June 2005: Summertime Issues: Treatment and Personal Care

How long to protect radiated area from sun?

Question from ShealaghB: I was told that I have to protect the area of skin that had radiotherapy from the sun. Do I have to do that forever? Do I need to cover these areas well, or just wear sunscreen? Thanks.

Answer —Marisa Weiss, M.D., president and founder: For the first year or so immediately after radiation to the breast area, I would protect the treated skin with a bathing suit that has a boat-neck neckline. The alternative is frequent use of a sun protection factor sunscreen of SPF 30 or higher. When going into a swimming pool with a lot of chlorine, or in the ocean with salt, it may be best to use a barrier cream or ointment (like Vaseline) to protect your skin against the chlorine and/or salt. In years to come, you can stick with sunscreen primarily and wear a lower neckline, if that's your choice.

How long after chemo to avoid sun? Why?

Question from Spatengirl: How long after chemotherapy do you have to avoid the sun? And why do you have to avoid the sun—what does it do to you?

Answers —Maria Theodoulou, M.D.: Many of the chemotherapy agents that we use are also radio-sensitizers, which means they can make the sun's rays work a lot stronger than they would if one were not exposed to any chemotherapy drugs. Certainly during the treatment with chemotherapy, we always ask that the patient avoid direct exposure to the sun as much as they can to avoid burning of the skin. If it's a summer day, it doesn't mean you have to stay in the house or avoid the outdoors, but a sunscreen with a SPF of 30 or higher, a floppy hat in the summer, or a cover-up if walking on the beach.

The effects of chemotherapy drugs can last for 1 to 2 months after the chemotherapy has been completed. By that time, most of the drug has been used by the body and is out of the system, so it should be safe to go in the sun. Of course, if the patient is going to have radiation after the chemotherapy, the patient should also protect the radiated area as there can be a phenomenon called "radiation recall." Not only can the affected skin burn, but skin on other parts of the body can become more sensitive as well.

One of the most important things a patient can do is not only protect themselves from the sun's rays during treatment and at least a month afterwards, but importantly in hot weather, one also has to be careful about becoming dehydrated. It's important to keep fluid intake optimal, making sure that not only is water being taken in, but also fluids with different salts in them too. The effects on the skin and on all of the healthy organs can be protected that way.

Tamara Shulman, Ph.D., F.A.A.C.P.: Another approach to enjoying vacations is to be creative and think of alternatives to being out in the sun. For example, instead of a typical Friday night movie, go to one in the middle of the day to avoid the strongest sun's rays. Reading a book in the shade is also a lovely way to relax. So do whatever you would enjoy to give you an enjoyable vacation that won't leave you out in the sun.

Maria Theodoulou, M.D.: The time of the day that one goes out into the sun is also very important. The sun's rays that one is exposed to in the early morning are much weaker than those in the noon or early afternoon hours. The late afternoon and early evening can be rewarding with less concern for burning and "being on one's best behavior" to avoid side effects. There's no reason to avoid a summer day completely if one uses good judgment with an optimistic spirit. You can walk along the beach at 9 a.m. and again at 4 p.m. A dinner picnic with the family can be fun too, so you won't feel you're missing that afternoon barbeque.

Marisa Weiss, M.D., president and founder: That's why it's so nice that the summer days are long, so you can enjoy sunlight into the evening.

Mastectomy bathing suits for younger women?

Question from JLRoss: Where can you find mastectomy bathing suits for young women? They are all matronly looking. It would be a good business for a talented seamstress! Thanks.

Answers —Maria Theodoulou, M.D.: There are a number of Web sites today offering some creative designs for younger women and also middle aged women who want a modern sophisticated line of bathing suits. They are out there, so surf the Web for these bathing suits. It can be very exciting when you can look your best and don't have to settle for looking matronly. Bathing suits today, especially with prosthetic inserts made especially for swimming can really free up the anxiety during summer weather when you want to be out there with everyone else and feeling as comfortable as you can.

Marisa Weiss, M.D., president and founder: You can take any commercial bathing suit that you like and feel good in and bring it to a specialty shop to have pockets sewn in that will hold the prosthesis. If you buy a regular bathing suit at Nordstrom's, they have a service that will sew in those pockets free of charge. Land's End catalogue does have a few classic style suits that are stylish and not matronly. Be creative!

