April 2009: Managing Fear and Anxiety

Alleviating stress to reduce risk of recurrence?

Question from Website question: I've been dealing with stressful family issues that have no possibility of being resolved, and I'm worried about its effect on my health. I had one breast removed in 2005 with 6 months of chemo and 1 year of Herceptin. Late last year, precancer cells were found in my other breast and I had it removed. I am seeing a psychotherapist. Is there anything else I should do to alleviate this stress?

Answers —Rosalind Kleban, L.C.S.W.: There is very little good research evidence that stress will have a direct effect on the advance of cancer. By worrying that stress will create more illness, you end up with more stress. It is important, however, just for a good life and lifestyle and satisfaction to find ways to lessen the stress in your life. Certainly, therapy is a good place to start. And through therapy, perhaps one can find other activities that create fulfillment and distraction.

Mitch Golant, Ph.D.: I think what Rosalind is saying is incredibly important. How painful it is to think that somehow whatever's happening in your life would make the cancer worse. It's tough enough dealing with cancer, the side effects and treatments, and to think your lifestyle is adding to it. All of the things that Roz said are important. And it would be important as far as the psychotherapy to address that question of the stresses of your life and the cancer, or creating them.

How to express inner anxiety?

Question from Daisy: How do you manage that inner anxiety that comes when you feel alone? As a wife, mother, and grandmother, you live presenting a positive attitude and being thankful each day. However, I cannot express my inner feelings or concerns. It seems as if it's all about how well you are doing on the "outside."

Answers —Mitch Golant, Ph.D.: That's a great question. The way we've been thinking about answering that question stems from the point of view of support. In particular is that family and friends want to be as helpful and caring as possible. They often find themselves in the position of saying things like "You're going to be fine" or "Everything's going to be okay." And painfully, that has the effect of holding your feelings inside, like they're not really interested in hearing about your emotions. One of the real values of a support group, especially professionally facilitated support groups, is that it creates a safe place to express emotions and that you're with others who understand what you're going through.

Rosalind Kleban, L.C.S.W.: I think we all have to give thought to the value of trying to always maintain a positive face. In many circumstances, particularly the family, it's possible to think about being neither positive nor negative, but being real. And it's quite okay to express to those around you that this recovery is tough. Most people actually know it's tough, and we play a game pretending it's not. We make it easier for those around us at our own expense. When somebody asks how you're doing, it's quite appropriate to say that this is difficult. And, of course, I have to say as Mitch said that there is probably nothing as positive as support groups to get rid of the feelings of being alone.

Quitting work, health insurance when stage IV?

Question from HeatherV: I wish I didn't have to work anymore. I'm a Stage IV cancer patient for the last 3.5 years. I'm worried that I can't quit my job because of health insurance issues -- pre-existing conditions, etc. Is there any resource available for us at this point? My family depends on my health coverage and I feel guilty about quitting my job, even though I wish I didn't have to work anymore.

Answers —Rosalind Kleban, L.C.S.W.: The issue of health insurance is very difficult. However, it's important to know that there is no such thing as a pre-existing clause. You can drop your present health insurance and if you pick up another policy within 3 months, the new company has to cover your care because it's against the law at this time to deny health insurance because of a pre-existing clause. That being said, whatever health insurance policy you may get as an individual will probably be very costly. As a Stage IV patient, if you're considering leaving work, you need to apply for long-term disability from Social Security and within a year or 18 months, you're entitled to Medicare. So, that will cover you, but does not answer the question about your family.

Mitch Golant, Ph.D.: There's an organization called the Cancer Legal Resource Center. It's run by Joanna Morales, and they can be reached at 866-843-2572. They might have some particular ideas or suggestions, depending on where you live and the size of the company you work for, particularly with regard to the Americans with Disabilities Act. These are very important questions, and this might be a very useful resource to follow up from today.

Rosalind Kleban, L.C.S.W.: In working with people living with Stage IV disease, there's a constant conversation and struggle about whether to work or not. Part of the discussion that leans towards working is that it very often acts as a distraction, a way to be involved in things and people outside of the illness. So, I think that both sides of the equation should be looked at very seriously because work, for all of us, (including people with an illness) has some value.

