Miri Cohen - Haggai Frid - Oct. 3, 2010
Psycho-oncologist Miri Cohen. “Israeli women are less dependent exclusively on doctors, and tend to look for information on the Internet and via other consultations.” Photo by Haggai Frid
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In honor of October being Breast Cancer Awareness Month, famous landmarks around the world have been bathed in pink light, the color that has symbolized the fight against this cancer since the 1990s. But despite heightened awareness of this disease and improved treatments and medications, it appears that the struggle still has a long way to go. Just two months ago breast cancer patients were disappointed to discover that Avastin is not, as some had hoped, an effective breast cancer treatment when combined with chemotherapy, according to the U.S. Food and Drug Administration. In Israel each year, 4,000 women (and 50 men ) are diagnosed with breast cancer, and 900 die of the disease.

According to statistics released by the Health Ministry yesterday, at the start of this year's door-to-door campaign to raise money for the Israel Cancer Association, the number of Jewish women with invasive breast cancer has been diminishing since 2000. Though the decrease holds for all ages, it is especially noticeable among women under 50, for whom the rate went from 40 patients per 100,000 women in 2000 to 34.93 patients in 2007.

But the downward trend is reversed for Arab women in Israel. Among Arab women under 50, the incidence of breast cancer rose from 16.49 cases per 100,000 women to 21.49 in 2007. Can it be that Israel's investment in educating women about the importance of early detection has passed the Arab population by?

Prof. Miri Cohen, a psycho-oncologist and researcher at the University of Haifa's School of Social Work, has recently been researching how Arab women cope with breast cancer. Cohen, a former deputy director of the social work unit at Rambam Medical Center in Haifa, discovered a great deal of fear and concern, which should begin to rouse the medical establishment.

How did you discover the differences between the way Jewish and Arab women cope?

We conducted a qualitative study among 40 women, with the support of the Israel Cancer Association, and discovered the coping characteristics of Arab women, as the interviewees expressed them. Studies have been carried out in Israel about the way Jewish women deal with breast cancer, and how cultural ties affect the stages of coping. We know that Arab women do not agree to mammogram examinations because of ideas and pressures that exist in Arab society.

We found that Arab patients had a need to hide their illness. They said that breast cancer is perceived as a death sentence by Arab society, and that people distance themselves from patients or talk to them out of pity, as if they had been sentenced to death. They are afraid to be seen in the oncology units and ask to undergo treatment far from their home villages, lest they be seen there. We saw how women with the disease tried to hide their difficulties coping with it from the people close to them, and tried to keep those difficulties to themselves.

This is a large problem, because today we know that support and encouragement are important parts of the healing process; Arab women are prevented from receiving that because of the need to hide their feelings.

Another study in the department showed recently that Arab women patients were less affected by the operation and change in the breast than Jewish women, because, unlike Jewish women, their external appearance was less significant to them, and because Arab culture places more emphasis on modesty and women's manners.

Can Jewish women help Arab women cope with the disease?

Definitely. In our work we have found that the disease is an element that brings Arab and Jewish women together, and in our groups strong friendships developed when Jewish women allowed Arab women to share their difficulties. There are many studies about the reduction of anxiety and depression and the improvement in self-image of breast cancer patients in group encounters. Most of the time, groups of 8-11 women are formed, where women express their concerns and learns methods of coping. They can air their fears in a process called venting.

Do Israeli women with breast cancer exhibit any particular characteristics?

I wouldn't say that Israeli women are more combative than others. In general, breast cancer has been a disease that one can talk and think about for more than 20 years. Most women in Israel diagnosed with the disease today seek out other women who have had it, and talk with them about it. In addition, it's my feeling that Israeli women are less dependent exclusively on doctors, and tend to look for information on the Internet and via other consultations.

What is your position on alternative medicine? How much does it contribute to treatment of and recovery from cancer?

This is a controversial subject. Of course there are alternative treatments that help from an emotional standpoint, treatments that aid in relaxation and improve feelings, or reduce anxiety and tension. But the problem with alternative medicine is that many times people attempt to attribute healing powers to these treatments, something which is unproven, and which we must be cautious about. Patients need to approach alternative medicine as emotionally supportive, and not to expect more than that.

Do you believe that women who survive breast cancer are stronger mentally?

The earlier breast cancer is detected, the more the chance of recovery rises. We would like to believe that mental health contributes to recovery, because that gives us a feeling of control. Emotional strength adds to a patient's quality of life, but as for recovery, there are studies here and there, but until now no research based on a large sample of people has managed to show definitively that one's mental condition contributes to the chances of recovery.

As an expert who has witnessed how women cope with breast cancer, do you think actively struggling against the disease helps people heal?

This is a complicated question and there is no one definitive answer. In my experience, the answer depends on the way the individual woman copes. If she is an activist who takes matters into her own hands and works for change, the struggle will give her a good feeling - that she is managing the disease on her own. If the woman has a passive style of coping, and she does what the doctors say but has no strength for a fight, it is more appropriate for her to accept treatment passively. If you tell such a woman that she must begin to fight the cancer, it will only increase her anxiety and will not contribute to healing. And so I do not believe there is one general way to recovery; each woman has to suit the way she copes to her personality.

Have you run across women who were pressured to make changes for which they were unsuited?

Yes, in the many years I've worked in the oncology unit, I have met a lot of women who have made a complete change in their diet, because they were told it would help the healing process. But just the omission of favorite foods and the need to make a change was stressful. Even if a change in nutrition makes a positive contribution, its advantage disappears and cannot be realized in a high-pressure situation. [Health care staff] must pay attention to the way women see things when helping them cope. We need to remember that a woman's degree of relaxation has an immeasurable influence on her mental state.

How does the way women cope with breast cancer compare to the way other patients deal with other cancers?

There is no one way to cope, and each patient deals with it according to her inner resources. In general, all types of cancer are associated with worries that they will worsen or return. With breast cancer, when a woman undergoes surgery and treatments, she may be considered healthy by her friends after a year, but for some years afterward, the possibility that the disease will return continues to threaten her. There are many challenges to coping with breast cancer, such as self-image and body image. In this case, which involves a part of the body that represents femininity, the patient's self-image and her approach to intimate relations will be affected.

How do worries about intimacy and family influence the partners and relatives of women with breast cancer?

A husband, children and the [extended] family experience these fears; most manage to box them off so they won't influence the day-to-day functioning of the family. We also try to help with interventions, to help women cope better through relaxation and group work.

Partners have a central role in healing, and the amount of support a woman receives from her partner is key to her emotional welfare, her mood, and to strengthening her ability to cope. During the stages of treatment, the partner undergoes changes because the disease influences him as well. We are talking about a family disease; when one person is sick, the entire family structure is changed, but the partner has an additional role - to be a supporter and an aide.