Maria Theodoulou, M.D.: Swimsuits to look for that will also enhance and flatter the body, especially in someone who has had a mastectomy, are ones with arms that are cut higher. It can be extremely comfortable and flattering when the swimsuit is designed that way. If the armhole is cut higher, you can give the illusion that the body form is a natural one.

Marisa Weiss, M.D., president and founder: You can often get an illusion top, like a sheer netting that you can wear over the bathing suit that can help hide the end of a scar or other things you might be concerned about.

Tamara Shulman, Ph.D., F.A.A.C.P.: Finding a flattering bathing suit is a challenge for just about any woman! It's worth it to take the extra time to find clothes and bathing suits that you feel really comfortable in to increase your sense of self esteem so you appear to be the beautiful woman you are.

Tips for keeping lymphedema garments cool?

Question from Pik: What do you suggest for keeping cool in our daytime compression garments for lymphedema? I just learned we can chill our foam-filled night garments in a plastic bag in the refrigerator before bedtime (the foam retains the cool most of the night—great for hot flashes too!) But heat, of course, makes the lymphedema worse—Catch-22 situation.

Answers —Maria Theodoulou, M.D.: On very hot nights, you can release the arm from that compression garment for a short period of time to counter the excessive sweating. If you live in an area where you're exposed to that very hot weather all the time, the suggestions about cooling the garment at night are excellent. But do be very careful during the daytime.

Marisa Weiss, M.D., president and founder: Lymphedema of the arm is really a challenge to deal with, summer as well as throughout the year. Many of my patients choose to wet the sleeves in summer, and the wetness keeps the arm a little cooler. I would not recommend using a wet sleeve on a regular basis, though. Only do this occasionally. If this is done for long periods of time, the moisture together with the heat and darkness underneath the sleeve can contribute to a yeast infection or other skin irritation. This is just an occasional solution for those very hot days. It is important to take the sleeve off at the end of the day, keep it clean, and inspect your arm carefully to make sure it is healthy and not irritated.

But also quite a number of my patients give up on the sleeve, and choose to use a carefully supervised pneumatic pump in the evening, in the privacy of their home, to help relieve the buildup of fluid. It is also difficult to keep the elasticized sleeve clean during the summer when you only have a few of them, and they get very sweaty.

How you manage this in the summer also depends, of course, on how significant the condition is. It can help a lot to stay in an air conditioned space during the heat of the day.

Tamara Shulman, Ph.D., F.A.A.C.P.: Lymphedema is such a stressful condition, physically and emotionally, that I think some flexibility in dealing with it can be helpful. On a hot day, consider air-conditioned activities, and do things that have a summertime vacation feel but will allow you to keep cool.

Insect bites, scratches cause lymphedema?

Question from Jenny: I am at risk for developing lymphedema, and have read that I must avoid insect bites and scratches and cuts on my arm. However, the surgeon who performed my mastectomy said people no longer worried about that and that he would use blood pressure cuffs.

Answers —Maria Theodoulou, M.D.: Any patient who's had a lymph node dissection may be at risk of lymphedema. Insect bites do not necessarily cause lymphedema unless they become infected. If you do scratch or break the skin around an insect bite, or even if your pet scratches you, it doesn't necessarily mean you're going to develop it. Just examine the skin and make sure it doesn't become infected. If the area that has been scratched or stung starts to look red and swollen, then see your physician immediately to get an antibiotic to prevent infection It can also prevent the occurrence of lymphedema down the line.

Any stress to the area can put a patient at risk, but we worry more about bigger stresses than small ones, like a scratch. We avoid blood pressure cuffs, not because of the procedure itself but because of the risk of the cuff being left on too long with excessive pressure. That increased stress can cause some future problems. You should not be blackmailed by fear of what might happen and worry about the everyday risk of developing the swelling of the arm. Pay attention to your arm, to cuts and scratches. Jump on any infections quickly with your doctor. If you use appropriate treatments in a timely fashion, most lymphedema can be avoided.