Mitch Golant, Ph.D.: You're making some really great points, Roz: the sort of trade-off, the secondary game coupled with the sense that life is slipping away. There's a tremendous opportunity to actually consider having more of an open conversation with your family because no matter what, the decision affects everyone. I can imagine it being quite worthwhile for you all to have a chance to talk about this all together. Of course, I don't know your family situation, but there are lots of counselors, social workers, and other support folks who might help if you're going that route.

Editor’s Note: For more information about managing health insurance and treatment costs, please visit the Breastcancer.org Paying for Your Care section.

Mood swings around diagnosis and treatment normal?

Question from Marissa: My feelings about my diagnosis and upcoming treatment seem to be all over the place: sometimes I feel strong; other times I feel like crying as I am overwhelmed. Is this normal?

Answers —Mitch Golant, Ph.D.: Yes!

Rosalind Kleban, L.C.S.W.: Women often describe dealing with the whole process like being on a roller coaster. Monday, you're positive, you can do it, it's not a big deal. Then Tuesday, you're under the covers, feeling overwhelmed, unable to face the world. The highs are very high, the lows very low. Just when you think you have your emotions under control, the roller coaster starts again. This generally calms down in the middle of treatment, because women concentrate on the details of treatment. The roller coaster starts again when treatment is over.

Mitch Golant, Ph.D.: The really interesting part about the question, at least to me, is the question of what's normal. As Roz is pointing out, the experience you're describing is so profoundly similar to many, many others. It underscores the value of being with others. Even this Web site, www.Breastcancer.org, is a chance to be with others who understand what you're going through. [Connect with others on the Breastcancer.org Discussion Boards.] And there are many forums, support groups, and educational programs that talk about the treatment. Cancer isn't just about the biology; it is also about the psychology. Good treatment includes both -- managing the emotions, which are all normal, all well within the range of human experience, especially with a diagnosis of cancer.

Rosalind Kleban, L.C.S.W.: What I've noticed, particularly with the treatment of breast cancer, is that the emotional effect is often more difficult to manage than the physical.

Mitch Golant, Ph.D.: Roz, I think your point is that breast cancer is so linked to stigma, physical changes, attraction, sexuality, intimacy. These emotions are so present as treatment progresses, and yet the outcomes are often so positive. No wonder you'd be on a roller coaster.

Friends and family annoyed by "complaining"?

Question from Meghan: I get the feeling that my friends and family feel like I’m just whining all of the time. They are supposed to be here to support me, but I feel like all I do is annoy them! If I can't count on friends and family, who CAN I count on?!?

Answers —Mitch Golant, Ph.D.: I think I'd go back to what I was trying to articulate earlier, which is that family and friends want to be supportive, but yet it's anxiety-provoking for them also. A way to think about this is that cancer affects the whole family. Often women with breast cancer find support from other women going through what they're going through. Not to sound like a broken record, but being able to give and receive support in a group or chat room helps.

Rosalind Kleban, L.C.S.W.: I think sometimes women are not accustomed to complaining. I'd like to say "complain" is a poor way to describe this. I think what is more accurate is that women are reporting how they feel, which may sound like a complaint, but it's more reality-based than what we would normally label as "whining." So, therefore, it may be that the person who is doing this is uncomfortable with what she's doing and saying, and is disturbed by it, and is possibly seeing annoyance in people around her when in many cases friends and family -- or some friends and family -- are not annoyed. Of course, when all else fails, the phrase "You need to walk in my shoes" always helps.

Mitch Golant, Ph.D.: To build on this, what actually is the function of complaining or whining? What I've learned talking to women is that there's a longing to connect. It's not easy for us to say "I'm scared" or "I'm not sure the treatment is working" so sometimes it's just familiar to us to complain.

Support for husbands?

Question from jef: My wife has just been diagnosed. They want to do chemo prior to surgery because of the size (8 cm). How common is it to do chemo first? I feel like my guts are being torn out. I want to be positive and strong for her. Are there support groups specifically for the husbands?

Answers —Rosalind Kleban, L.C.S.W.: The first thing I would recommend is a book called Breast Cancer Husband by Marc Silver. He has interviewed many partners and talked about their responses and the ways in which they learned to be helpful. Having chemo before surgery is called neoadjuvant therapy and is quite common for exactly the reason you mention.

Mitch Golant, Ph.D.: I would also recommend a couple of things. There's an organization called Men Against Breast Cancer: Caring About the Women We Love. There are support groups for men, and it seems like a really good idea to consider them. There are groups like that at the Wellness Community, your local cancer center, Gilda's Clubs, etc. (not knowing where you live to help you figure that out).

