In the summer of 2009, Debbie Woodbury was recovering from a mastectomy after receiving a diagnosis of breast cancer two months earlier. Although her cancer was caught very early and her treatment was successful, she found herself unable to get back to life as usual. She realized that she was angry.
“I was dealing with what I had just gone through, what I had lost and what I now knew about my mortality,” Woodbury says. “And that brought up a lot of resentment and anger.”
Feelings of anger are common among cancer patients, and those feelings can crop up at any time. According to oncologists, anger is one of the first emotions that patients express upon being diagnosed, but it is also common for those who suffer relapses. Others, like Woodbury, grapple with anger even after their cancer has been successfully treated.
“When you’re going through treatment, it’s hardcore, 24/7 cancer-time,” says Woodbury, 53, of Morristown, N.J. “And when that part of it is over, all of a sudden everything that you didn’t deal with [emotionally] comes crashing down.”
“Anger is a common stage of coping with a crisis,” says Philip Bialer, MD, a psychiatrist at Memorial Sloan-Kettering Cancer Center in New York. Anger evoked by a cancer diagnosis is no different from anger that arises in any other crisis, such as after the loss of a loved one. And although anger is commonly regarded as a negative emotion, it can have advantages for cancer patients. “Some patients can take the anger and say, ‘I’m going to use this to fight back,’” Bialer says, “so it can be used in a constructive way.”
But for cancer patients to use anger to their advantage, they must first recognize and acknowledge it. Counseling sessions with a trained therapist can provide a much-needed emotional outlet for cancer-related anger. Woodbury met weekly with an oncology therapist who helped her understand that her feelings were normal.
Patients who find themselves lashing out at loved ones or feeling isolated or depressed may be suppressing anger or simply not dealing with it appropriately.
“If you don’t give vent to [these emotions] as they occur,” Spiegel says, “then they wind up being exposed in the wrong way or being directed at the wrong people for the wrong reasons.” The key to avoiding pent-up anger is to express it in a safe, supportive environment, he adds. “In the therapeutic setting, it’s helpful for patients to express their anger, so we know what’s going on and can figure out how to help.”
Unchecked anger can alienate family and friends or cause disruptions at work. In extreme situations, unresolved anger may make patients more likely to become self-destructive and abuse drugs or alcohol. Indeed, Spiegel’s work showed that group therapy lessened the likelihood that patients with metastatic breast cancer resorted to aggressive or irresponsible behavior as a means of coping with their anger and negative emotions.
Cancer is often accompanied by feelings of loneliness and isolation—feelings that can intensify with anger, which Woodbury experienced after her mastectomy.
“When your surgery is over, everybody wants to move on and go back to life the way it was,” she says. “And the same people who supported you really aren’t there anymore to the same degree, so your isolation becomes much more acute.”
Cancer patients simply want to be their old selves, Spiegel says, so they often can fail to make their new needs clear to their loved ones and caregivers, which can lead to frustration and anger. And by taking anger out on members of their support network, patients run the risk of alienating the very people they rely on the most.
In conjunction with group therapy, Spiegel teaches his patients self-hypnosis as a stress management tool to help them cope with intense emotions like anger. He also touts the benefits of a healthy lifestyle.
Anger is not something that you just shake off once you finish treatment.
“I tell them to do what their grandmothers told them to do: Eat well, sleep well and get plenty of exercise,” he says, pointing out that people handle all types of stress better when they’re healthy and well-rested.
Woodbury was so grateful for the support she received after her surgery that she started her own blog (WhereWeGoNow.com) as a resource for other cancer patients. There, anger is a recurring theme. “Anger is not something that you just shake off once you finish treatment,” she says. “I think that’s the most surprising and shocking thing to a lot of survivors. They think, ‘I’ve been through the worst, and therefore, it should be over.’ Realizing that creates some anger.”
Spiegel puts it simply, saying, “Emotions are your friends, not your enemies, so see them as a signal system that’s there for a reason.”
“Some patients can take the anger and say, ‘I’m going to use this to fight back. So it can be used in a constructive way.”
“You need to see anger as a normal part of what you go through and not as something to be bottled up or [repressed],” she says. “It’s not a bad emotion … it’s completely legitimate, and you’re entitled to it.”
In fact, says David Spiegel, MD, a psychiatrist at the Stanford University School of Medicine in Stanford, Calif., “If you’re not sometimes angry, fearful or sad that you have cancer, then there really is something wrong with you.”
Dealing with anger constructively, such as in group therapy, may even confer health advantages. An early study conducted by Spiegel’s group suggested that psychosocial intervention prolonged survival by almost 18 months in a group of patients with metastatic breast cancer. Another study reported better five- to six-year survival in patients with malignant melanoma who participated in psychiatric group intervention. Less anger suppression has even been linked to an increased activity of cancer-fighting cells in the blood of men with localized prostate cancer.
But these studies are small and controversial, and other researchers are not convinced of the link. “There’s no evidence to support that ‘negative emotions’—anger or depression—can actually decrease survival or cause progression of disease,” says Bialer, who is concerned about sending a message to patients that negative emotions could hasten their own deaths. “I don’t think people should feel that pressure.”
But Spiegel says that so-called negative emotions are not the problem and expressing them in a supportive group atmosphere is an opportunity rather than a burden. “I don’t tell [my patients] to come to the group because they’re going to live longer,” he says. “I tell them to come to the group because they’re going to live better. If they happen to live longer, that’s icing on the cake.”
A later study by Spiegel’s group failed to show a survival advantage for group therapy in another group of metastatic breast cancer patients, although the effect was still seen among those with estrogen-receptor (ER)-negative tumors. A treatment effect in those with ER-expressing tumors may be masked due to recent strides in treating these patients, largely due to hormone-based treatments, such as tamoxifen, which blocks the activity of estrogen. “There’s one group of patients who are exempt from that benefit, and that’s women with ER-negative breast cancer,” says Spiegel, offering a potential explanation for the disparate results.
Experts do agree, however, that supportive therapy improves quality of life and can help reduce anxiety and the risk of depression. As a result, patients may be more likely to keep doctors’ appointments, stay on top of their medications and adhere to their treatment plans—changes that would be expected to affect survival. “This is a very plausible point of view,” Spiegel says. “But in our studies, we looked very carefully at adherence to treatment, and we didn’t see any differences.”