A Shared Diagnosis: Managing Breast Cancer Together

• Working Therapeutically in Uncharted Territory
• A Therapist's Cancer Experience Shapes Treatment

Over the course of my treatment for breast cancer, I found myself feeling professionally challenged in many ways. But the most significant source of my growth as a therapist during this time came from the fact that I was following in the path of one of my own patients, Jessica Chin (a pseudonym). She was diagnosed with breast cancer in 2019, and three years later I would receive the same diagnosis while she was still in treatment with me. At my request, and with homage to Irv Yalom’s Every Day Gets a Little Closer, Jessica shared her thoughts (in italics) throughout this essay. Working together was a privilege and it is my hope that our combined voices will serve to deepen the conversation about the potential impact of a therapy relationship for both patient and therapist.

In our profession, we rely on our ability to treat people who differ from us in a variety of ways. Our training and our capacity for empathy allow us to develop deep connections with patients despite differences in such things as age, gender, and ethnicity.

In contrast, my experience with Jessica highlighted for me the complexity and power of having a shared experience with a patient.

Working Therapeutically in Uncharted Territory

Jessica first came to my office in 2012 to discuss generational issues in her Asian family. Through our work, her self-esteem improved. She found her own voice and was able to extricate herself from the family business, marry, and move to another state. We ended our work together after four years, and both felt encouraged by her progress and the prospects for her future.

Unexpectedly, three years later, she was diagnosed with breast cancer at the age of 35 and reached out to me seeking to resume therapy. Her prognosis was good, but the road ahead was scary and fraught. She had chemotherapy, followed by surgery, and then radiation. Although she and her husband had decided that they did not want to have children, the fact that her treatment would lead to early menopause and the consequent side effects was a harsh reality to absorb.

When I was diagnosed, I immediately thought of reaching out to Maggie. I thankfully had family and friends to lean on, but I needed support from someone that understood the nuances of my family and personal history and how it could impact my treatment and wellbeing. I also needed an outside perspective to help navigate my treatment. Genetic testing revealed I have a positive gene mutation which meant I could choose a bilateral or double mastectomy rather than a lumpectomy and radiation. There was also data suggesting those who carry this genetic mutation might have a higher chance of breast cancer recurrence if exposed to radiation. I spent most of my sessions with Maggie weighing pros and cons and what if's. She regularly advised me to make the decision that was backed by data and to lean into what felt right to me. There would be what if's no matter what — only I knew what I could manage during this time and to hold onto that. This advice grounded me in my personal and medical decisions throughout treatment and to this day.

I had been in practice for over 30 years at the time of Jessica’s diagnosis, but I had almost no experience working with patients who were actively undergoing cancer treatment. Even more surprising, despite the prevalence of breast cancer (1 in 8 women in the United States receive a diagnosis of breast cancer over the course of their lifetimes) I had never had a patient undergoing treatment for breast cancer while in my practice. My instinct was to help Jessica hear her own voice through the cacophony of advice she was receiving and support her while she had a multitude of difficult decisions to make.

My knowledge of Jessica’s background and complex family dynamics from our prior work together gave me a benchmark against which to assess the changes in her mood and outlook. As is common for people with a life-altering diagnosis, she became more intolerant of “wasting time” and pushed back against familial and cultural expectations for her to be compliant in her role as a daughter, woman, and patient. I supported her through all the phases of her treatment and then shortly thereafter found myself facing a similar diagnosis.

A Therapist's Cancer Experience Shapes Treatment

  From a routine mammogram screening in December of 2022, I was diagnosed with breast cancer. This was terra unfamiliar for me, but fortunately my prognosis was excellent. I scheduled my surgery during the week between Christmas and New Year’s, a period I had already arranged to be off.

My original plan was not to tell my patients of my diagnosis,  but after surgery it was determined I would need chemotherapy. Being immunocompromised, I would have to end in-person sessions, and anticipating a radical change in my own appearance, I decided to tell my patients about my cancer.

As I thought through my caseload, each patient brought different concerns to mind about how they would handle this news. Their concerns ranged from fear of losing me to death or retirement, or to the worry that their issues felt insignificant in comparison to my situation. I felt confident that I could work through the ups and downs with each patient.

Jessica was the patient I most dreaded telling. She would know from personal experience what I was facing, and I was concerned that my diagnosis would overwhelm her. 

At the time of my diagnosis, she had just entered the maintenance part of her treatment. I wasn’t sure what would happen to the boundaries between us as my treatment began to replicate hers.

When Maggie told me about her diagnosis, I was shocked and sad. My heart sank thinking of her going through the gamut of appointments, ultimately robbing a year of her life. From what she shared, I understood from a high level what this meant logistically and what it could possibly mean physically, mentally, and emotionally as each cancer experience is so unique. I wasn't surprised Maggie would keep seeing patients during her treatment from what I knew of her, plus, it would help to keep life “normal.”