Editor’s Note: You can also read past transcripts of our conferences with Rosalind Kleban and Marc Silver:

• February 2007: Partners, Loved Ones, Caregivers: Taking Care of You
• September 2004: Family and Loved Ones

Where can survivors help others in need?

Question from marlena: I'm a breast cancer survivor and I would love to get involved and share my story. How can I help out? Where can I go to help counsel women in need?

Answer —Rosalind Kleban, L.C.S.W.: There are many, many organizations that welcome volunteers, such as The National Breast Cancer Foundation, the Susan G. Komen for the Cure, Living Beyond Breast Cancer, and the American Cancer Society. But I would start in your local community and actually, I think you should start with the American Cancer Society.

There's also a great site, the National Cancer Institute, at www.cancer.gov. They have a series called Life After Cancer Treatment, which has a whole list of organizations that you can consider joining. Giving back is a form of empowerment. This is a huge opportunity, and for many the feeling of gratitude after treatment is expressed by wanting to participate in many organizations. Susan G. Komen has the Race For the Cure.

The American Cancer Society has traditionally had a program called Reach To Recovery that connects newly diagnosed patients with survivors.

Using humor to handle stress?

Question from Jackie: Please tell me I'm not the only one who uses humor to get by! I have been criticized for the way I handle my stress, anxiety, and fears. It can't be that unusual, can it? I'd rather be laughing than crying, but it seems people think I’m just being insensitive and that's not it at all!

Answers —Mitch Golant, Ph.D.: I suppose there's room for both. In the way you're describing coping with cancer, the critical piece is that it works for you. That it's having an impact on others around you is something to explore, because you're describing a disconnect between your intentions -- that is, using humor to help cope with the anxiety and stress associated with cancer treatment -- and somehow it's being interpreted as dismissive or insensitive.

Rosalind Kleban, L.C.S.W.: I think that humor is an excellent way to cope with many issues in life. And if it works for you, it's a gift.

Thought Field Therapy (tapping) for stress?

Question from rose4: I'm a 7-year Stage III (no recurrence) Lobular Breast Cancer survivor who has used Thought Field Therapy (Tapping) for high-level stress and found it extremely helpful. Do either of you have experience with this simple technique of tapping on designated acupuncture points?

Answers —Mitch Golant, Ph.D.: That technique has been used in high-stress situations and in those experiencing trauma. It's also been called EMDR (Eye Movement Desensitization and Reprocessing), but tapping is also part of it.

Rosalind Kleban, L.C.S.W.: Any technique that works for you is wonderful!

Can stress cause a recurrence?

Question from Kathleen: My job in the emergency services field can be intense and filled with long, long hours. My fear is the stress will somehow trigger a recurrence. What, if any, validity is there to such concerns? How can I rationally deal with these fears so I can enjoy a job that can be so rewarding? Thank you so much for holding this conference.

Answers —Rosalind Kleban, L.C.S.W.: Kathleen, there is nothing, nothing to support the notion that stress will bring on a recurrence. It sounds like the stress you are experiencing is very positive and fulfilling, and to give up this work would probably create more stress.

Mitch Golant, Ph.D.: The diagnosis and treatment of cancer is stressful. The experience that your body is out of control can just be overwhelming, not only physically but emotionally. The thought that somehow what you are doing at work is causing the cancer, I've learned from some other women with breast cancer, is a way of feeling more in control. "At least I can do something about my job. My body is out of control." So Roz’s comments are really important in light of that conflict.

Rosalind Kleban, L.C.S.W.: The whole issue of stress causing cancer, I believe, is disseminated by a community of lay people who are trying to find a way that they believe will protect them. They reduce a very complicated medical matter to a very simplistic issue: "I will reduce stress in my life and I will never have an illness." The problem is that is all untrue and only serves to terrorize patients.

Mitch Golant, Ph.D.: It is important to recognize that untreated depression may lead to poorer outcomes, because if you're depressed you're less likely to go to treatment. You might skip treatments. Untreated anxiety, similarly, might have that effect. If you're so anxious about the treatment (chemotherapy, side effects, nausea) that you avoid regular doctor visits, that may negatively affect your outcome.

