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Chapter 1
The Impact
It is difficult to find writings and/or studies that investigate the combination of low-income women and cancer. However, literature is available to substantiate the meaning of each factor within the context of society. That is to say, we can readily learn what it means to be low-income, apart from being a woman who has cancer. On the other hand, some attention has been given to middle-class women with cancer. Although it is not enough, they do have support groups and resource centers, most of which do not reach out to help women in the lower classes. In fact, it is rare to hear of one that does. Unfortunately, low-income women with cancer have been neglected by their middle-class counterparts and researchers alike. They are nonpersons.
The need for considering this population is as important as longevity itself since death rates due to cancer are higher among poor women in the United States, according to Anderson (1986, p. 73).
Although we acknowledge delay in treatment can result in death and Kosa and colleagues (1969, p. 205) tell us “lower class persons are more likely to delay seeking treatment than higher status persons” a more global view implies that these high death rates may be more closely linked with poverty itself, rather than with one type of behavior alone. Delay in treatment may not be universal among poor people. Also, if poor people could only afford treatment, perhaps they would seek it sooner.
A study in Bursa cited poverty as one of the significant factors responsible for esophageal carcinoma in northeastern Turkey (Memik, Gulten, and Nak, 1992). Likewise, very low income, or subsistence income, was recorded as a risk factor for cervical cancer in Ethiopian women (Pelzer et al., 1992). In Texas, black, white, and Hispanic women all gave “cost” as well as “lack of physician referral” as reasons prior to the study for not having mammography (Vernon, 1992).
Besides the lack of financial resources, the social stigma of poverty has bearing on whether a poor woman survives cancer. As Belle (1982, p. 96) tells us: “Stigmatization makes the individual seem less than human, allows others to explain her difficulties as a result of her inferiority and to exercise discrimination in ways that effectively reduce her life chances.” Since discrimination is linked to stigmatization, why focus primarily on poor women—why not poor women and men together?
“Historically, women have suffered from oppression and discrimination simply because of their sex” (Belle, 1982, p. 109). Otherwise—when it is easy to name many emotionally healthy women who have breast cancer—how can the travesty against them be accepted, according to Bacon’s (1952/1979) study of forty women which determined the following personality predispositions:
- 1. A masochistic character structure
- 2. Inhibited sexually
- 3. Inhibited motherhood
- 4. Inability to discharge or deal with anger, aggressiveness, or hostility, covered by a facade of pleasantness
- 5. An unresolved conflict with the mother, handled through denial and sacrifice
- 6. Delay in securing treatment (pp. 453–460)
In addition to further stigmatizing women who have cancer, Bacon and her colleagues totally ignore the oppression of women in a society in which rich white men are in power, nor do they consider servitude as a personality predisposition for women in a patriarchal society. Moreover, a sample of forty cannot represent the thousands of women who die every year in this country from cancer, many of whom are poor. Who will speak for them?
In reality, women, particularly poor women with cancer, have shown enormous strength and resourcefulness. They are expected to deal with far more than a male-dominated society might be willing to admit. Furthermore, these women’s lives speak for themselves. They have had to do more with less money, make wiser decisions with less education, carry more responsibility with less power, and somehow survive in a society that seems to always find new ways to abuse poor people and which shows little respect for women.
In a medical setting:
the age group that seemed most difficult for the nursing staff, from the points of view of social loss, family stress, loss of body image, functioning and independence, as well as pain, suffering, and anger were those in their late thirties to early fifties … As one patient stated: “I’ve just got to get home; I have so many responsibilities. My daughters are only fourteen and sixteen; I have a seventeen-year-old son and two older ones. My mother is semi-senile in a nursing home …” (Germain, 1979, p. 184)
Further, Anderson (1986, p. 197) tells us women must act as patients and then “leave their cancer in the hospital,” which is especially difficult when dealing with the side effects of chemotherapy. They must assume their roles as wives, mothers, workers, and friends. Many have to carry on conflicting roles in a hardship-as-usual life, while they go through an ongoing, overwhelming, multitragic, catastrophic illness that could very well end their lives altogether.