I was wrong to worry about sharing my diagnosis and treatment with Jessica. Our boundaries did shift, and the sessions changed but I believe in ways that were beneficial to both of us. Being open to receiving from her was the beginning of my learning. She began to recount her cancer treatments with more details than she previously had shared. And I had a context to understand her references which I lacked before my own treatment. There was a clear shift in our roles as she became the teacher, sharing her experience. Despite being almost twice her age, I found Jessica’s personal understanding of cancer treatment deeply affirming of my own experience. Remarkably she was the closest person in my life at the time with a similar diagnosis.

Our sessions fell into a pattern: during the first ten minutes or so of each Zoom session, she asked me how I was feeling and together we discussed the ins and outs of whatever point in treatment I was facing.

It was initially uncomfortable for me to have so much of the focus on me but with time I came to appreciate how helpful our sessions were for both of us. In contrast, I also had to process my feelings about patients who never asked how I was feeling or showed any interest in my well-being. I didn’t want to bring any more attention to myself than I already had by sharing my diagnosis, but each patient’s response to my diagnosis revealed something about them and our relationship.

As Jessica learned about my experience, she was prompted to address how she felt during her treatment.

I didn't want to be evasive, asking how Maggie was doing during our sessions. I was genuinely concerned and didn't want her to feel like she owed me more of an explanation because of a shared diagnosis. I'd cautiously ask questions, not wanting to overstep personal boundaries. During certain points of her treatment, I'd share some of my experiences with Maggie, with the hope that it would serve as a form of support, and she wouldn't feel alone. Cancer is so lonely. If I could offer Maggie even the slightest amount of comfort, it would be an honor and a gift to do so.

Before my last chemotherapy treatment, she warned me that I would have to “ring the bell,” a customary ritual at the end of chemotherapy. She knew me well enough to know this was not something I would welcome. She had never talked about this experience before, and it led to an exploration of her feelings about how powerless she felt as a patient to say, “No.”

Our increased understanding of each other helped me personally, but it also helped me be a better therapist for Jessica. The nuances of our work deepened as we grew closer and her voice continued to get stronger, to the point that I felt comfortable enough to ask her if she would like to participate in writing this essay. I trusted she would be able to give an honest answer.

A significant way our treatment protocols diverged was that I was offered cold capping with my chemotherapy treatments to help prevent hair loss. In the end my hair loss was negligible which was a huge relief to me. Jessica, by contrast, lost all her hair during chemotherapy; this loss prompted many sessions focused on her distrust of her body and her despair over her altered appearance.

By the time of my diagnosis, Jessica’s hair had grown back, not exactly as it had been before treatment but sufficiently that the change was not obvious to a casual observer.

As she witnessed my lack of hair loss, she spoke in greater detail about her own ordeal of losing her hair, being fitted for a wig, and the physical discomfort of her hair growing back. We talked about the financial burden of a cancer diagnosis and the lack of insurance coverage for “cosmetic” concerns such as hair loss. Our shared knowledge base deepened my ability to support her unresolved anger with the medical system. Her need to fight the insurance company for access to care is an ongoing source of stress for her.

Cold capping was presented as “nice to have” and questionably effective for my treatment plan. That, coupled with it not being covered by my insurance, was disappointing. I was surprised cold capping was presented as a positive option for Maggie and was intrigued what the results would be. I hoped the cold capping would work and she'd be spared the physical and mental trauma of losing her hair. I was thrilled the cold capping worked for Maggie and equally enraged this is not a standard part of every woman's treatment and insurance plan.

The difference in our age was most pronounced in discussions about long-term management of our cancer diagnosis. As a young woman, Jessica is facing far more extensive interventions and questions about how to stay cancer-free without compromising her health in other ways. As she continues to grow professionally, she also has to contend with issues related to maintaining her health insurance coverage. As someone on Medicare and nearing the end of my professional career, I have more autonomy in making decisions about my work-life balance.

Since resuming our work together, Jessica’s father has died and there have been other major transitions in her life. Separate from our shared experiences around cancer, we have done some important work about managing grief and setting limits with her family of origin. Even when we are not directly talking about her cancer, it is a reality that colors the conversation.

In a way, our shared cancer experience has allowed me to open up more to Maggie during our sessions. I've felt comfortable and trusted her throughout the years, but something has changed. I feel strongly this has been instrumental in working through the grief of losing my father.

There was something profoundly different in my work with Jessica since my cancer diagnosis from my work with any other patient. As I gain more distance from my cancer treatment, we have shifted away from the weekly check-ins. But she will always be at the forefront of my mind, and gratefully so, when I think about what it was like to continue to practice through my cancer diagnosis and treatment.

***   

Allowing our patients to know us, let alone directly help us, is a controversial topic in the field of psychotherapy. But sometimes life intervenes, and we have to adapt. I am glad I continued to practice during my cancer treatment. As Jessica said (she also worked throughout her treatments), it helped keep a semblance of normalcy in my life while allowing me to feel like more than just a patient. And I move forward with confidence that I am a better therapist for her and other patients who might follow in our shared diagnosis.
 

Questions for Thought and Discussion

• How did the therapist's approach to her client resonate with you?
• What are the advantages and disadvantages of sharing such Personal, and in this case intimate, information with a client?
• If you have had a personal circumstance that converged with those of your client(s), how did you handle it?  

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