Rosalind Kleban, L.C.S.W.: However, under those circumstances, it's the lack of treatment and lack of compliance that is causing the illness.

Managing fear of recurrence, doctor visits?

Question from sara: Soon it will be 3 years since my diagnosis. I don't fit in anywhere anymore. I look older, feel older, and act older, and I'm so tired all the time. I cope with life by building a wall around myself and pretending that I didn't have cancer, but deep down, I just know it will be back. Doctor visits make my heart race; I just want to run out of there. Is this normal or do I need professional help?

Answers —Mitch Golant, Ph.D.: First, congratulations on being almost a 3-year survivor. What you're describing is profoundly similar to most women: when treatment ends, it's as if they've fallen off the edge of a cliff. You are describing a couple of symptoms that would be worthwhile to explore. Let me elaborate. The anxiety you're describing at the thought of visiting the doctor, while extremely common especially around anniversaries, gives you a clue that the treatment and the side effects of treatment being experienced is a traumatic event. And that's pretty common. Look -- the diagnosis of cancer is stressful, the treatments are stressful, the side effects of treatment are stressful, the fear of recurrence is stressful, all of which has an impact emotionally. Expressing emotions, particularly fear, anger, or sadness can be very helpful in reducing that anxiety -- or better, coping with it.

Rosalind Kleban, L.C.S.W.: Just from a medical scientific point of view, the bulk of recurrences happen in the first 2 years. So, as you go further from that point it would be helpful to look upon your situation as more hopeful.

Helping children manage their anxiety?

Question from Linda: Sometimes I think my children actually experience more anxiety than I do. I've taken them to "sessions" where they learn coping methods, but how do I find a support group with other children their ages in my area?

Answers —Mitch Golant, Ph.D.: Great question.

Rosalind Kleban, L.C.S.W.: Look for a Gilda's Club. If they have one, they have something called "Noogieland," a group program for children. In dealing with children, one of the most helpful ways of helping them is to see to it that their schedule, their activities, and their life remain the same. Generally, children do well because it is quite age-appropriate for them to be mostly concerned about themselves. So, actually, more time spent in their age-appropriate activities with their friends would be more helpful.

Mitch Golant, Ph.D.: I would continue that line around looking at the developmental stage of each of your children, meaning that when you describe how your children are coping with your illness, helping them cope depends upon their age. There are some books. Kathleen McCue has written a book called How to Help Children Through a Parent's Serious Illness. It's for the adult to know how to best help the child. Wendy Harpham has a book called When a Parent Has Cancer.

Editor’s Note: You can also read past transcripts of our conferences on talking with children about breast cancer:

• May 2006: Talking with Kids About Breast Cancer
• August 2000: Kids and Mom’s Breast Cancer

Why does it take longer for some to bounce back?

Question from Tia: Why do some women bounce right back within months and others like myself still can't function after 3 years? I get a lot of advice on that subject and it's more hurtful than helpful.

Answers —Rosalind Kleban, L.C.S.W.: It's an individual situation. It would probably be helpful to get individual counseling, where you get help on how to cope with the situation and not just advice from others who don't understand what you're going through.

Mitch Golant, Ph.D.: What Roz is really talking about is somehow protecting you from blaming yourself because this is still stressful for you.

Rosalind Kleban, L.C.S.W.: Another thing I'd like to add is that cancer has a different meaning for all of us. Clearly, the meaning it has for you is different than for other people. It's actually different for everybody. And the job ahead is to understand what it means to you, which will give you information about how to cope with it.

Should I join a metastatic support group?

Question from Deborah: Roz, my cancer has now spread to my chest wall. I am having major panic attacks about how I will be able to afford treatment. Should I now start coming to the metastatic cancer group led by you at Sloan? You might want to share with others what these groups are like. I think it would be beneficial. You helped me a lot in the non-metastatic group. What you are offering has been a lifesaver.

Answers —Rosalind Kleban, L.C.S.W.: If the group was helpful, and I'm glad that it was, certainly the group for metastatic women will be helpful. We actually have two of them: one for young women and one for the older crowd, because the issues can be very different. The issue of cost I'm not sure I understand, because it's always covered by health insurance. For those that don't have health insurance, if you qualify there's Medicaid, but I would urge you, Deborah, to call me and we'll work this out. I understand people with metastatic disease, particularly those newly diagnosed, are in a panic. The issue of health insurance we can tackle. And with time and the help of other women, you can see that it's possible to have a fulfilling life and deal with cancer. At this point, we look at it as a chronic illness.

