One self-exam and one diagnosis changed Diana Escanaverino’s sunny outlook on life. In November 2013, the vivacious singer and cosmetologist learned she had breast cancer, and it dragged her down into a dark place.
“I was feeling depressed because I didn’t understand,” she said. “I said ‘Why me?’ … I was breaking down. I didn’t know what to do.”
Escanaverino, 59, began chemotherapy in January. The next month she sought help from Sameet Kumar, a clinical psychologist with the Memorial Cancer Institute at Memorial Hospital West in Pembroke Pines, to deal with the depression.
“It shocked me, because my life changed. I was working in a beauty salon, and had my clientele for 30 years. I am a Flamenco singer, and I had a show I used to do on weekends,” the Pembroke Pines resident said. “And all of that came down. I had to change my focus and how to take care of myself.”
About 9 percent of breast cancer patients are diagnosed with depression, about twice the rate of the general population, according to the American Society of Clinical Oncology. But some studies say that through the course of breast cancer, up to 25 percent of women will be diagnosed with depression, said Kumar of Memorial Cancer Institute.
Depression has an ugly relationship with breast cancer, according to Dr. Marc Lippman, a breast oncologist and deputy director of the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine.
The cancer itself produces chemicals that can cause depression. And depression, in turn, can contribute to the spread and recurrence of breast cancer.
“The data are overwhelmingly clear from thousands of patients and many studies, that being depressed increases the occurrence rate and recurrence rate of breast cancer,” Lippman said. “The risks are substantial — up to 25 or 35 percent increased rates of recurrence.”
Depression is not only that you feel terrible, he said. It’s an inflammatory disease associated with chemicals that can inhibit the immune system and contribute to the progression of breast cancer, among other diseases.
“We know depression is a contributing factor. The question is, how?” Lippman said. “And once you know how, can you use that as an alternative means of therapy?”
Lippman received a grant from the Florida Breast Cancer Foundation to study the link between breast cancer and depression. In the fall, he will begin a 16-week clinical study of 80 breast cancer patients with depression. The study will examine if interventions to help depression — drugs or behavioral therapy — are associated with improvements in the immune system and decreases in the chemicals that can cause breast cancer to recur.
“We’re trying to provide the scientific basis for how it is that you can treat depression and alter a woman’s immune system so that she will not have a recurrence,” Lippman said.
To put it in perspective, Lippman said many women who have been treated and are likely to be cured of breast cancer still have living breast cancer cells in their bone marrow.
“That’s astonishing — living breast cancer cells — and yet these women aren’t going to recur. And that helps you to understand that something that happens to the woman later on — she gets depressed, she gets diabetes, she becomes obese — could tip the balance and activate those cells,” he said.
Many women have the potential to remain well, and something about who they are, rather than the breast cancer itself, determines whether they will be on the good list or the bad list, Lippman said.
WHEN DEPRESSION OCCURS
A peak time for depression in breast cancer patients is between diagnosis and treatment, Kumar said, but after treatment is finished is also a vulnerable time, because of the uncertainty of survivorship. In breast cancer patients, depression peaks in the 40s, when a woman has young children, or is just hitting the peak in her career. In many ways, older patients are protected from depression because they’re seasoned by life, and they’ve figured out what works for them, Kumar said.
Risk factors are fatigue and lack of social support. Women who have had depression before are at greater risk.
“A lot of people make the mistake that being depressed is just about feeling sad. Although sadness can be a big feature of depression, it’s almost a lack of feeling … so feeling sad is almost a sign of improvement,” Kumar said. “It feels pretty much like you’ve shut down — emotionally, physically and mentally.”
Side effects of chemotherapy also can mimic depression symptoms: fatigue, loss of appetite and difficulty sleeping, short-term memory problems and difficulty focusing, Kumar said.
Nancy Zavac, 61, of Miami, learned she had breast cancer in 2011 after a routine mammogram. She battled with depression after the diagnosis. “When you get that diagnosis, you think ‘So many people die from cancer.’ The reaction is disbelief,” she said. “It was a hard time.”
THERAPY, SUPPORT GROUPS
Many women battling cancer and depression prefer talking to someone over medication, according to a recent study in the Journal of Psycho-Oncology, Kumar said.
“Most women want to talk to someone and figure out what kinds of things they can do to help themselves,” he said. “Women feel scared, vulnerable and alone.”
Often someone who is depressed needs to talk about their feelings with someone other than family and friends, said Kathryn Bishopric, director of Care and Counseling Services at Baptist Health South Florida, a faith-integrated therapy service. Loved ones sometimes are not the best listeners because they fear the worst, she said.
Treating depression with medication can be a challenge, because some commonly used anti-depressants interfere with the way cancer drugs like tamoxifen work in the body.
“For this reason we are very selective about the types of anti-depressants we use,” Kumar said. “The challenge we find is that they’re taking so many pills, and they feel so medicated that they’re looking for another approach. But in some cases an anti-depressant is just the best course of therapy.”
For Escanaverino, the Pembroke Pines patient, Kumar recommended meditation and breathing exercises, which she practiced daily. Escanaverino attended therapy sessions, found solace in church, and made jewelry, which was therapeutic, she said. “Every time I went back (to Kumar), I was feeling better and better.”
Zavac had been on anti-anxiety medication before she learned she had breast cancer. That helped, but she felt she needed social support. Zavac began meeting with Linda Burrowes, a care coach at South Miami Hospital, who recommended a therapist, made appointments and helped navigate the process.
