September 2001: Stress and Your Immune System

How does stress affect body and mind?

Question from LindaB: How does stress affect your body, and your ability to think?

Answers —Mitch Golant, Ph.D.: That's an excellent question because it draws into two important areas. What is the mind/body connection? What is the relationship? The vehicle of that is stress. But we have to say first that cancer is a very complex disease. In many ways, it is biological as well as genetic. When we talk about stress we talk about long-term unremitting stress. There are some forms of stress that are long term, where the end is unknown. It's one kind of stress to stress over a final exam and then you are done. It's a different stress if you are in a relationship that makes you unhappy or you are caring for an elderly parent. There is research that shows this long-term stress has physiological impacts. But does that cause cancer? No one has that answer to date. The work that we are doing to reduce stress and thereby enhance function through support groups is looking at just the answer to that question.

Marisa Weiss, M.D., president and founder: How does stress make your body feel?

Mitch Golant, Ph.D.: There are a number of different responses physiologically. Often you can experience a tightening in your stomach, anxiety, agitation. For others, sleeping more or eating more is the response. There is no one unique response, but all of those taken together give you a clue that there is a message being sent to you by your body that you are experiencing stress. You can also see it as irritation, edginess, or anger.

Marisa Weiss, M.D., president and founder: How about lack of ability to concentrate or low energy?

Mitch Golant, Ph.D.: Sure. Low energy. Those pieces are very important because often women with breast cancer talk about struggles to exercise and how exhausting and stressful it is just to deal with the disease itself.

Marisa Weiss, M.D., president and founder: How about the effect on your GI system, like constipation, belly pain, etc.?

Mitch Golant, Ph.D.: That would be absolutely true. Irritable bowel syndrome is often linked to stress response.

Marisa Weiss, M.D., president and founder: Many of my patients experience hot flashes, problems with memory and sometimes confusion about simple things. Sometimes crying for no apparent reason is an issue. And women who are before menopause may have a further disruption of their normal menstrual cycle.

Neupogen, Procrit to reduce stress on body?

Question from Miracle Baby: I was fortunate to have received Neupogen, a white blood cell stimulator, 10 days prior to each treatment. Why do I not hear more of today's survivors being given this, as well as Procrit, to stimulate the cells, thereby reducing stress on the body due to the chemo?

Answers —Mitch Golant, Ph.D.: I am not a physician - I am a psychologist - but both of those medications are used to combat low blood counts and to prevent the suppression of the immune system as a result of the chemotherapy, and they are prescribed to most of the patients I interact with.

Marisa Weiss, M.D., president and founder: These medications - Neupogen (used to increase white blood cell/immune cell count) and Procrit (used to increase red blood cell counts) - are given when these levels are critically low. Chemo makes your white blood cell count go down. If they go down below a level that will protect you from infection, your doctor will probably recommend the use of Neupogen to bring your counts back up to a safer level. Avoiding infection is a very important goal when managing the side effects of treatment. Procrit is given to improve red blood cell counts, the cells responsible for bringing oxygen to your body. These red blood cells provide the energy that your body needs to conduct its business. Every doctor has a different style of using these medications. The main thing is that these are available options for you to help minimize side effects of treatment.

Exercise, healthy diet, positivity help stress?

Question from Carish: Should exercise and a healthy diet be combined with a positive mind frame in help with combating stress?

Answers —Mitch Golant, Ph.D.: At some point it becomes a little chicken and egg. If you are feeling overwhelmed or stressed out or fatigued, you are actually maybe experiencing some depression. If that is the case, it makes it more difficult to follow a regimen of exercise and diet. Although exercise and diet are important, far more important is your belief that those are important to you.

Marisa Weiss, M.D., president and founder: Are you saying that basically if doing it is important to you and you get the energy together to accomplish it, and you can do it on a regular basis, then it really reinforces your sense of control over your life? (Plus all of the good things that come with exercise.) Can you explain how exercise makes you feel better and what it does to your immune system?