Poor women must do all this—without money, respect, and sometimes without the support of a loving family, which can:
lead the patient to feel rejected or abandoned by loved ones. The patient may also respond to this ambiguous or negative feedback with a lowered sense of self-esteem … In some cases cancer patients are “victimized” … relationships have become problematic because, rather than providing support for the patient, those around her have isolated, rejected, or even blamed her for the cancer … often seen as unclean and sinful in origin … (Anderson, 1986, p. 235)
Thence, we are just beginning to understand the impact poverty and its interwoven psychosocial stressors can have on women who are trying to deal with cancer. Cooper (1984, p. 73) says “to employ an engineering term, external stress [persisting situations such as poverty and lack of emotional support] leads to strain on the structure.” It is no surprise to find depression, low self-esteem, and financial difficulties among the major problems faced by cancer patients (Stoll, 1979, p. 136). Undoubtedly, these problems become much more intense among those women beset by both cancer and poverty.
Therefore, it is crucial that we ask not only what is the link between all these stressors and cancer, but also what is the most important factor leading to survival and a sense of well-being? Gawler (1987, p. 141) agrees with Cooper (1984), who states:
The animal and human studies of stress, psychoneuro-immunology, and cancer find that effective coping has a striking impact on both tumor development and on immune system-related hormonal changes which can be expected to influence tumor growth Herein is the potential link between depression and stress in relationship to cancer; studies in both areas are likely to be measuring an inefficient coping style when they report a significant relationship to cancer. … In addition, there is clear application of the measure of self-derogation to coping style … which seems to reflect a special vulnerability to life stressors, (pp. 44–45)
It does not seem likely that a patriarchal society that disrespects and abuses low-income people, particularly women, through a multitude of financial and social stressors would then provide them with the means to cope. And, it seems even more unlikely that poor women, who rarely name their oppressors, would be able to develop optimal coping styles without help. It is this problem we as social workers must address for women who, stigmatized and deprived by poverty, are struggling against malignant cancer. Beyond that, we need to increase sensitivity toward women of color with cancer because they have an even greater struggle against oppression (Belle, 1982, pp. 109–110).
Fortunately, the number of middle-class women campaigning against cancer is on the rise, as evidenced by the march in Sacramento on Mother’s Day 1991. The movement has begun; more efforts will follow. Activism itself is a means of coping.
However, the woman of lower socioeconomic status may not feel comfortable or welcome with the middle-class. She may even feel like an outcast. And when she discovers she has cancer and realizes her life may be cut short, where will she turn? Who will help her cope? Who will speak for her?
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Chapter 2
The Aftermath
Throughout their life, cancer survivors continue to have special medical concerns, preoccupation with fears of recurrence, a sense of greater vulnerability to illness, a pervasive awareness of their own mortality, a more negative view of the future, and a permanent sense of being physically inferior. All remain permanently and conspire to diminish self-assurance and confidence. Concern about infertility often submerged at the time of diagnosis and treatment, reemerges with great power when patients marry, often causing severe distress. (DeVita, Hellman, and Rosenberg, 1989, p. 2202)
Assuming the above observation is correct, why can’t cancer survivors simply make the transition from illness to wellness? How can so many people from diverse backgrounds, having been declared well, or cured, or in remission, be different in so many ways from the way they were prior to diagnosis? Having become tumor free, does it matter what the illness was as far as resuming a normal life is concerned? And what about expectations in a society where the strength of the individual is stressed? Are survivors not victorious over their disease? Are some actually lagging behind physically, economically, emotionally, and socially? If so, what do these questions mean to those who work with low-income women in treatment for cancer when that treatment ends?
If we consider the possibility of an aftermath of cancer, we can develop a much better understanding of the low-income female survivor through examining the physical, economic, social, and emotional changes that may have taken place. Although every person may not experience a significant aftermath, there are far more who do than is realized, and economic vulnerability tends to predispose the low-income woman for posttreatment difficulties, regardless of expectations.
