Getting through treatment is only the beginning. The impact of breast cancer is as individual as the women who survive it. It can be an arduous though temporary challenge or an experience so transformative that it divides existence into two parts before and after.

Perry Colmore has experienced the disease both ways. When she was 45, she was diagnosed with lobular carcinoma in situ, a noninvasive disease that signals an elevated risk for invasive breast cancer. Given the choice of preventive double mastectomy or simply removing the small tumor, she opted for a lumpectomy. “I breezed right along, assuming I’d be among the 80% who don’t have a recurrence,” she says.

And so she was for seven years. Then a lump in her other breast turned out to be an invasive cancer that had already reached 12 lymph nodes. She underwent a mastectomy followed by radiation and chemotherapy. Colmore has been cancer-free for more than a decade, but her health has suffered. Radiation treatments damaged one of her lungs, causing wheezing and breathlessness. She’s weathered bouts of pleurisy and pneumonia. And intensive antibiotic therapy for her lung diseases triggered severe diarrhea, resulting in a 40-pound weight loss.

Colmore’s experience isn’t typical, but it does suggest the range of later effects that can follow in the wake of breast cancer. The good news is that most breast cancer survivors are living long past the five-year survival benchmark of yesteryear. But many also find themselves facing the long-term consequences of the treatments that saved their lives.

This essay is in honor of Breast Cancer Awareness Month.

This month plus all other 11 months of the year I’m reflecting on an experience that has rattled me and turned me inside out and back again. I’m also remembering, missing and mourning all the dear friends I’ve lost (especially my two best friends, Wendy and Shelley). And lastly, I’m holding each and every women who is fighting breast cancer deep in my heart, sending them strength and love.

Imagine, if you can, being handed a gift. It’s not your birthday or any other special occasion. You’re a bit stumped. Why am I getting this, you think? Where did it come from? Once you take hold of the package it’s thrust upon you; you simply have no choice you notice its heft: Its bulky form defies definition. It’s confusing, unexpected and quite ugly. It weighs heavily on you, alters your breathing and makes you quite sad, really.

You yearn to give it back, or even heaven forbid re-gift it (but you don’t have the heart to do that).What is this? I don’t want it. I don’t know what to do with it.Why me? But as soon as the gift is given, the giver disappears, leaving you on your own to figure it all out.You’ve heard rumors that it is, indeed, a gift that you will be grateful for one day. You’ve heard people say it was the greatest gift they’ve never wanted.

At first, you resent it, curse at it and throw objects, like sneakers, at it. It makes you bellow with rage. Hole up under the covers. How dare life go on around you; people smiling and celebrating and enjoying themselves when something like this is in your life?

You place it out of the way, on a high shelf.

But even though it’s not within reach, it brings out an ugly side of you that you barely recognize and are surprised to discover: An anxious, bitter, angry and cynical person. Your former self the one who couldn’t wait to get up in the morning and embrace the day; the one who made people laugh; the one who loved her children so deeply she was afraid they’d crack under the weight of her hugs has gone missing.

Time passes. And with each day, you begin to figure it all out.

It’s hard work, making sense of this gift. Every once in a while, you glimpse it sitting up on a high shelf and its amoeba-like form begins to take on a more distinctive shape. The edges are not as blurry; the surface not as rough.

You eventually dare to take it off the shelf and hold it.And when you do, you’re surprised: It’s not as heavy as I thought, you say out loud to no one. It feels quite nice, you think; almost comforting in a way. You stroke its strong, smooth shell, wondering what happened to the bumps that you swore once poked out of its surface.

And just as unexpectedly as the gift’s shape has changed you are hugging it tightly to your chest. As you squeeze it, you know that it won’t crack by then you have realized your children haven’t cracked either and you will be OK.

Breast cancer. It challenged, humbled and frightened you beyond measure. It was bumpy, heavy, cumbersome and ugly. You wanted to give it back.

But then that gift, which metamorphosed into survivorship, sparkles and glows with such startling brilliance that you find that you need it just as much as the air you breathe.

All things suddenly seem brighter, more luminous. Was the color red ever so brilliant and complex at the same time? Why hadn’t you ever before noticed that traffic doesn’t matter and a bad mood will pass? Why did you ever think that a new day was a given and not to be celebrated?

That gift the one once thrust upon you, unwanted and unwelcome has morphed into a beautiful swan. It’s brought new meaning to your life. Along with its challenges, it’s granted you peace, health, serenity and a brute strength that you never imagined could or would ever belong to you again.

Growing recognition of survivor needs

As the ranks of cancer survivors have swelled to more than 10 million, their health has attracted increasing attention from scientists and physicians. The Institute of Medicine (IOM) has formed an expert committee to consider the quality of life and care of cancer survivors. The panel’s report, From Cancer Patient to Cancer Survivor: Lost in Transition, published in 2005, acknowledged that cancer care too often ends when patients complete their initial treatments. There may be little communication between the patients’ oncology teams and their primary care doctors. The IOM advises physicians to craft a “survivorship plan” to guide health care in the years following treatment.

Several large cancer hospitals around the country, such as Dana-Farber Cancer Institute in Boston, Fred Hutchinson Cancer Research Center in Seattle, and Memorial Sloan-Kettering Cancer Center in New York, have already instituted special programs or clinics for survivor care. At these centers, clinicians specialize in keeping cancer patients healthy and strong, reducing the risk of subsequent disease and, for breast cancer survivors, recognizing and treating the effects of breast cancer therapy.