Mitch Golant, Ph.D.: One of the things that happens so often in women with breast cancer is that they have an enormous amount of expectations on themselves during treatment, so they make judgments about themselves, about their diets, etc. There is no right or wrong about this. You have to decide for yourself - based upon treatments that you are receiving, your energy level, what other efforts you are making in your work and personal life - whether you believe it is helpful to you. If it is, then we can get into how valuable exercise is.

There are so many things that you can do. Exercise is one of them. A fabulous program at the Wellness Community is called Back To Wellness, in which we combine a support group with a program of exercise (body movement, rubber band, and other forms of exercises) because of the well-being associated with it. Lymphedema is reduced or improved as a result of being able to do some stretching exercises.

Marisa Weiss, M.D., president and founder: You make an excellent point that often times we may create some of our own stresses by having too many expectations or too big expectations on what we can or cannot do. After finishing up with treatment for breast cancer, few women take the time they need to heal. They may end up managing many people's expectations that they will return to normal quickly. What I find most often is that the woman's own expectations tend to be the most stressful.

Mitch Golant, Ph.D.: And at times overwhelming.

Marisa Weiss, M.D., president and founder: Exactly.

Mitch Golant, Ph.D.: I think this is a good point to bring in one of the unique aspects of the Wellness Community, which is the patient's active concepts. At the heart of the patient's active concept is that if you participate along with your health care team in your recovery, you not only improve the quality of life but may enhance the process of recovery. There are options and attitudes that you believe are important to you. And no one else can decide what those are but you. What support provides is a vehicle of information exchange to help clarify what is important to you and thereby reducing the stress of the disease or illness.

Marisa Weiss, M.D., president and founder: I could not agree more with this progressive and sensitive approach. In creating all of the original content and program for www.breastcancer.org we have been fierce advocates for the individual. We try all the time to make sure to respect a particular person's own way of doing things and helping people not judge themselves or each other in the way that they make their path through this tough time.

Modern living leads to less activity, bad eating?

Question from Shantel: Do you think that the lifestyle changes, with modern living, has added to people being less active and not eating enough nutritional food?

Answers —Marisa Weiss, M.D., president and founder: Studies of how people move around and access the things they do in their life show, in the U.S. at least, that people will jump into a car if they have to go more than 5 minutes away from their home. We are also very busy, working long, long hours, often from a desk chair. All of the demands in our life do seem to make us more sedentary. So many of us find that we have to go out of our way to incorporate regular physical activity into our lives.

Mitch Golant, Ph.D.: This discussion is interesting for a few reasons. One is that we are focusing on the value of exercise and there is no question that that is there. The research that we have been doing on women with breast cancer has linked not only diet, nutrition, exercise, relaxation, and visualization, but also the notion of social support as the unifying factor in helping reduce stress. It is the idea that whatever you are doing, if you are doing it with others who are doing it; the benefits are tremendous. From my perspective, we are focusing on exercise at this moment, but keep in mind the value of social support. We are really talking about the support where you can share your actual feelings and emotions.

Marisa Weiss, M.D., president and founder: Dr. Golant, what are the words that you hear women express that mean 'stress' in your book?

Mitch Golant, Ph.D.: There is a whole range of words. The word usually used first is 'anxious' - "I'm feeling edgy, alone, hopeless. I'm feeling isolated." And often they will start talking about having a knot in their stomach, tightness in the chest.

Marisa Weiss, M.D., president and founder: How do you draw the line between having a busy life that feels important and significant versus a life that has too much stimulation, too many demands that are tough to manage?