Marisa Weiss, M.D., president and founder: As Dr. Theodoulou has said, your skin is your best friend against infection. Using a regular moisturizer to keep the skin supple, so it doesn't crack, is a good idea. I have some patients who have a nervous habit of picking the skin around their fingers. This is something you have to really control. Just wearing a cotton glove for a few hours a day may be able to help you break that habit. Avoid biting your nails as well as the skin around the finger-bed. Wear sunscreen in the summer and avoiding sunburn on the arm of the affected side is important. Sunburn to any part of the body is not considered healthy.

Maria Theodoulou, M.D.: It's important that the skin under the lymphedema pressure sleeve is checked frequently to make sure there hasn't been a breakdown of the skin. Even during cool weather, that arm skin should be checked on a regular basis to make sure we are not ignoring a potential area of infection.

Who removes port, fixes scarring?

Question from Footers: My port scar, located a couple of inches below my collar bone, is wider and uglier than my lumpectomy. When it's removed at the end of summer, would it be okay to ask a plastic surgeon remove it, so there would be less scarring, and so I would have more clothing options? Would a plastic surgeon know how to remove the port, or would they have to assist the radiologist?

Answer —Maria Theodoulou, M.D.: The metaport or the infuser port, when it's removed, is usually removed by the person who placed it. So if a surgeon placed it, the surgeon will generally remove it. If it was placed by an interventionary radiologist, then that person would remove it. The skin often heals fairly well over that port site. If there is a risk that the skin overlying that port may be scarred, it is a good idea to have it examined by a plastic surgeon before the port is removed to see if the plastic surgeon should be involved. Many patients have a port in that area around the collarbone. I recommend to my patients in that situation that they be examined by a plastic surgeon and take their advice whether they should be involved in the removal.

Tips for swimming with drawn eyebrows?

Question from Makati: Swimming would erase even the most waterproof brows when accidentally rubbed when drying off or preventing irritating salt water or chlorinated water from getting in your eyes. What can I do if I don't tattoo them?

Answers —Maria Theodoulou, M.D.: One of the most important things is to avoid any makeup that's placed in order to make an eyebrow. One of the things that one can do in order to have some freedom from the threat of an eyebrow washing away is to try to swim early in the morning, or later in the day when the water is less populated and that concern may be a lesser problem.

The way one looks is such a problem, especially when we're feeling vulnerable and wearing a swimsuit. But tattooing can be a problem, not only from the issue of possible infections, but just the overall health and integrity of the skin being approached with a tattoo. It's important to speak with some of the cosmetic people to find out if there are some waterproof products you can use for your brows, or decide not to submerge if you have to, or swim in water that is less irritating. This is not to take away from the absolute joy of swimming in the summer, or not appearing how you want to if the water washes away your makeup. Again if it's important for you to put your head under water, try those off-hour swims when there aren't as many people there. Try to avoid being the middle of crowds of people so you don't feel more exposed.

Marisa Weiss, M.D., president and founder: You might also try using big sunglasses that would cover that area of your face. Also, some women have found temporary tattooed eyebrows to be a good option. These tend to stay on during swimming, but need to be augmented every week or so.

Tamara Shulman, Ph.D., F.A.A.C.P.: I wanted to add that while you're in treatment, it can really feel that it's going to be forever. It feels like it is forever, and that it's taking over your life. But in fact, it's a time-limited period and it can make sense to adapt to swimming early in the day and other suggestions that have been made. Try the side stroke or breast stroke where you don't have to put your face in the water. And realize that this will not be forever, but something you can do to make this summer more relaxing for you.

Alternatives to wigs in hot summer?

Question from NYCMom: What are some alternatives to wearing a wig, which is so hot in summer?

Answers —Maria Theodoulou, M.D.: One of the alternatives is to wear the "easy hair" which is a halo, a ring that sits on top of the head and there is hair on the halo, but the top of the head is empty so you can wear a cap, but you can see hair underneath it. So that might be an alternative to wearing a wig on those hot summer days. These halos are at most wig shops. They're called "halo wigs," and have become very popular. They're lovely during the hot summer days. It's a very easy alternative to those times when you want to take a walk on the beach and you don't want to just tie on a scarf. But it relieves the top part of the head so you stay cool. Ask any professional wig place for this product. There are two places in New York City—Bits and Pieces on Columbus Avenue, and Angels of New York on 61st Street. Certainly they may be able to guide you to the appropriate website or a retailer in your own area. Try making a couple of calls to see if you can get a list of suitable local retailers.