Schedule of follow-up exams for breast cancer survivors
Exam	When
Physical exam	Every 3–6 months during the first 3 years after treatment Every 6–12 months during the 4th and 5th year after treatment Annually after 5 years
Breast self-exam	Monthly
Mammogram	Annually
Pelvic exam	Annually
Source: Guidelines developed by the American Society of Clinical Oncology

Treatment’s toll on the body

Cancer survivors are at risk for two kinds of side effects from treatment: Long-term effects, which begin during therapy and persist after it is completed, and late effects, which arise months or even years after treatment has ended.

The most common long-term effects include the following:

Fatigue.

About 30% of breast cancer survivors are fatigued for five years or more after successful treatment. Any number of physical factors, including anemia and inflammation resulting from radiation or chemotherapy and loss of muscle mass, can account for fatigue during and after treatment. The psychological toll of treatment can also be exhausting. Though there’s little research on the subject, many women continue to shoulder responsibilities for jobs and managing households during and following their cancer treatment. Who wouldn’t be exhausted?

Weight gain.

For reasons that science hasn’t fully explained, women undergoing breast cancer chemotherapy gain an average of five to eight pounds. Moreover, the excess poundage is all fat, rather than a combination of fat and lean tissue.

Nerve damage.

Surgery can damage nerves in the treated breast and chest, resulting in numbness or pain. Chemotherapy may affect peripheral nerves, particularly those in the hands or feet.

Breast cancer’s effects on the psyche

The end of treatment is one of the most stressful events in the cancer experience. Often friends and family expect a woman to be fully engaged in life the day she finishes treatment. But while a breast cancer patient may rejoice that radiation and chemotherapy have ended, she typically feels anything but normal. Not only is her body irrevocably changed, she’s also likely to be on uncertain emotional terrain.

“What others usually don’t realize is that the recovery from treatment may take as long as the treatment itself,” says Hester Hill Schnipper, Director of Oncology Social Work at Beth Israel Deaconess Medical Center in Boston. Schnipper and other health professionals who work with cancer survivors have observed that the emotional effects of cancer therapy are far less recognized than the physical effects, yet they are just as profound.

Typically, a woman marshals all her psychological defenses to get through treatment. When therapy is over, she can finally let her guard down but then may be flooded with intense and conflicting emotions. The occurrence and intensity of reactions vary from woman to woman, but most experience the following:

Fear and anxiety.

For women who have just completed chemotherapy or radiation or five years of tamoxifen therapy the end of active cancer treatment can be disconcerting. After months of regular medical care and attention, they often find themselves abruptly severed from the oncology team that’s sustained them during treatment. Equally common, and more distressing, is the specter of recurrence, which can color every aspect of life.

Grief.

Breast cancer brings loss be it as minor as the claim to perfect health or as monumental as the ability to have children. Grieving is a natural response to loss, and it may take months or years to complete.

Erosion of self-image.

The physical effects of treatment loss of a breast, hair loss, weight gain, radiation burns, and surgical scars are reminders of one’s vulnerability. Breast cancer survivors may feel that they’re less attractive and that their vitality is diminished. The adjustments can be especially hard for young women who are thrown into menopause by chemotherapy.

Changes in intimate relationships.

It goes without saying that a woman’s sex life is affected by breast cancer. Illness is a notorious thief of libido. In addition, a survivor’s partner may feel breast cancer’s toll on body and body image as deeply as the survivor herself.

Effects on the family.

Breast cancer is a family affair. Family members are likely to want to get the household back to normal after treatment ends, and they may not be patient with the partner or mother who needs more time to recover.

Being a survivor

Breast cancer is a rough storm, but many women weather it well, buoyed by gratitude for life, hope for the future, and the support of loved ones. Some, like Perry Colmore, use it as the fulcrum for a major life change. When breast cancer returned, Colmore was a newspaper editor. As she experienced the intensity of the disease, she decided that it was a story worth telling. She told it through the experiences of 40 breast cancer survivors in the photo-essay book, Living with Breast Cancer: 39 Women and One Man Speak Candidly about Surviving Breast Cancer (Andover Townsman, 1997).

Perry and her husband also took stock of their life together. Their children were grown, so they traded their suburban home for an apartment in the city and a house on the beach. She quit her job to devote more time to working with breast cancer patients. She now volunteers at a hospital as a companion for women undergoing treatment and leads a cancer support program at her church. “I can’t say that I’m happy I got cancer, but I’m happy with my life,” she says.

Getting the help you need

If you’re a breast cancer survivor, these steps may help:

Work closely with your primary care doctor.

According to Jennifer Potter, M.D., director of the Women’s Health Program at Boston’s Beth Israel Hospital, it’s important to make sure your clinician has your complete cancer history — including surgical reports, radiology records, and drug information. At your first post-treatment visit, you may want to discuss your treatment experience and openly air your fears. If your doctor seems ill at ease with your new status, find one who has experience with cancer survivors.

Join a support group.

Breast cancer survivorship may not be a sorority you ever intended to join, but its ranks are legion. It can be therapeutic to talk with someone who’s walked in your shoes. If you’re looking for a specific type of survivor group, for example, single women or mothers of teenagers, there’s a good chance you can find it if not in your community, then possibly online.

Stabilize your relationships.

If cancer has put a strain on your relationships or unearthed problems that took root earlier, consider getting help. A mental health professional can help you develop healthier ways of interacting.

Treat yourself.

When you were sick, it was probably comforting to have others take care of you. You may not be a patient any more, but there’s no reason for the nurturing to end. Make a list of things that might give you pleasure from a vase of fresh flowers to a visit to a day spa and schedule them into your life.

Invest in the future.

This can be something as small as planting an amaryllis bulb to bloom in a few months or as large as launching a new career. Planning for the future is one of the best ways to overcome the fear that it won’t be there.

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