Mitch Golant, Ph.D.: That again is an excellent question and there is no simple answer. What seems to happen is that women in support groups begin to talk about what is called goal reappraisal. They begin after the diagnosis to re-think what is important to them. Prior to the diagnosis, you are most likely thinking that your life is going along like everyone else's. The diagnosis of cancer - an event perhaps not too dissimilar to what happened this week with the terrorist attacks - completely changes your life. And we begin to re-prioritize. That process of re-thinking and re-feeling what is important is often called the silver lining around the cloud of cancer. Often people who have gone through it have talked about how they have changed their life and in what way. It's a wake up call. The answer really is the process of exploration of what is important.

Marisa Weiss, M.D., president and founder: That is one of the values of a support group - to help facilitate that inner process of sifting through the things and people in your life that mean the most to you and make you feel the most connected.

Does stress cause cancer?

Question from MissyTX: I keep reading that stress causes cancer. Is that true?

Answers —Mitch Golant, Ph.D.: There is no data that indicates stress causes cancer. The way we are thinking about the relationship between stress and any function is the following. The way to think about this is that cancer cells exist in our bodies all the time. Our immune system is fighting off those cancer cells time and time again. What we are looking at is if you can enhance the power of the immune system by doing things that make you happy. We talk about the three most significant stressors, namely, unwanted aloneness, loss of control, and loss of hope. If you can address those three stressors, you can enhance the power of the immune system, which may have an effect on how it's able to fight those cancer cells.

Marisa Weiss, M.D., president and founder: There is no question that stress feels terrible and really takes away your energy and quality of life. The pain and stress of a divorce, of the loss of a child, of fights with adolescent children, can sometimes be unbearable. Under those circumstances, it can be very hard to function in any way. But as Dr. Golant said, there is no direct link between a person who has these difficult challenges in their life and a subsequent higher risk of getting cancer.

Mitch Golant, Ph.D.: We should take a moment and make a distinction between stress and your reaction to stress. It is a really important distinction. Not everybody reacts to the same situation the same way. It's not so much the stress itself but your interpretation or attachment of stress to yourself. If you can do things to soften that relationship...for example, finding language that you can use when you are feeling upset, it can help reduce the stress. First, you have to note that you are reacting. "I am upset at my son for coming home late after curfew and I am worried." Then you can say to yourself, "But he has been fine all of these times before. He is trustworthy," as a way of softening the impact of that fear.

That is one of the functions of relaxation or medication - to help reduce our reactions to stresses. I love to use the example of a woman getting on the freeway and someone cuts her off. Her usual response would be honking and tailgating, and she could feel her stress level increase. Then she asked herself, "Why am I doing this? Maybe this guy had a bad day at work." Then she became less anxious and upset. Rather than thinking about a situation as stressful, we should think about how we are reacting to that stress.

Does smoking affect the immune system?

Question from qamuSHA: Does smoking affect the immune system, although some use it to alleviate stress?

Answers —Marisa Weiss, M.D., president and founder: Reducing stress is about the only thing that smoking is good for, but the problem is (as you all well know) that smoking decreases the readiness of many of your body's organs to deal with physical and emotional challenges. Smoking, for example, does decrease the health of blood vessels. Immune cells spend much of their lives circulating in those blood vessels. We know that, as an example, if you injure yourself or cut yourself and you are also a smoker, your body's ability to heal that area with your immune cells and your other blood cells is reduced. Healing takes longer and may be less complete in someone who is a smoker. It is important to try to find other ways to reduce the stress in your life besides cigarettes.

Mitch Golant, Ph.D.: I think perhaps the heart of the question is really what it means to be addicted to tobacco, and the stress of needing to smoke. What we are talking about then is, in a very deep way, the challenge to many smokers and to many women in terms of all of the information now available about tobacco and the need for alternative treatments. There are some interesting research issues about stopping smoking through treatment of support groups, anti-depressants, etc.

Marisa Weiss, M.D., president and founder: I think that any time we change our lives there is a potential to experience stress and if you are someone who is smoking for much of your life, giving it up can be very difficult.

Does chemo attack immune system?

Question from Sandree: Does chemotherapy attack the immune system?