Tamara Shulman, Ph.D., F.A.A.C.P.: That's a wonderful alternative. Another thought is there are bangs available at those kinds of places. They can be attached with Velcro, and easily attached to any hat to give you the look of bangs under a hat that would be cool and comfortable. You could try a big floppy straw hat, maybe one that ties under the chin for extra security.

Maria Theodoulou, M.D.: In this era of fabulous accessories, the creativeness of what's being done with scarves today is no longer just a triangle tied behind the head. There are lovely scarves that can be held with buckles and clips, to accessorize the dress or outfit you wear in the summer when everything is colorful and airy.

Find cotton suit due to latex allergy?

Question from TheresaM: After chemo and breast radiation, I have a latex allergy (get a rash) and would like to know where I can purchase a cotton (non latex) bathing suit. Thanks for your help.

Answer —Marisa Weiss, M.D., president and founder: It would be important to find out exactly what you are allergic to. You may be able to tolerate a cotton bathing suit with a little bit of spandex rather than latex. Some women get irritation around the leg and arm holes, where the latex or spandex product is concentrated on the surface to keep the bathing suit in position. Some women may choose to wear short shorts as well as a cotton camisole with a shelf-bra inside as an alternative to a standard bathing suit. You can also call a retailer with a good customer service department, like L.L.Bean, Land's End, Nordstrom's, who can tell you about the exact fibers present in the bathing suit you are looking at. It's good to have a return policy in case it doesn't work out for you.

Taking flaxseed oil protects from sun?

Question from joan: I believe that flaxseed oil taken internally can protect you from the sun. Have any of you had this experience?

Answer —Maria Theodoulou, M.D.: There really isn't anything that has been proven to protect you from the sun if taken internally. Flaxseed oil is commonly taken, and it certainly has some positive properties associated with it, but none of them have been scientifically proven. As far as I know, there's nothing you can take internally that will protect you from the sun.

Fatigue affects travel plans?

Question from Myra: It's two and a half months since I finished chemo. I try to go for a walk every day and I have joined a gym and try to go twice a week, but I'm still very tired. My daughters and my grandchildren want me to visit them and I want to go too, and both mean travel of 4 or 5 hours, I don't want to be too tired to take part in everything. Any suggestions?

Answer —Tamara Shulman, Ph.D., F.A.A.C.P.: I think that the fatigue that goes with chemotherapy often persists for many months after treatment. It's wonderful that you want to visit and participate in things, but it's also important to take care of yourself and acknowledge that the fatigue is very real. With fatigue it's not a question of giving into it, as it is of accepting it and finding ways to be with your family despite the lingering fatigue.

The effects of treatment are temporary and you will regain your energy. But while you're fatigued, it's best to pace yourself and also choose activities that will be good for everyone. In planning travel, you want to allow times to rest and take a break. When you arrive, it's fine to let people know that you are tired, and allow them to help and offer support in any way they can. This is one time you can really allow yourself to relax and be a "guest" and know that people really will understand.

Don't put yourself under undue pressure to do all the things that you will be doing again when you're feeling better. There are lots of ways to enjoy grandchildren and family even when you don't have a lot of energy. For example, reading a book together with a young child. If you're too tired to read to them, they're usually delighted to read to you. Another idea is seeing a movie or video, sitting in the shade, and doing things together that don't require a lot of energy.

What I think children and family value are the times spent together, and that is more important than the particular things you do. It is so important for your family, children, and grandchildren just to have you in their presence instead of having to wonder what you're doing. Even if you can't participate, your presence can sometimes be the greatest participation you can give your family where they can share what they're doing with you. It's all about conditioning and listening to your body, resting when you need to, and slowly taking small steps until you can take much larger steps. Hopefully, you'll be looking towards that normalcy in a fairly short time.

Reassure children that the fatigue is due to the special medicine you're taking to get well, so they don't get frightened and think that you are sicker.

 

Taking break from Taxol okay?

