The articles below are to provide inspiration for your own positive survival strategies.

• Cancer Prevention
• Coping with Sexual Changes After Cancer
• Insurance Issues
• How important is exercise for cancer survivors?
• Employee Rights of Cancer Survivors

Cancer Prevention

by Marian Johnson, Clinical Coordinator with the Prevention Clinics at Seattle Cancer Care Alliance

Prevention — there's a lot you can do! Studies show that Americans say cancer is their number one health concern, yet they believe it is impossible to prevent. They believe cancer is beyond their control.

It's especially important to explore this misunderstanding for cancers survivors as they are at increased risk for recurrence of their original cancer as well as the development of second primary cancers. The heightened risk is the result of cancer therapy combined with factors such as family history.

Nutrition Advisor Karen Collins from the American Institute for Cancer Research (AICR) characterizes these misconceptions as distressing. "Popular frustration about cancer is on the rise. An 'everything causes cancer' mindset is taking hold, which causes Americans to throw up their hands and overlook the steps that can lower their risk." According to a 2007 AICR study, most Americans don't realize that they can lower their cancer risk by eating healthy foods, getting more exercise, and managing their weight.

Only a third of adults in the United States realize that a diet high in red meat increases one's risk for cancer (most specifically, colon cancer). About the same number of people know that alcohol is linked with cancers of the colon, breast, esophagus, mouth, larynx, and pharynx. Fewer than half of Americans realize that there is strong evidence that being overweight or obese increases risk factors for eight different cancers, including those of the colon, rectum and breast.

Most people believe that cancer is out of their control and that pesticides, food additives, and hormones in beef are the primary causes. Research says, however, that the links between these factors and cancer is low and that there is a lot people can do to minimize their risk.

A second AICR report, entitled "Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective," is the most comprehensive scientific analysis of cancer prevention and causation ever undertaken, authored by an international expert panel that reviewed 7,000 research studies and classified the accumulated evidence for specific diet-cancer links. The report is online at www.dietandcancerreport.org/.

The AICR also has compiled specific resources and recommendations for cancer survivors at www.aicr.org/site/PageServer?pagename=cs_home.

Coping with sexual changes after cancer

by Dr. Sylvie Aubin, Ph.D., clinical psychologist at Seattle Cancer Care Alliance

Cancer survivorship is associated with adaptation to changes in multiple areas of your quality of life. To the majority of cancer survivors and their partners, couple and sexual relationships are important aspects of their quality of life and are thus significantly bothered by any negative changes, especially if irreversible. To some, these changes may even trigger or contribute to emotional distress such as depression or anxiety. Fortunately, there are many ways or interventions that are available to help you redefine and achieve satisfying couple, intimate and sexual relationships.

Regardless of your diagnosis or treatment, you may expect some changes in your sexual response, frequency and quality of sexual activities as well as overall couple intimacy. In addition to the changes in your sexual response, a number of ongoing treatment side effects may also negatively affect your couple and sexual life. These may include fatigue, low energy level, mood disturbances and physical changes altering your body/self-image. Issues of weight gain, asymmetry/growth of breasts, hot flashes, decreased urinary control and loss of muscle mass not only challenge your perception of self as an attractive and desirable partner but also your ability to experience sexual desire and pleasure.

A number of effective interventions are available to address sexual as well as relationship changes after cancer. Interventions may be tried individually or as a couple. However, for a more satisfying outcome, it is best to involve your partner. The majority of couple and sexual strategies are part of a learning process with a series of trial and error consisting of mutual adjustments accomplished mainly through communication.

Regarding sexual function changes of the erectile, vaginal and orgasm response, strategies may include PDE-5 inhibitors (Viagra ™, Levitra ™, Cialis ™), injections, vacuum devices or penile implants for erectile dysfunction and lubricators (short/long acting), vaginal dilators or hormonal gel/creams for vaginal dryness/atrophy. Problems in the orgasm response may be alleviated by the use of vibrators, pelvic muscle exercises (Kegels) and for premature ejaculation, the intake of an SSRI type of anti-depressant medication (Paxil ™, Prozac ™). Used in combination with the above, other strategies found particularly helpful by partners to increase sexual desire and arousal include the practice of sexual fantasy before and during sexual activities as well as the use of erotic literature (visual/written), sexual toys (vibrators) emphasizing sexual play and experimentation.

However, enhancing couple and sexual intimacy starts with setting aside or planning time together, an exercise often experienced by couples as a date night. Ideally, it may consist in a weekly 3-4hr block of time where partners are engaged in a relaxed, mutually enjoyable activity that may or not include sexual activities. Paramount to re-establishing couple and sexual intimacy is partners' willingness to re-connect on a non-sexual, intimate level and to expand their definition of sex to include non-performance focused sexual activities. For example, mutual sensual caressing or erotic massage alleviates the pressure of performance and allows for the learning of new, alternate sources of sexual pleasure.

Other key ingredients to greater couple closeness may include partners' commitment to share sexual advances, engage in mutual disclosure and active listening of concerns, fears, especially about the changes in their sexual preferences and needs.

In conclusion, a number of treatment options are now available to address changes that may have affected you personally as well as your couple, sexual relationships. It is thus important to become educated about these interventions either by talking to your care team or by consulting available resources.

Insurance issues

by Bobbi Christensen-Meins, Community Program manager from Cancer Lifeline

Probably the second most paralyzing thought after you have been given a cancer diagnosis is "How am I going to pay for all of this?" Following are some questions and answers about insurance and cancer, as well as some helpful resources.

