FEAR, RISK AND CHOICES

In the DCIS study, which came first, the anxiety or the tendency to overestimate the risk? That’s not clear, says lead author Ann Partridge, M.D., M.P.H., a medical oncologist at Dana-Farber Cancer Institute in Boston. “Are women with higher anxiety more likely to misunderstand their risk, or are women somehow developing inaccurate risk perceptions and then developing anxiety? I’m not sure,” she says.

Diane Glass
Her fear of her cancer
returning led her to have
a second mastectomy.

Whatever the answer, this inflated sense of danger can affect how we take care of ourselves. In some cases, anxiety can make us more protective of our health—for instance, women who believe they’re at high risk for breast cancer are more likely to get regular mammograms than those who think they’ll stay healthy. In other cases it can create a head-in-the-sand mentality, leading people to avoid essential tests and safeguards. A 2001 study from the UCLA School of Medicine found that anxious women were less likely to perform regular breast self-exams—presumably out of fear of finding a lump.

When a woman is actually diagnosed with breast cancer, she faces the stress of making the right decisions: Do I do chemo? Should I have a lumpectomy or a mastectomy? What about reconstruction? That’s a lot to process, and when a patient is also struggling with anxiety, it can affect the course of action she decides to take and the way she looks at her options, Maner says: “Too much anxiety is not good for decision-making. It can be paralyzing, leading the person to avoid decisions so they can avoid risk.”

Anxiety can also lead us to make more drastic decisions than may actually be called for. In the case of breast cancer, women might choose a treatment based on an inaccurate perception of their risk of developing the disease. A 2001 study from England examined 143 women at increased risk of breast cancer who were offered the choice of having their breasts removed as a preventive measure. Nearly a third of the 79 women who opted for mastectomy did so because they were convinced they were fated to develop the disease at some point. Accordingly, their anxiety level dropped in the 18 months after their surgery, while the women who took a more cautious wait-and-see approach remained as anxious as before.

Even though her cancer was found in only one breast, Diane Glass chose to have the other one removed after her chemo and radiation treatments. She was concerned that the remaining breast already had cancer, and her priority was reducing the risk of recurrence. “I did not want to live with that threat,” she says. Sammye Johnson chose a mastectomy because the location of her cancer made breast-conserving surgery difficult. “Getting rid of the whole breast—even though I really had no choice—calmed my fears,” she says. Two years after diagnosis, she has returned to life as usual, her anxiety reduced to a once-in-a-while worry.

A strong relationship between a patient and her medical team is essential in making choices on care, Partridge says. “Women and their doctors should have a detailed discussion of their risks and personal values to appropriately weigh their treatment options.”

GAINING CONTROL

Anxious people seek control, which is why they tend to avoid risk, and cancer deprives them of that luxury, Maner says. “The loss of control is very threatening.” Confronting their fears is essential in combating their anxiety, and starting treatment can actually help. “The first step is often the hardest,” he says.

Glass says her initial shock subsided after the first month. “After chemo started, I knew what I was dealing with,” she says. “Reading about all this is sometimes harder than actually going through it.” She confronted the possibility of death head-on by talking about it openly with her husband and friends. She even had a dream during treatment that death came to her front door. “My husband told me to send it away. I thought I should let it in and deal with it. I wanted to face it as a reality.” While fighting to survive, she has developed a matter-of-fact approach to the possibility of her death.

“We are all going to die,” she says. “We are all very much in the same position. I’m much more interested in getting on with the life I want to live.” Confronting the worst possible outcome and accepting it as a possibility has made it far less threatening to her. This, Maner says, is a classic approach to overcoming anxiety.