Overall Societal Change: Families and Cancer

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Overall societal change: families and cancer

            Because our society, as well as most other societies is family oriented, the impact of a family member getting, being treated for, or dying from cancer affects not only the immediate family, but also others such as co-workers, friends, healthcare workers, and a list of other people and organizations seemingly unrelated to cancer.  In other words society in general.  Cancer is a pervasive type of disease that can affect anyone at any time and its occurrence can cause a “ripple effect” throughout society.  When an individual gets cancer he or she becomes the focus of attention, but may not actually be the specific person who initiates social/medical changes mentioned in this report.  Often, because of the plight of the patient, family members, friends, physicians, and nurses are the ones who begin to institute new practices and approaches to cancer in response to the patient’s condition. 

For instance, one example of this initiation of change by others is the effort to develop cancer treatments that are less painful and or stressful to the patient by physicians and scientist.  Immunotherapy is such a treatment because in its purest form it does not require the use of chemotherapy to combat the cancer.  Since it makes use of the cancer patient’s own immune system, the side effects of such treatment are minimal.  In the future, it is quite possible that treatments such as these may allow the patient to lead a normal life while being treated (Alexander 2011).  Without having to think too hard about how the development of such a treatment could be given high priority one only has to think of the fact that almost everyone involved in the decision-making process of immunotherapy’s development has or has had a family member treated for cancer with chemotherapy and they have watched them suffer from its toxic side effects.  This is also a demonstration of the “ripple effect” caused by cancer in our society.  The family unit and the members in it are conduits, which funnel emotional responses and in many cases policy and practice-changing ideas out to the larger society.

            Often when the words “family unit” are used the concept that comes to mind is the traditional family: consist of a mother, father, and siblings.  However, most of the family units in our society and others are of the non-traditional type.  The 2000 US Census Bureau figures reveal that less than 14% of American households are of the traditional type (US Census Bureau 2005).  The other households consist of a complex arrangement of individuals consisting of a sustainable family unit.  With this complexity comes a complex response to one member being diagnosed with cancer. 

Even with traditional families, the response varies depending upon which member (mother, father, or sibling) contract the disease.  Each situation brings with it various types of responsibilities and stress in response to the stricken family member.  For instance, breast cancer in a traditional family is very stressful for the other members and can result in long-lasting emotional problems within the family.  Since it can be inherited through the discovery of the BRCA gene, there can be guilt associated with its discovery in a mother.  With prostate cancer, issues of sexual performance and incontinence put a strain on a married couple’s relationship.  Problems such as these also occur in non-traditional families and result in a significant amount of emotional turmoil.  Addressing this emotional turmoil is one of the major changes society has gone through in recent years and will continue to be an area of increasing importance as far as cancer is concerned.

            As mentioned in the Individual who gets Cancer section, how cancer patients deal with stress in some respects is as important as the anti-cancer therapy that they receive for the disease.  Excessive stress lowers the body’s ability to not only fight the cancer, but also heal from the deleterious effects of chemotherapy.  In addition to these effects associated with having cancer, caregivers (husbands, wives, same-sex partners, or friends) undergo tremendous stress dealing with the day-to-day events surrounding their loved one with cancer. 

Psychological intervention methods (psychotherapy) methods such as mentioned in the previous section are available for both cancer patients and their family members.  However, many non-traditional family members such as same-sex partners face discrimination when participating in such programs that are usually tailored to patients or family members of traditional family units.  In many cases these programs are vital to either the patient, who is undergoing cancer treatment and needs to deal with the stress associated with it, or a partner who needs the feeling that they are not alone in their struggle to cope with a loved one who has this disease.

            Another area of change that has taken place because of the advanced technology involved with cancer treatment and the resuscitation of patients near death is the do not resuscitate (DNR) option.  In many cases a family member(s) is asked (when the patient is incapable of making the decision) to sign a document (DNR form) that would allow the physician to end further treatment and care when a crisis occurs and the patient is near death.  There are two factors that have impacted this aspect of cancer treatment and care.

             First there is the technology.  A person can now be kept alive using advanced technology that allows a persons body to exist in a coma-like state for extended periods of time.  During that time it is possible (in a minority of cases) that the patient not only survives the cancer, but also heals their body during the coma state.  Thirty years ago this technology was unavailable and when a patient went into crisis they died.  However, today the physician must consult either the patient or a family member and make them aware of the situation at which point the DNR form may come under consideration. 

