Having breast cancer will change you. With luck and the safe passage of time, you will find ways to appreciate what this life-changing diagnosis has done for you. You will grieve for the woman you used to be as you come to understand and value the woman you are becoming. The process you will pass through is complex and multifaceted and will demand your energy, your attention, and all of your patience. It is a journey in much the same way that life itself is. The final destination for everyone is, of course, death. But if you continually focus only on the destination, you will miss the journey, and it is the process of living day by day, and night by night, that constitutes the voyage. The final destination will come soon enough.

Living with breast cancer is similar in many ways to grieving other losses. As those of you who have suffered the loss of a dear one or other life tragedies already know, grieving is a complex and demanding task. It takes patience and courage. You will find, as time passes, that you experience a wide range of feelings and reactions. Some common feelings include:

? Shock, disbelief, denial, and anger

? Active suffering in the mourning process, letting the pain penetrate and register, letting yourself feel and express joy and sorrow

? Acceptance (and this happens only slowly)—coming to peace with yourself, your altered image, the loss of your former state of health and your sense of immortality, perhaps the loss of body parts and perhaps the loss of the potential to conceive and bear a child. You have lost who you were and will grow into who you will be.

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Tamoxifen is the most common hormonal therapy used for the systemic treatment of breast cancer. Tamoxifen has been used for many years to treat metastatic breast cancer, and more recently, to treat postmenopausal women with new breast cancer. Even more recently, it has been added to the full treatment of some younger women, usually after the completion of chemotherapy.

Breast cancers are classified as being either estrogen and progestrone receptor positive or negative. This will be one of the things described by the pathologist who reviews your tumor cells. Those cells which are er/pr positive require estrogen to grow and divide. Tamoxifen acts as an estrogen blocker (anti-estrogen), making any remaining cancer cells unable to respond to estrogen. The cells then die.

Many node-negative postmenopausal women whose breast cancers are er/pr positive will be given tamoxifen for five years in lieu of systemic chemotherapy. Older women whose breast cancers are er/pr negative may well receive chemotherapy. Occasionally, the situation demands that postmenopausal breast cancer be treated with both chemotherapy and tamoxifen.

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Your plastic surgeon will likely tell you of his/her successes, and there most certainly are some. We have known women who have comfortably gone to nude beaches after breast reconstruction. However, you need to remember that not everyone is so happy with the result, and once a reconstruction is done, it is hard to undo. Talk with other women about their choices. Try to see several reconstructed breasts. Take a little time to consider your choices.

The technique of reconstruction may involve a saline implant, an expandable saline implant, a flap of tissue (muscle, fat, skin) moved from the abdomen (TRAM flap) or from the back (latissimus dorsi flap), and not infrequently both a flap and an implant. To determine which choice you prefer, you should do two things: first, schedule an appointment with one or more plastic surgeons to discuss your options; second, find women who have had the different procedures you are considering and talk to them. Although your plastic surgeon will be very knowledgeable about the various procedures, unless she has undergone the surgery herself, she will not know what it feels like to live with the results of the surgery on and inside the body ever after.

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Latency age children may have lots of questions. Some children will be more curious than others; try to answer all questions as briefly and honestly as possible. Answer only what you are asked. Remember to think of this the way you would health or sex education, if you do not know the answer, say so.

Children this age also need reassurance that they will be cared for while you are in the hospital or having treatments. They need to know that their daily lives and routines will be disrupted as little as possible. If you will be spending time in the hospital, they may like to have a calendar to mark off the days you will be away. Some might like a special blank book to write or draw in. Others might want to write you notes while you are in the hospital; give them paper, cards, envelopes, and stamps. Frequent short phone calls are a boon.

Invite your children to accompany you to the hospital when you are going for a short appointment. Particularly if you ask your doctor or nurse to suggest a good time for a visit, your children will be welcomed; they will be interested in meeting your caregivers and seeing where you are spending so much time. Children are rarely frightened by the treatment areas; indeed, they are generally quite reassured by seeing them. Their fantasies are much more frightening than the realities.

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Several of us have found it helpful while living through this crisis to encourage different family members to attend age-appropriate support or focus groups. Even when children don’t want to go to such meetings initially, they almost always feel surprisingly positive afterwards. With children, it is important to find groups divided by age; the issues most important to elementary school children are quite different from those most pressing to high school students. Even though your kids may be reluctant or resistant to going the first time, most of them will find solace in being with peers (even though they will be strangers) who are dealing with a parent’s cancer. They find it a relief to be able to talk about a range of deep-seated fears and feelings that they are reluctant to discuss with friends whose parents are healthy. If you choose to involve your children in a support program or group, you must inquire about the family situations of other children in the group! Just as it would be frightening for you to attend a group with women who are dying from breast cancer, it would be completely overwhelming and destructive to your children’s well-being to be in a group with others who have a terminally ill parent. Be sure of this before you send your children anywhere!

Having made a careful decision, trust yourself and trust your new doctors.

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