Answer —Marisa Weiss, M.D., president and founder: Chemotherapy circulates throughout the body. It affects the 'factory' that makes blood cells. Chemotherapy affects any cells that are growing or actively functioning. Your immune cells, your red blood cells, and your clotting cells (called platelets) are all sensitive to chemotherapy. That is why your blood count drops after you receive such treatment. The good news is that your body is capable of producing new blood cells every day, so your body is able to replenish these cells. But it takes time to do that.

Vaccine to prevent or treat breast cancer?

Question from Soccer Mom: When do you think they'll have a vaccine to prevent or treat breast cancer?

Answer —Marisa Weiss, M.D., president and founder: Vaccines are a preparation of antigens, which is material that stimulates your body's immune response. Vaccines train your body's immune system to fight the "enemy" targets contained in the vaccine. Once your body's immune system kicks in because of a foreign substance or antigen, it makes special proteins called antibodies that fight that foreign substance. For example, a vaccine against the measles virus contains little parts of the virus itself. Your body remembers these foreign materials and creates antibodies against it. So in the future, if the virus comes into your body, your immune system is ready to make specific antibodies against it.

The difficulty in creating a vaccine against breast cancer has to do with a number of factors. First, breast cancer cells are very diverse. There are many different kinds of breast cancer cells, even in the same person. So if you prepare a vaccine that contains all of these variations, then your body should be able to make antibodies against all of those variations. What happens over time as tumors grow is that they invent new variations within themselves. Over time, your immune system's abilities to fight the new, emerging type of cancer cells may be limited. Also, another limitation to the vaccine is that the molecules that make up the vaccine have to be small enough to get into cells. It is a complicated process of teaching your immune system to respond not only to the cancer that it first develops, but also to any changes to that cancer's personality over time. I am hopeful that with further research, this area will become more promising.

Alleviate stress, build immunity for moms?

Question from Cold TX: How does a young mother who has three children and is recovering from breast cancer alleviate stress and try and build up a healthier immune system?

Answers —Mitch Golant, Ph.D.: Mothers in the situation you are describing often say what is heart-wrenching for them with the diagnosis of breast cancer is that they may not live to see their children graduate or see the life cycle events happen, and that is very stressful for many women. They are also faced with doing a second shift - working during the day and at night caring for their children, and also dealing with breast cancer. So it seems important to begin to think about how to ask for help or gain some support by joining a support group, where you can be with others who are going through what you are going through. There is no simple answer. Of course, my heart goes out to you, given all of the pressures that you will be dealing with at one time.

Marisa Weiss, M.D., president and founder: For many women, it is uncomfortable to ask for help. This may be something that you have to learn how to do. It's also really hard to accept help after you have asked for it, because when other people help you, the task may be done in a way that is different than you would have done it. Sometimes you also have to let go of things and jobs that are not so important to you. But it is also important to hold onto those things that you really care about. It really happens that women feel able to give up most of their responsibilities, but one thing that is true is that if you give up things that are important to you, then you may end up feeling less significant as a person.

Mitch Golant, Ph.D.: I think we can elaborate a little more. How do you decide what is important? Often with the diagnosis of breast cancer, the notion of 'supermom' has taken on a super-large proportion.

Marisa Weiss, M.D., president and founder: The job description more than doubles.

Mitch Golant, Ph.D.: Exactly, and what that brings with it is this incredible tension to decide what is most important to you, given that there is an inclination to do it all. The value of support is that you are not alone in this. What matters is that our children are our life's project and we want to be there, and yet we are also needing self-care. Even the caregiver of our children needs self-care.

Theories on imagery and health?

Question from Miracle Baby: Is there a proven theory between mind/body connection in regard to imagery and 'thinking healthy thoughts'?

