapy, is usually achieved by placing small irradiated pellets, also called seeds or capsules, into the cancerous tissue to kill the diseased cells. There are two types of brachytherapy: one where the radioactive seeds are placed in the tumor tissue, and the other where a radioactive capsule is put into a cavity such as the vagina. This is normally a one-time treatment with a short hospital stay.

Radiation therapy to the breast can cause irritation or swelling in the breast or arm. Radiation to the pelvic areas for gynecological and other pelvic cancers can cause urinary tract irritation, diarrhea, cramping, excessive bowel movements, rectal bleeding or discharge, and even a bowel obstruction or bleeding that may require surgery. It may also lead to decreased genital sensitivity, which may occur a few years after treatment when the internal scarring from radiation affects the nerves in the genital area. Radiation can also leave the skin itchy, which can be highly irritating and may affect some women’s sexuality.

Chemotherapy induces a broad range of effects, not only on the diseased tissue, but also on the body in general. Commonly reported effects such as hair loss, nausea, and diarrhea are due to the way chemotherapy drugs act. Tumors are made up of rapidly dividing cells, so the drugs have been developed to kill these cells. Unfortunately, there are normal tissues that also have rapidly dividing cells, most notably hair and the cells in the digestive tract. All of these cells are affected by the chemotherapy drugs. In younger women, early menopause may occur due to the drug(s) affecting the ovaries’ ability to produce hormones. Varying hormone levels may cause hot flashes, night sweats, and vaginal dryness.

Women in many support groups have said that hair loss is psychologically more devastating than losing their breasts. In one focus group, the women spoke with one voice, claiming that their hair defined them as women. Even Roberta, treated for ovarian cancer, was most devastated when she lost her hair.

Many women resort to wigs that are soon discarded because they are uncomfortable and too warm. Women desiring a comfortable wig that can be worn all day might be interested in the type made for Orthodox Jewish women. Jewish law prescribes that women following Orthodox tradition must cover their hair. Since these wigs are intended for constant wearing, wigmakers catering to Orthodox Jewish women have developed techniques to provide maximum comfort. These wigmakers have been crafting their techniques for hundreds of years. Anyone wanting to explore the possibility of purchasing such a wig should contact an Orthodox Jewish synagogue and ask for names of wigmakers. Handmade wigs are likely to cost several thousand dollars.

Tender Loving Care, or TLC (www.tlcdirect.org), a website and catalog of the American Cancer Society, emphasizes that a synthetic wig is the easiest type to care for, as well as the lowest priced. The organization offers synthetic wigs in a wide range of colors and styles at reasonable prices, with most costing in the $40 to $50 range. The company also sells wigs which have no crowns (tops) designed to be worn under hats, as well as a large selection of attractive scarves, turbans, and hats. Some of the hats are specifically designed for warm-weather wear. TLC also sells mastectomy bras, breast forms (prostheses), swimwear, camisoles, and more.

A complementary medical approach to dealing with nausea and pain is acupuncture. Studies have shown that acupuncture can be used to block pain and lessen nausea. Some women have indicated that acupuncture increases the effectiveness of anti-nausea medication such as Ondansetron (Zofran). Acupuncture is further discussed in Chapter 11.

Other chemotherapy side effects that affect daily quality of life include lack of appetite, bladder problems, bowel difficulties, mouth sores, muscle pain, urinary tract infections, vaginal bleeding, lack of sexual desire, anemia, possible weight gain or weight loss, and a side effect called “chemo brain.”