This is a complex issue because there is a shred of hope that the resuscitation and further treatment for the disease may actually free the person of cancer.  Then there is the suffering involved with the treatment and many patients opt to sign the form to not only alleviate their own suffering, but the suffering of loved ones who must witness the pain and anguish of continued treatments.  There are also ethical issues involved when the patient can not make the decision themselves because unfortunately in some cases it is in the best interest of the family member to allow the patient to die because they would be the beneficiary of the patient’s estate.  All of these issues were never dealt with before in society and the hope is that many of these cases are resolved properly, ethically, and in the best interest of the patient and their family members. 

The next area of social change as far as families and cancer is concerned is the “cost” of cancer.  There are two types, which are emotional and financial.  Both of these areas leave long-lasting effects and can literally change the course of events in many people’s lives.  The emotional effects of cancer have been discussed at length in both of these sections, but what hasn’t been thoroughly discussed (except in this section) are the repercussions (“cost”) associated with those emotional aspects of the disease.  For instance with couples and cancer, many times intimacy (emotional or sexual) is negatively affected because often one partner withdraws from the relationship during a critical phase of the cancer treatment.  This may cause resentment by the cancer patient.  This resentment may never go away even though the cancer has gone. 

Situations like this can lead to a break-up many years later and the fact is that neither partner may realize that it began during cancer treatment.  Cancer treatment itself can alter the psychological wellbeing of an individual in ways that are just now being understood.   It has been found that survivors of childhood leukemia are often found to have maturity problems because often when any trauma occurs in youth a part of the adult is “stuck” there.  What happens as they become adults is that their minds often drift back to that time of trauma (cancer treatment), but unknown to them is the fact that they are re-experiencing the emotional state of say, a 12-year old, which was their age when they were treated and cured of their disease. 

This condition can cause severe emotional problems for some adult cancer survivors, but with the help of psychological counseling the problem can be identified and the person can recover.  These are just two of many long-term psychological effects of cancer.  Not long ago, conditions such as this went unrecognized, which resulted in continual suffering from a disease that had been cured.                            

            The financial cost of cancer in many cases, but not all, are obvious due to the fact that even with insurance cancer is an expensive disease to treat.  It can be observed that in many cases when families are put in these situations where insurance doesn’t cover the cost, they must alter their finances.  This affects society because not only are banks affected, but also businesses that no longer provide services to these families because the money has been diverted to pay for expenses associated with the cancer treatment of a family member. 

Cancer cost can also affect retirement savings and in some cases houses are sold or have to be re-mortgaged to meet this new financial responsibility.  Then there are the hidden expenditures associated with having a family member with cancer.  Hospital visits by family members cost money such as lost wages, transportation, food and lodging.  Many times the family simple runs out of money after long periods of treatment and relapse where the process becomes repetitive and financially draining.  Often friends and extended family members hold fund raising events to offset these cost, which at times can spiral out of control.  Because cancer care became increasingly expensive over time, the fund raising efforts grew into what is now considered a small industry.

            By the 1990s the cost of cancer care and research had increased dramatically and the death rate from cancer, despite being reduced, was over a half-million annually (Anderson 2002).  Many of these grass-roots efforts to pay for the cancer care of an individual were converted into non-profit organizations, which began to raise money to financially support the care of other patients and fund cancer research.  The 1990s heralded several significant social changes associated with cancer.  As mentioned previously in the section, in the late-1980s, where there was an even higher cancer death rate, major cancer fund raising organizations such as The John Wayne Foundation, The Susan G. Koman Foundation, and Alex’s Lemonade Stand Foundation were formed and begun to raise billions for research and cancer patient care.  Many of these organizations such as the Vince Lombardi Foundation raised money for the establishment of cancer center (patient and research) facilities and sponsored events to raise money for cancer research.  This was a significant change in society as far as cancer was concerned, but the latest area to be impacted is cancer awareness.  As well as raising money for cancer research many of these organizations such as the Susan G. Komen Foundation began to publicly advocate the promotion of cancer awareness, mostly through TV and print adds.  In addition, the government has been increasing its efforts to educate the public about cancer by using several government-funded organizations such as the American Cancer Society (ACS), National Cancer Institute (NCI), and the Centers for Disease Control (CDC).  These organizations disseminate cancer information not only to the public, but also to physicians, scientist, and administrators involved in cancer care, research, and treatment.