Answers —Mitch Golant, Ph.D.: There is a lot of research being done in this area. Proven is too strong. We are not there yet. Where we are is that there is a mind/body connection - that our attitudes and actions impact our physiology. Is there a one to one correlation? No, we don't know that. However, that doesn't preclude us from taking the actions and behaviors and consciously applying the attitudes that we believe are valuable. If you believe prayer reduces stress, then for God's sake, pray. In the same token, if you believe exercise is valuable to reducing stress, then exercise. It is the consciousness of thinking about that connection that seems to be important. There is a body of research that believes that you can change some of the ways your brain reactions to stress. It is not a cure for cancer, but along the way you surely can improve the quality of your life a lot, and that matters. And if you are happier because your quality of life has improved, then perhaps your will to live will increase - and that just may have an impact on the immune function.

Marisa Weiss, M.D., president and founder: If you have never thought about or tried these interventions like support groups, talk therapy, and relaxation, I think it is worth opening your mind up to some of these methods of mindfulness because there may be an opportunity there for you that you have not been able to take advantage of so far. Many of my patients are skeptical about these types of things. It is frustrating for me because I want to help them and they are looking for help. But my job is to help them open their minds up to the possibility that there are things worth trying that may bring 'magic' (or just simple comfort) into their lives.

Mitch Golant, Ph.D.: What we have learned at the Wellness Community is that what helps people make that adjustment is addressing the three psychostressors that people with cancer face - loss of aloneness, loss of control, and loss of hope. When people are unwilling to try, they are talking about a sense of hopelessness, and hopelessness always implies helplessness - that there is nothing they can do. Through support - being with others in a similar situation to themselves - you see that they are coping, they are changing, they are taking charge of things that can take charge of. When they see those changes, they see that the other persons are no different than themselves, and that helps.

Marisa Weiss, M.D., president and founder: What has been exciting for me is to see people learn new skills and learn new tools for managing many of the challenges in their lives, not just breast cancer. I find that learning how to meditate, learning yoga, learning how to talk to people in a group, are really tools that they can bring with them well beyond the breast cancer experience.

Mitch Golant, Ph.D.: I should add that there is actually a body of research that talks about the impact of such steps on not only improving the quality of life, but enhancing survivorship. A study at Stanford University revealed that women with metastatic cancer who were in a medically-associated support group lived twice as long as those not in a support group. The women lived 38 months in the support group versus 18 months in the group that did not receive support. What is important is that the group provided several ways to enhance not only living longer, but living better. One thing that the group provided was the idea of goal reappraisal - re-evaluating your life through other people's stories. They improved their relationship with their families and friends. They found ways to reduce stress through meditation and relaxation. They faced their deepest and darkest fears. The process of connecting with each other and dealing with all of those issues helped them, not only in living longer but in living better.

The Wellness Community provides these methods as well. We often think of the program as a water fountain - drink from us as we provide education programs, relaxation, and support groups, all at no charge, because we want women with breast cancer (and all cancer) to get as much help as they can in their fight for recovery.

Marisa Weiss, M.D., president and founder: The discussion boards at www.breastcancer.org are open all the time and are available for a safe and comfortable interchange between other users of the site.

Importance of sleep in stress, immunity?

Question from Carrieau: How important is getting enough sleep in guarding against stress and maintaining a healthier immune system?

Answers —Mitch Golant, Ph.D.: There is no question that sleep and rest are really important aspects of dealing with cancer. For one thing, the treatment and its side effects impact sleep. What we are also concerned about is fatigue, which is a kind of tiredness that rest doesn't alleviate. By far, the sense of fatigue is what becomes a tremendous impact on people's energy and feeling like they want their lives back, so we are also talking about the quality of rest, not just logging hours. I would invite all of you here to look at ways that enhance and lead to more restful sleep and feeling refreshed. Some of those ways have to do with learning relaxation exercises, and actually having more intimacy or closeness.

Marisa Weiss, M.D., president and founder: There are some things that feel beyond our control that interfere with sleep, like the fears that pop up and the hot flashes that occur.