To begin, there is an expectation of a simple, prompt transition from illness to wellness that is projected by the medical community and consequently is accepted by family, friends, and society at large. This in itself can be demoralizing to the woman who is experiencing difficulties beyond treatment and who needs to have that experience validated, rather than denied. It is as if there is a cutoff point at the end of treatment that has an expectation of full recovery. And, if the patient still complains of feeling sick, she may be seen as lacking gratitude for having survived.
Actually, gratitude is often accompanied by a myriad of problems that can give one a sense that it is not really over. However, when treatment is deemed successful, cancer and its treatment, along with all the ramifications, seem to be perceived as transient phenomena that are without an aftermath. Perhaps this is due, in part, to the medical profession’s fear of lawsuits. Certainly, it complicates “reentry problems at the time of return to normal life” (DeVita, Hellman, and Rosenberg, 1989, p. 2201).
Nevertheless, iatrogenic problems can and do occur:
Ralph W. Moss, author of The Cancer Industry, takes a far different view of chemotherapy in his book. He cites the common side effects of chemotherapy treatment as though they were permanent rather than temporary, going so far as to state, “the use of chemotherapy is often accompanied by the destruction of the immune system.” (Reyes, 1991, p. 2)
Moreover, “Orthodox methods have one particularly difficult side effect in common: radiation and chemotherapy both damage the body’s immune system” (McGinn and Haylock, 1993, p. 26).
Likewise, it is entirely possible for a survivor to have ongoing symptoms of chronic fatigue immune dysfunction syndrome (CFIDS) that include extreme fatigue; chronic, intermittent sore throat; muscle pain; joint pain; and other flulike symptoms (Bell, 1991, pp. 34–35). Unfortunately, these symptoms are likely to be ignored, unrecognized, or passed over by many doctors who seem to see tumor-free status as synonymous with health. Some even demonstrate an attitude of “Don’t complain or you will be viewed as a mental case.”
Clearly, the debilitation and misery caused by a poorly functioning body has long-term implications that must be considered when working with this population. Otherwise, it is possible for an uninformed worker to slip into a blame-the-victim stance if the low-income survivor fails to measure up to treatment expectations.
Continuing our focus on posttreatment problems, even the Merck Manual, a conservative medical book, admits to posttreatment pain syndromes:
Post-surgical syndromes: Post-thoracotomy, Post-mastectomy, Post-radical neck, Phantom limb and stump pain.
Post-chemotherapy syndromes: Peripheral neuropathy [nerve damage], aseptic necrosis, [increasing changes] of the femoral [thigh] head, steroid pseudo-rheumatism.
Post-radiation therapy syndromes: Fibrosis of brachial or lumbrosacral plexus, Radiation myelopathy [spinal changes], Radiation necrosis [changes from cell death] of bone, Radiation-induced second primary tumors. (Berkow, 1987, p. 1342)
Although it is neither feasible nor desirable to explore in depth every aspect of cancer treatment in our discourse of the aftermath, it is useful to specify the possible incidental side effects of several widely used cancer therapy drugs that can have permanent impact on the individual. This will help us to understand, rather than judge, those women who appear to be too slow in their recovery.
For that reason then we will review Adriamycin, cyclophosphamide, Decadron, and tamoxifen, respectively. Decadron, a strong corticosteroidal drug, is frequently used in conjunction with tumor-destroying drugs such as adriamycin and/or cyclophosphamide during aggressive treatment. Many breast cancer patients are given this combination along with a third drug such as 5-fluorouracil. Tamoxifen, which we might think of as an estrogen blocker, is often prescribed for breast cancer when the aggressive treatment ends and the posttreatment period begins. It is usually taken for a period of five years.
According to the Physicians Desk Reference (1993):
Adriamycin [also known as Doxorubicin]
Congestive heart failure and/or cardiomyopathy may be encountered several weeks after discontinuation of Adriamycin therapy…. [It] may potentiate the toxicity of other anti-cancer therapies, (pp. 560–561)
Cyclophosphamide [also known as Cytoxin]
Cyclophosphamide interferes with oogenesis and spermatog...