Question from June: Can I take a break from my Taxol treatment this summer? I have a wedding and Relay for Life coming up. I was diagnosed with mets to my liver and bones December, '04 and am in my sixteenth week of Taxol. With the warmer weather, I have a rash all over my head and face, my lymphedema is very bad, and I am bruising easily. My tumor markers are down to 351, and my oncologist says it is up to me.

Answers —Maria Theodoulou, M.D.: A chemotherapy vacation is not uncommon, and it's something that has to be decided by the patient with her treating physician. The response to the chemotherapy needs to be balanced by the side effects.

There has to be a period of time when you can look forward to going to that wedding with your skin as good as it can look. There are so many treatment options today that sometimes borrowing from another treatment might be appropriate if your doctor doesn't want you to stop treatment. But it's not uncommon to take a vacation from chemotherapy for family occasions, and if the treating physician deems it safe, then that's very doable.

But, and I emphasize the but, it's a decision that needs to be made with the physician who knows you, the pace of your disease, and what would be safe for you. There are multiple treatment options available, so you and your doctor together will be able to find the appropriate treatment that will keep the disease under control while minimizing side effects. Also, in that period of time you wish to lessen side effects, if it's not an appropriate time for a vacation, it may be safe for you to reduce the dose for that short one-to-two week period.

Treating a patient with breast cancer is not treating just one disease. Different women present with different types of breast cancer at different stages, and so treatments can be very different for different women. Metastatic breast cancer is often a diagnosis that requires long-term chronic care, just as any chronic disease like diabetes or heart disease does. With so many treatments for breast cancer, the options are many and the choice of treatment is based on the goals that are established between the patient and her treating physician.

For example, a goal may be to decrease as much of the cancer as quickly as possible. A goal may be to treat the patient and optimize her quality of life with fewer side effects. A goal may be to decrease the disease burden and reach a point where a milder treatment can keep it in check for as long a period as possible. The treatments are so varied today.

You mention Taxol, but there are many others. All chemotherapy drugs such as capecitabine (Xeloda) which are fairly easy to take today but may have side effects may be appropriate for one patient and not another. With the advent of targeted therapies such as Herceptin and Avastin and other small molecules that target breast cancer cells, the choices that are made between the physician and the patient are very custom tailored and quite individual.

There is a difference between treating a patient over a long period of time for a stage of disease that will be long-term, and having to balance the side effects of those treatments with as excellent a quality of life as one can offer. The other side of this is treating a patient with an early breast cancer diagnosis when the treatment is only for a finite period of time, with the goal of treatment being a long term remission or "cure". In that setting, a brief period of chemotherapy, even with higher side effects, may be an appropriate goal for that physician and patient. Many of the drug therapies, chemotherapy, and targeted therapies, and various hormonal therapies that are used in advanced breast cancer are also used today in an earlier setting to prevent metastases.

One of the major contributions that not only scientists but the excellent patients that have participated in clinical trials in the advanced setting have allowed us in the medical arena to gather sound clinical proof that smaller and more diverse treatment options are now available to help save lives. Where a drug like Herceptin is sometimes used indefinitely in a patient with metastatic disease (when I say metastatic, I'm talking about disease outside the breast and local area of the breast, in a site outside that area), the continuation of treatment may be broken up with rest periods, knowing that treatment will soon resume.

If an earlier setting, when a patient has early breast cancer, adjuvant chemotherapy is prescribed for a short finite time with a goal of cure, fewer treatment breaks are recommended to be as sure as we can that our goals for getting rid of any cancer cells that might remain after surgery are not compromised. In breast cancer, with so many varied treatments in the metastatic setting, we can often successfully tailor a regimen of therapy by trial and error. These treatments will keep the advanced disease in check and allow the patient to get on with as much of the regular activity of her life as possible. In that setting, yes, allow a break here and there, or when the drugs become too toxic, it's a good idea to back off and switch to another regimen.

In the early setting, you the patient with your doctor want to do everything you can, as safely as you can, to eliminate or greatly decrease any risk of recurrence. And knowing that this period of going into battle to do everything you can do to keep you as safe as you can be for your future will in most cases give you the courage to get through that one less-than-great summer—the summer that seems like it passed you by. But your goals are huge, and that's what you look forward to—that period of treatment time early on that has a beginning and an ending.