Burrowes, a breast cancer survivor herself, also runs a support group, Your Bosom Buddies, www.yourbosombuddies.org, that she founded 17 years ago. Zavac attended meetings and was assigned a mentoring buddy.
“It was wonderful, because you have so many questions,” said Zavac, who is now in remission. “She was great, because it was stuff you don’t know who to ask.”
The meetings also helped Zavac, a librarian at the University of Miami Frost School of Music. “Everybody was very caring, and you know people will understand because they’ve been going through it,” she said. “You form friendships, and it gives you a feeling of belonging.”
Kumar said a large part of what he does is encourage patients that feeling lousy is normal.
“What’s more important is not feeling great all the time, but feeling a sense of purpose and connection and feeling you have something to live for, a sense of meaning in life,” he said.
Exercise is the most important thing women can do, Kumar said. “We know that it affects rates of recurrence, mood, memory, muscle tone, and most importantly, with a lot of women, it affects body image,” he said. “The more active a women is, the more likely she will feel comfortable in her body again.”
Good, evidenced-based nutrition, and not fad nutrition, is important, as well as meditation and stress management skills, Kumar said.
“I like to challenge my patients: What is the life that they’re fighting for? What do they want that life to look like?” he said. “In many instances, women realize that they’re not really fighting to get back to the status quo. They want a better life than they had before breast cancer.”
Kumar said depressed individuals tend to make decisions that aren’t in their best interest. “For that reason, they’ll isolate, blow off social obligations, won’t exercise or eat right,” he said. “So the challenge is to change the momentum and give them a schedule. Get up and go to sleep at the same time. Go for a walk in the morning. Walk with a friend. It’s getting them away from making decisions in depression that are detrimental to recovery.”
WHY TREAT DEPRESSION?
Depression often goes unrecognized and untreated, said Lippman, the breast oncologist, and that needs to change.
“How a woman feels and how she is behaving in terms of weight, and depression and stress can actually, measurably, influence recurrence of breast cancer,” he said. Patients need to know the truth, and figure out how to intervene, Lippman said.
Escanaverino said though she was in a dark place at the beginning, she was determined to climb her way out, and fight for her life. In August, she began taking psychology classes, and hopes to begin singing again soon.
Kumar said Escanaverino gained a resilience and renewed sense of purpose going through treatment.
“Even though it’s not easy, even with significant emotional challenges along the way,” he said. “I think it’s helpful to point out that those challenges are very real, but they are surmountable, and it’s possible to live a very different life, a much more fulfilling life, after breast cancer.
Breast cancer events
Here is a sampling of events:
Baptist Health Low-Cost Mammograms: Baptist Health South Florida is reducing the cost of digital mammograms for uninsured patients from Oct. 1-31. All digital mammograms are reviewed and interpreted by board-certified radiologists. $50 for screening mammograms; $100 for diagnostic mammograms. A doctor’s prescription and appointment are necessary. To schedule an appointment or find a diagnostic center, visit BaptistHealth.net/BreastHealth.
Breast and Cervical Cancer Screening Day: To qualify for free screenings, participants must by 50 or older; low income; not screened within the last year and meet financial eligibility guidelines. Registration is required by Oct. 2; 8 a.m.-noon Oct. 4; Women’s Health and Preventive Services West Dade Clinic, 11865 SW 26th St., Building J2, Miami. 305-470-5634.
Hope For Pink: A breast cancer awareness walk-a-thon. Takes place at Shelter 13; 10 a.m. Oct. 4; C.B. Smith Park, 900 N. Flamingo Rd., Pembroke Pines, $35.
Orgullosa’s Breast Cancer Awareness Month: Latina actress and breast cancer survivor, Adamari Lopez, presents La Liga Contra el Cancer with a donation on behalf of Procter & Gamble’s Orgullosa, an online community for Latinas, while announcing the launch of an donation program that benefits Latinas battling breast cancer; 11:30 a.m.-1 p.m. Oct.1; Liga Contra el Cancer, 2180 SW 12th Ave., Miami. Free. 305-856-4914.
Party in Pink Zumbathon: All funds raised go to the new Zumba Global Research Grant for Breast Cancer Prevention ; 11:30 a.m. to 1 p.m. Oct. 11; InterContinental at Doral Miami, 2505 NW 87th Ave., Doral. $15 at the door, $10 in advance. To purchase tickets, contact Martha Nuñez at Martha.Nunez@R-HR.com or 305-468-1400.
Photo exhibit: Susan Buzzi continues her photographic series of breast cancer survivors and their stories with “Beautiful, Bold and Brave: The Warrior Project.’’ The event will take place from 7-9 p.m. Oct. 10 at helium creative, a design studio, 500 NW First Ave., Fort Lauderdale. Suggested donation is $15.
PINK N’ Heels Breast Cancer Walk: Registration starts at 7 a.m. Wear your most outrageous pink outfit; 7 a.m. Oct. 4; Betty T. Ferguson Recreational Complex, 3000 NW 199th St., Opa-locka. 786-279-1222.
Susan G. Komen Race for the Cure: Oct. 18 at Bayfront Park, 301 Biscayne Blvd., Miami; registration, 6 a.m.; survivor procession, 7:30 a.m.; survivor ceremony, 7:45 a.m; 5K certified timed run, 8:30 a.m., 5K non-timed walk, 8:50 a.m.; tot run, 10 a.m. To register in advance and for more information, go to http://www.komenmiaftl.org