Vitamins, supplements benefit immune system?

Question from Ms Believin: Can vitamins and supplements be of any benefit in helping to strengthen the immune system?

Answer —Marisa Weiss, M.D., president and founder: There is no question that good nutrition is necessary for a healthy immune system and that means a healthy variety of proteins, carbohydrates, fat, minerals, vitamins, fluids, etc. We know that the healthiest source of vitamins and minerals comes from food because it is not just the vitamins that you want, but also all of the 'helper' molecules that surround these vitamins. Sometimes, however, having fresh fruits, vegetables and grains in your diet, as well as organic foods, is a tall order. It is one more big expectation that is hard to fulfill each day. Certainly taking vitamins and minerals in tablet form is a whole lot easier. There is no 'right' answer on this. I know it is frustrating to hear that. I think you need to speak to a doctor, nurse, or nutritionist that is familiar with this important question to get an answer to your individual situation.

Long-term emotional effect of cancer?

Question from JD: I am a 15-year survivor (five years post-chemo following recurrence), but I still get teary-eyed talking about my experiences. Do you think it's due to stress or incomplete healing of the psychological effects of my experience?

Answers —Mitch Golant, Ph.D.: First I want to thank you for asking that question. What is painful about that question is that there is a long-term effect of cancer on many of our lives, and while we want to think that the cancer is done and gone, it can affect us. What you also brought up that is very important is really two points. One is that in the dealing with cancer, there is the long-term, late effects. There are physical late effects that begin...some women talk about chemo-brain - their memory isn't the same. But also there are emotional effects of the diagnosis of cancer. Sometimes prior history also triggers this emotion, especially if the treatment itself for cancer has been particularly difficult. One measure of that kind of stress (and we are seeing it as a result of the terrorist bombing) is called intrusive thought. Intrusive thoughts are nightmares - flashbacks that are triggered when someone mentions cancer; it takes us right back. Another avoidance for people with cancer is that they don't want to drive by the hospital anymore. What you are describing is important because it is not just the physical treatment of cancer, but the emotional side of it.

Marisa Weiss, M.D., president and founder: Breast cancer awareness month (October) can be particularly hard if there are constant reminders of breast cancer on the radio, TV, magazines, sitcoms, yogurt tops, and cereal boxes. And sometimes, a prior experience may take on new meaning for you in the future. What may not have been so important in the past may become bigger as you move along. Genetic testing is such a possibility, or when a neighbor or another person close to you may become affected, it makes you feel more vulnerable.

Immune system weakened by loss of nodes?

Question from Salad Eater: What happens if I lose lymph nodes to surgery or my white count drops dramatically because of chemotherapy? Is my immune system weakened, and will I become vulnerable again to cancer and infection?

Answer —Marisa Weiss, M.D., president and founder: There are many hundreds of lymph nodes throughout the body. When some are removed from under the arm during breast cancer surgery, usually lymph nodes in the surrounding areas pick up the slack. These days, there is a tendency to take out as few lymph nodes as possible to avoid disruption of lymph fluid drainage, as well as to keep your immune system as undisturbed as possible. Yes, chemotherapy does reduce immune cell count. Standard dose chemotherapy drops the count down only temporarily. Almost always, your body is able to recover completely within a short period of time. Bone marrow transplant patients, a procedure used mostly in the past, did knock down your immune count beyond what your body could normally recover from. That is why, after the chemotherapy was all finished, you needed to transplant new bone marrow cells back into your body. These are the cells that make your blood count. But a low immune cell count does not increase your risk for recurrence of cancer.

Can stress cause hair loss?

Question from Daisy: Can stress cause you to lose your hair? What can be done about it?