Marisa Weiss, M.D., president and founder: If the goal of your treatment regimen conflicts with a prepaid vacation, ask your doctor for a letter to help you get your money back or move the vacation to another time that doesn't conflict with your therapy.

Tamara Shulman, Ph.D., F.A.A.C.P.: When you're in treatment, it's very important to focus on future summers and future pleasures, and be as hopeful and optimistic as you can be. Don't let the diagnosis and fears about breast cancer scare you into thinking this is your last summer, so you need to do everything this summer. This summer you are in a difficult and temporary time, and for most women in treatment, there will be many happy times ahead when treatment is finished. That perspective—that this is a time you're doing battle with a serious disease—means it's important to concentrate your energies on getting well. This time will pass, and you will be able to do many of the things that you're perhaps missing this summer in future summers.

Maria Theodoulou, M.D.: For the women who have advanced disease who are looking towards a long future with ongoing therapies, it's important to be hopeful that your next summer will have smarter therapies with less side effects that will allow you to spend your summer with your family as you did in the past, because of the new breakthroughs. So don't look at this summer as your very last one.

Allowed to take a break from Herceptin?

Question from HelenT: Can I take a break from Herceptin this summer? Is there any clarity since ASCO on what is the optimal frequency and total number of weeks someone with HER2-positive, node-positive early breast cancer should be given Herceptin? I have just completed a treatment of AC and Taxol chemo as well as radiotherapy.

Answer —Maria Theodoulou, M.D.: Based on the Herceptin data presented at ASCO this year, women diagnosed with HER2-positive are being offered Herceptin as part of their adjuvant therapy as long as their underlying cardiac function is normal. The results presented showed a clear and impressive reduction of disease recurrence in women who have received Herceptin that have HER2-positive disease.

Some women completed their chemotherapy without Herceptin because they were randomized to a non-Herceptin arm in the clinical trial, or were not part of a clinical trial from the beginning of their treatment. But now, Herceptin is being offered to women diagnosed with HER2-positive disease as long as it is within 6 months of completing their last chemotherapy cycle. The Herceptin is given in these circumstances, as the one just described, once every three weeks. This allows for a nice block of time to be away from your treating physician and clinic.

Because Herceptin is accepted worldwide now, as part of the early treatment in the adjuvant setting for HER2+ breast cancer, it is fairly easy to find. Even on vacation, you can probably find a physician who will help and cooperate with your care in order to avoid missing a dose for more than 6 weeks. If you plan to leave your home town, where you normally receive care, and travel during the summer months for longer than 4 to 6 weeks, your doctor can help coordinate with a doctor in the other area, in most cases.

Whether you are on Herceptin or not, when you travel, always, ALWAYS carry your physician's phone number and contact numbers with you. When traveling with prescriptions, such as prophylactic antibiotics in case you are at risk for lymphedema, please fill those prescriptions before you leave. Don't just take the written prescription with you.

The world has become a very small place with electronic mail and cell phones, and you can be tied directly to your physician even when you travel. Have that information in your wallet; carry your filled prescription bottles with you. When you're traveling for longer than 2 or 3 weeks, take an extra lymphedema sleeve with you. Treat yourself with the care, consideration, and love that you would your baby when you pack all those extra supplies to take care of him or her wherever you go.

Any safe sunscreens, self-tanners?

Question from Tina: I wondered what sunscreens and even self-tanners you recommend using that do not contain the harmful chemicals that mimic hormones, ie, parabens, etc? Thank you.

Answer —Maria Theodoulou, M.D.: We do not know the established harmful effects of any parabens at this time, or what harmful elements are contained in sun protection lotions or self-tanners. We do not know what the risks are, but if these products are used appropriately—not on the whole body, not every day—then it can be nice to have a tan on those exposed parts of the body when you're undergoing chemotherapy to avoid the chemo pallor.

It can be safe if used sparingly. There are times when you're going out, there's a special occasion, when you want to look particularly good, so using a product like this can give you that lift. Lotions which have SPF minimum of 30 have not been proven to be unsafe in patients with breast cancer. But we don't know if the more harmful effects of the sun are offset by this SPF. When sun protection is used, it should be applied at least 20 to 30 minutes before you go out in the sun to give you the most protection. If you're going to use a self-tanner like the Estée Lauder products for some nice occasion, use the ones that have some sun protection built into them.