Mitch Golant, Ph.D.: For others who, sadly, might not be able to join Roz's groups, there are a couple of other resources. The Wellness Community has a book available online called Frankly Speaking About Advanced Breast Cancer. It was produced in collaboration with Living Beyond Breast Cancer. You can download that book at www.thewellnesscommunity.org. Second, if there's an issue of insurance (and it may be around copay of treatment), there are patient assistance programs run by pharmaceutical companies. You can actually access all the various programs for those who are underinsured, non-insured, or low-income at the following Web site: www.rxassist.org.

How to move on when managing lymphedema?

Question from Ellen: I'd like to "move beyond" breast cancer, but with lymphedema, I find I am aware of it and my limitations daily, and it becomes depressing. What would you recommend?

Answer —Mitch Golant, Ph.D.: Well, there's been some pretty good data on exercise programs, very tailored therapy for women with lymphedema. I would definitely talk to your doctor for a prescription for physical therapy with someone qualified and trained. There are some movements that are more helpful than others.

How to deal with fears at night?

Question from Tabitha: I'm pretty good about keeping myself occupied and surrounded by friends during the day, but nighttime gets lonely and is usually followed by nightmares. Dating to find a soul mate seems out of the question at this point. Any suggestions?

Answers —Rosalind Kleban, L.C.S.W.: What we really need is a support group at 2 in the morning. That is clearly the time when it is hardest to protect yourself from the very normal terrors. Probably the best thing I can say is that old cliché that with time, things will get better.

Mitch Golant, Ph.D.: One of the great values of the Internet and online support groups is that they provide an environment where you can be with others going through what you're going through at any time of the day or night. In fact, organizations like Cancer Care in New York, as well as The Wellness Community (there are others) have online support groups that are provided at no charge. In these groups you have the opportunity to give and receive support at any time day or night. The Web sites are www.cancercare.org and www.thewellnesscommunity.org. There's also www.Breastcancer.org, of course.

Rosalind Kleban, L.C.S.W.: Let's address the issue of finding a soul mate, which is always a daunting task and certainly it feels more so after a diagnosis. This is another area where support groups are helpful. Many books address the question. The organization Young Survival Coalition at www.youngsurvival.org addresses this issue and their online chat room keeps a dialogue about this, which is helpful. In my 20 years I have happily witnessed the marriage of many patients and the birth of many children, all following a diagnosis.

How to stay positive after diagnosis of second primary?

Question from Karen: When I was diagnosed with breast cancer 4 years ago, I did all I could to stay positive and to move forward. Now I have a second primary breast cancer and have to go through everything all over again. But this time I can't seem to move forward into a positive space. I feel that I will never be able to move forward again. What advice do you have for people like me?

Answers —Mitch Golant, Ph.D.: After a second primary, the experience that your body is out of control is terrifying. You're also sharing a level of despair and yet, as both of us have shared, more and more cancer is being viewed as a chronic illness -- that we may have multiple cancers that are treatable. It's important, as we've said earlier, that treatment of cancer is not just about the biology. It includes the psychology, the emotions, getting support, and seeing a therapist or clergy to address the emotions associated with the new primary is as important as the treatment.

Rosalind Kleban, L.C.S.W.: It's been my experience that we do not have an unlimited capacity to cope. It could be that all of the optimism during the first experience has worn you out. It's sort of like running on empty. Being less optimistic may make this feel more difficult, but it doesn't mean it will be less successful. The success rate with breast cancer is enormous, whether you're optimistic or pessimistic; it just makes it harder. As you recovered from the first, even though it may be harder and more daunting, you will recover from this one.

How to manage always feeling on edge?

Question from Sally: Since my diagnosis, I often get very strong startle responses to ordinary things. I am also often very irritable and "edgy." I can't seem to handle the daily stresses of life. Is this normal and what can I do about it?

Answers —Mitch Golant, Ph.D.: I think it's back to a little of what Roz was saying earlier, that tapped out feeling that diagnosis and treatment of cancer is a multiple, traumatic event. As said earlier, there's the diagnosis, the treatment, the side effects of treatment, and recurrences or threat of recurrences, all of which are distressing. You are describing a stress response to the diagnosis and treatment of cancer. Receiving support, counseling, therapy, or joining a support group may help. But you probably would also want to talk to your doctor about any potential anxiety or depression.