Q: My insurance company denied my claim for part of my treatment. What should I do?
A: One of the most important points for cancer patients concerning paying for treatment is never to accept the word "no." You will have to spend time preparing and filing appeals, but you may be able change a "no" to a "yes" and get the procedure covered. Check your plan benefits. If you think a procedure should be covered but your insurance company denied it, appeal in writing and ask them to reconsider. Include with your appeal a letter from your doctor explaining why the procedure was necessary.

Q: Can my new employer's group health plan deny me or impose a waiting period if I have been treated for cancer in the past?
A: If you have had continuous health insurance for at least 63 days before switching to the new plan, your new insurance cannot deny you or impose a waiting period for any pre-existing conditions, such as cancer. If you have had a gap in coverage, your new insurer can make you wait before it will cover care for pre-existing conditions.

The following organizations can provide you with more information:

SHIBA (Statewide Health Insurance Benefits Advisors)
www.insurance.wa.gov/shiba/index.shtml
(800) 562-6900

For information about and assistance with insurance.

Senior Services of King County/Seattle
www.seniorservices.org/
(206) 448-5720

Not just for seniors! Cancer patients may qualify assistance with a variety of issues.

Cancer Lifeline
www.cancerlifeline.org
(800) 255-5505
A 24-hour resource that provides information, emotional support and referral to other cancer services.

How important is exercise for cancer survivors?

by Lexi Harlow, Physical Therapy, Seattle Cancer Care Alliance

Very important! The American Cancer Society recommends a physically active lifestyle, along with an appropriate weight and healthful diet, to prevent recurrence, second primary cancers, and other chronic diseases.1 Studies have shown that exercise improves cardiovascular fitness, muscle strength, body composition, fatigue, anxiety, depression, self-esteem, happiness, and quality of life in cancer survivors.2 Often, survivors tend to decrease their physical activity levels after being diagnosed with cancer and most continue lower levels of activity through treatment and beyond increasing their overall risk for a second cancer, obesity, diabetes, and/or heart disease.1 Most, if not all, cancer survivors would benefit from a consultation by a physical therapist to help develop a comprehensive exercise program. Physical therapists can make recommendations on the type, frequency, duration, and intensity of exercise. This exercise program should be individualized to your age, diagnosis, treatment, previous activity level, and other medical conditions. Physical therapists can evaluate specific needs in the following areas: strength, flexibility, cardiovascular re-training, scar tissue work after mastectomy/lumpectomy, fatigue, balance, incontinence and neuropathy disorder treatment and to teach lymphedema prevention and/or treatment education.

How can we help you start a safe exercise program?

The Seattle Cancer Care Alliance has physical therapists on staff with expertise in recommending specific exercise programs to cancer survivors with a wide variety of diagnoses and stages of treatment. If you are interested in meeting with a physical therapist at the SCCA, please discuss this further with your doctor, who can make a referral to our department. Survivors who are seen in the Survivorship Program's MOST Clinic can receive a comprehensive evaluation, which will include a discussions of the benefits of exercise and any possible risks. We can also refer you to one of our physical therapists for a consultation. We look forward to helping you meet your physical fitness goals and enhancing your quality of life as a cancer survivor.

For more information on the Fred Hutchinson Cancer Research Center Survivorship Program, or to arrange an appointment for yourself, a friend or family member, call 1-866-543-4272, e-mail us at survivor@fhcrc.org. We hope to hear from you soon.

References
1Doyle C, Kushi LH, Byers T, et al. Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices. CA Cancer J Clin 2006; 56; 323-353. 2Courneya KS. Exercise in cancer survivors: an overview of research. Med Sci Sports Exerc 2003; 35: 1846-1852.

Employee Rights of Cancer Survivors

by Dana Hess, Civil Rights Investigator, Washington State Human Rights Commission

One in three persons will be diagnosed with cancer in his or her lifetime. More than 10 million people in the United States are living with cancer. Additionally, more than 1.3 million persons in the U.S. will be diagnosed with cancer this year. Sixty-five percent (65%) of adults diagnosed with cancer today will be alive five years from now. And the large majority of these persons are employed when diagnosed, undergoing treatment, and after treatment ends.

As employees, a person with cancer (or who had cancer) is, in most cases, considered "disabled" under federal and Washington law and is protected by the American with Disabilities Act (ADA) and the Washington Law Against Discrimination (WLAD). An employer must accommodate an employee's condition when the impairment is "known or shown through an interactive process to exist in fact," and the impairment has a substantially limiting effect on one of the following:

• the individual's ability to perform his or her job;
• the individual's ability to apply or be considered for a job; or
• the individual's access to equal benefits, privileges, or terms or conditions of employment; or
• the employee puts the employer on notice of the impairment and medical documentation establishes a "reasonable likelihood that engaging in job functions without an accommodation would aggravate the impairment to the extent that it would create a substantially limiting effect."

The duty to provide reasonable accommodation is a fundamental statutory requirement because of the nature of discrimination faced by individuals with disabilities. Although many individuals with disabilities can apply for and perform jobs without any reasonable accommodations, there are workplace barriers that keep others from performing jobs which they could do with some form of accommodation. These barriers may be physical obstacles or they may be procedures or rules (such as rules concerning when work is performed or when breaks are taken). Reasonable accommodation removes workplace barriers for individuals with disabilities.

For more information see the newly released Breast Cancer Legal Resources Guide at: http://www.wsba.org.