Advice for treatment weight gain?

Question from karylann: Chemo and reconstructive surgery is over, and I am now going to start on Arimidex. I have already gained 30 pounds. Will Arimidex cause further weight gain and wrinkles? I am very ashamed of my body because of all this and don't look forward to the summer months, when I'll have to expose more than I would like. Thank you.

Answers —Maria Theodoulou, M.D.: Metabolism slows down with chemotherapy. There's no question that being thrown into early menopause will make an already sluggish metabolism more of a problem. The major complaint of my patients is not the side effects like nausea or requiring injections to boost their immune systems, but the weight gain that can occur when the metabolism does slow down.

When weight gain is significant—more than 10 percent of your starting weight—it's important that your doctor do an evaluation of your thyroid function to make sure it's working correctly. Often we don't think of things as simple as a low-functioning thyroid, but it can offset any of the energy that you're using to try hard to lose weight. It's a test of wills to be able to modify the diet and it is not an easy thing to achieve during a time when your body has been assaulted with multiple chemotherapy drugs, radiation therapy, and the psychological assault of what you've been through. But you need the will and some support to stay on track with your weight. You might consider working with a dietician who can help guide your dietary needs, or with a friend or professional who will slowly get you back to an exercise routine or even start one if you didn't have one before. All this will contribute to shedding some of those pounds that are so difficult to face when you look in the mirror.

Here are some suggestions: try to avoid that piece of bread in a restaurant, stick with one helping rather than two, don't eat in between meals and avoid that late night snack when you are sitting alone and feeling very alone because of what you've gone through. Even more importantly, speak to your physician and to the people in your support network including family and friends and your nurse and social worker to make sure there isn't an underlying depression that so rightly needs to be addressed. All of this can contribute to gaining back some control. It is not easy, but it is doable and it's so gratifying when your energies are directed towards how good you can be and look. You won't realize it until a few months down the line, but that's the part that you will work towards with the help of everyone who cares for you. What you do not want is to avoid treatments that can potentially reduce the risk of recurrent disease and thereby increase the time you live without this disease.

It is hugely important that you sit down with yourself as honestly as you can and make a plan for all the things that you can work towards. Think about adding these elements to it: a low-fat diet, which we know reduces the chance of recurrent disease. Moderating alcohol intake, which we know will reduce the risk of new breast cancer. Decreasing calories that are not important will only be your most excellent friend. Increasing exercise will make you feel better about yourself. Even though it's difficult the first day/week/month, eventually you'll get to a place where you'll be able to look at yourself, take your Arimidex in the morning, and feel good about yourself.

If the weight gain is since your chemotherapy, you have the utmost potential to work towards losing it. If it's a weight problem you had before your breast cancer diagnosis was made, you will now have outreaches through your medical clinic and your community support to help you achieve a goal you might have wanted to achieve for many years. But these are the things that are difficult because your physician cannot write the order for you. You'll have to write the order for yourself.

Tamara Shulman, Ph.D., F.A.A.C.P.: The question about weight gain really raises a lot of concern with the kind of pressure and expectation that women may put on themselves during the course of treatment. It's important to allow yourself time to come to terms with the changes and make the changes you want with diet, exercise, and lifestyle. But it's equally important to acknowledge that you've been through a major crisis coping with your breast cancer diagnosis and the treatment, and to take an active role in making the changes you want to so that you can resolve weight issues and any other issues that have come up.

I feel that depression is an important issue. During diagnosis and treatment, there's so much energy necessarily on getting well and participating in the necessary treatments and procedures that psychological issues get ignored. When primary chemotherapy is over and the next option is ongoing adjuvant treatment, that's often a time when patients experience the full emotional turmoil. It's a time when many women are expecting to feel great, but they now need to acknowledge feelings that may have been suppressed during therapy. It's incredibly important to address the emotional concerns.

Marisa Weiss, M.D., president and founder: We all wish for you during this summer some fun, meaning, spontaneity. Try some new things that bring joy into your lives.