Answer —Marisa Weiss, M.D., president and founder: Some individuals may respond to stress by pulling or twisting their hair. If this happens a lot, you may lose patches of hair. Less commonly, some women may experience more significant hair loss several months after a huge stress in their lives. In that situation, the shock of the experience - like childbirth or a very serious infection - may jolt the growing hair. This diffuse hair loss that can occur over a few months does resolve. Eventually, the hair grows back in. This, thank goodness, is unusual.

Meditation, aromatherapy, oils help stress?

Question from Elma: I have a friend who had breast cancer and she used meditation tapes, aromatherapy, and oils. She said she felt tremendously calmer and less stressed. Can these help?

Answers —Mitch Golant, Ph.D.: The simple answer is yes. Many, many people use that quite successfully.

Marisa Weiss, M.D., president and founder: These are gentle and effective ways that you can help yourself recover. Doing any of these things, over time, either slowly or more regularly, can be beneficial. You have to start somewhere. Try one thing at a time to help you get going.

Where to find support groups, medical answers?

Question from Kathy: How do I find a support group and answers to medical questions that I am stressing over?

Answers —Mitch Golant, Ph.D.: You can log on to www.thewellnesscommunity.org and there are some other resources to draw from. Often, a cancer center will offer support groups where you receive treatment. Also, the county psychological associations will have a division of health psychology that will have support groups. A college associated with a treatment center may offer support groups. There are other organizations, like the Komen Foundation, or the American Cancer Society website at www.cancer.org, and, of course, www.breastcancer.org.

Marisa Weiss, M.D., president and founder: The best thing to get answers to your own medical questions is from your own team of doctors and nurses because they know you best, and they understand all of the things that make you and your situation unique. These days, it is tough to get enough time with your doctor to get all of your questions answered. And we know that once your first crop of questions is answered, you think of new ones. The whole purpose of breastcancer.org is to make sense of all of the overwhelming and complicated information about breast cancer.

Mitch Golant, Ph.D.: One of the values of support groups is helping women with breast cancer to ask better questions of their doctors. Often at The Wellness Community, we have breast cancer networking groups led by physicians who will answer your questions in a general way, but it helps in the process of being able to formulate better questions to your doctors. We also created a support group online. We have had so much success with our face-to-face support groups, we decided to develop a research project to get a pilot study for online support. As a result we are very heartened by the findings that people in the study had more zest for life, reduced reaction to pain, and increased spirituality.

Strengthen immune system after radiation?

Question from Karen S: I just finished radiation therapy after four lumpectomies. My immune system is finished and I can't seem to strengthen it. I've tried everything. What do you suggest?

Answer —Marisa Weiss, M.D., president and founder: I'm not sure what you mean by your immune system is finished. Radiation to the breast alone only decreases your immune system a little bit. But if radiation comes on the heels of chemotherapy, surgery, anesthesia, and all of the stress of living with uncertainty, then it is normal to feel very run down. Many times people say my immune system is down as a way of speaking. But the main thing is that you have been through so much, your life has been disrupted and derailed. You have to stop for a bit, give yourself credit for all that you have been through, and take some time out to heal and recover. Keep in mind that it takes time to recover. And progress may not feel steady. You may have ups and downs. Some days you may feel like you are losing ground. But overall, the goal is to head in the right direction, toward a new sense of normal, and a life that you find meaningful and joyful again. At that point, hopefully you will be able to have more fun and a greater sense of spontaneity.

Yoga helps relax and minimizes stress?

Question from Sydney Gal: Can programs such as yoga help to relax and minimize stress?

Answers —Mitch Golant, Ph.D.: The programs of yoga should match your own ability. There are many different types of yoga, if you decide that is what you want to do.

Marisa Weiss, M.D., president and founder: There are many choices out there. Some yoga classes are really rigorous, where they put you in a very hot room and make you work out during the entire class. And then there are other yoga classes that are much more relaxed and meditative, focusing more on stretching and posture, tone, and concentration. It is important to be gentle and kind to your body as you try to recover.

Mitch Golant, Ph.D.: And to exercise due diligence as Dr. Weiss described.