Rosalind Kleban, L.C.S.W.: I think that we have omitted something very important. While we both agree that all of the emotions mentioned tonight are not only normal but to be expected, among the many things that can be helpful such as therapy and support groups we've neglected to mention the appropriate use of medication. In many cases, either antidepressants or anti-anxiety medications can be very helpful. One of the more eminent oncologists at my center has often suggested that we put Prozac in candy dishes in the waiting room!

Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take. Some antidepressants -- including Paxil, Wellbutrin (chemical name: bupropion), Prozac (chemical name: fluoxetine), Cymbalta (chemical name: duloxetine), and Zoloft (chemical name: sertraline) -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.

Mitch Golant, Ph.D.: Actually, a side effect of the treatments of cancer themselves may create the anxiety or depression, so treating it medically is incredibly important, at least to investigate.

What to do when daughter has breast cancer?

Question from JoAnna: How does a mother cope with her only daughter having breast cancer? What do I say when she is not feeling well?

Answers —Rosalind Kleban, L.C.S.W.: A very difficult question. A very painful question. A psychiatrist who works with cancer patients has often said, "Hurry up and do nothing." The important thing is to be there, to be with, to care and support.

Mitch Golant, Ph.D.: Just to add, I like to say that "we will get through this together."

Rosalind Kleban, L.C.S.W.: But I don't want Mom to think there's a magic word, answer, or wisdom that will make this better. As Mitch said, we will get through this together. The thing that I would strongly caution against is falling into the trap of saying things like "You'll be fine," "There's nothing to worry about," "It'll be okay," and worst of all, "You have to be positive." You need to accept the feelings (which are just feelings, not reality) and just be there to support. There is an organization, by the way, Mothers Supporting Daughters with Breast Cancer, that provides information and support and can match you with a mother volunteer who has a daughter with a similar diagnosis.

Mitch Golant, Ph.D.: A thing I would add as well: it would be very reasonable to ask your daughter how she would like you to help her. One of the challenges of having a child with cancer is finding her more dependent on you, and that goes against the grain. As children become young adults become women, the natural order is for them to move away. These questions around boundaries and limits, and how to be supportive, become very, very important questions. It's ideal if you can talk to each other about it.

Rosalind Kleban, L.C.S.W.: I would add that's a very critical point that Mitch has suggested. Whenever a caregiver asks "What can I do?" the answer is to ask the patient what they would find helpful.

How to get message out about metastatic cancer?

Question from Shelly: Any ideas for Stage IV patients when friends ask, "Are you all finished with chemo?" The general public seems to think there is only one kind of breast cancer -- the curable kind. We Stage IV-ers are often still working, still parenting, not at all throwing in the towel, but we are not the same as the pink-wearing masses. Help!!

Answers —Rosalind Kleban, L.C.S.W.: This is a very difficult issue. The public and the media have long ignored the Stage IV community. I have often said that "metastasis" is today's "C word." It is unfortunate that on top of all the other burdens that they should have, that they are called upon to educate the public. However, in answer to the question, the answer is, "I have the kind of breast cancer that requires constant attention." One of my patients was asked, "How long will you be taking Taxol?" and her answer was, "Hopefully 25 years."

Mitch Golant, Ph.D.: The powerful piece of your question, it's come up in many other contexts, but particularly it's embedded in this idea of “live strong,” that somehow everyone falls into this category of getting by cancer. There's a whole population, a whole group of folks, who will be living with cancer their whole lives. And in its own way, it can be quite isolating, to somehow not be in the group.

Rosalind Kleban, L.C.S.W.: It's really incumbent upon healthcare workers, and to a lesser extent upon patients, to get the word out that it is all one community, a portion of which lives continually with the illness. There are strides being made in making this message public. There is an organization called the Metastatic Breast Cancer Network, I think it's 3 or 4 years old, who held their first conference at Sloan-Kettering. We had 300 people, coming from 12 different states and Canada. It was the first time a program just for advanced disease was held. The following year, it was done at M.D. Anderson in Texas, and this May it will be at Dana-Farber. This is a program dedicated to and addressing advanced disease. I would encourage anybody with the illness to look into this organization, and to request or demand at their facility that they create services for women with advanced disease.