            It is apparent that during the mid-1980s an explosion of activity occurred concerning cancer in society.  Family members of those stricken with the disease initiated most of the public efforts.  These efforts were not only in response to the suffering and death of family members, but also the “cost” of cancer as described above.  Never before in the history of cancer in society has there been so much activity as that seen in the 1990s.  Despite the fact that the death rate from major cancers has fallen, nearly 5,000 people a day are diagnosed with the disease.  Because of these cancer fund raising and awareness initiatives many of these people will be successfully treated because of advancements in cancer treatments through research and early detection through awareness of cancer symptoms.  The family has played a major role in the progress toward a cancer-free society and the hope is that this will continue into the future.

Number 13 Families and cancer

The plan is for me to write a series of blogs about cancer. You will read this small paragraph every time you read one of these blogs because it is an explanation and a disclaimer. First of all, why should I do this and what qualifies me to do so? The answer to the second question is that I am a cancer immunologist with a PhD from the University of Pennsylvania and have 30-years experience in not only research, but also in the experiences of cancer patients. I have published numerous articles and a book about immunity to cancer and have two other books about my experiences with research and cancer patients as well as a fictional account of the final cure for the disease. However, none of this experience allows me to give advice or otherwise tell people what to do if they have cancer. I can be viewed as a participant/observer who will be relaying current and past observations about this world called “cancer”, which many people do not understand. That’s the answer to the first question, which is why I should do this. The first step in overcoming anything is to understand it first. With that being said, here they are:

Number 13 Families and Cancer

The consequences of cancer for the family

Cancer death and the family

A final focus will be on cancer and death. This is the last topic anyone wants to think about. The eminent loss of a loved one is something most people would rather not think about, but this is part of the cancer reality, it brings with it death. Cancer is a unique type of illness because it cannot only affect the person who has it, but also their family, those that care about them, and the healthcare system that is treating them. Most of this discussion about families and cancer has focused on how family units cope with a member who has been diagnosed, treated, or is recovering from cancer. One of the things about cancer death is that many times it can be accurately predicted. This is both a good thing and a bad thing at the same time. The good aspect of this “predicting the time of death” for a cancer patient is that they can plan ahead and maybe do things they always wanted to do or determine what they want to leave for their loved ones afterwards. The sometimes-bad aspect of this situation is that at some point, a decision must be made to either continue treatment or allow the patient to die. The question is: who gets to make this decision?

This aspect of cancer was discussed in detail in the Individual and Cancer section, but initially it’s the adult patient themselves or if a child, the parents that actually make this decision. For adults who no longer have the ability to make that decision this responsibility falls upon the family and the physician. For legal reasons the patient is often asked to sign a “do not resuscitate” (DNR) form that allows the family and the physician to decide at the appropriate time. These decisions as far as the family is concerned, is complicated by the fact that they are also caregivers and have emotional and moral issues to deal with in this situation. Many decisions such as this that are within a large nuclear family are usually decided by quorum with main input by the closes member to the patient. However, sometimes it’s just a single individual such as a spouse/partner, brother, or sister. Regardless of who is involved there is considerable psychological stress that has to be dealt with in situations such as these. Occasionally, there are conflicts between the physician and family about what to do either way and unfortunately the laws about this issue, despite the fact that they seem to be definitive, sometimes do not apply here. Often in these situations the care of the patient is transferred to another institution, which is an unfortunate consequence of a situation like this. It is clear that this issue of cancer death for families can be an exceptionally complex situation, but there is help for family members who have to cope with the subject.

The sociological “cost” of cancer and the family

Another area related to the consequences of cancer is cost. There are two aspects of cost that are important. The obvious one is financial because of the general cost of healthcare in the US. This affects families in various ways, which at first glance don’t appear to have anything to do with money. The second aspect of cost has to do with society. This is a very complex area that affects the family unit in multiple ways. It focuses on the individual with the disease, but the family is affected because of the relationship between the two. Just like the individual, families are an integral part of society, and this is why family members of cancer patients initiate many of the sociological changes related to cancer. Because of the “power” of the family voice in society, many changes within it occur rapidly and without much resistance. Therefore, this would be the logical place to start this discussion of the “cost” of cancer.

The individual and the family are indeed components of the larger society, but there are mini-societies within the larger one. For instance one could view an individuals family and friends as one of these mini-societies where, depending upon what that individual does, change occurs within the mini-society. This is an exact analogy of the larger society and how its parts can induce societal change. Obviously, as mentioned in the beginning of this discussion, the diagnosis of cancer affects this mini-society by realigning responsibilities, emotions, and opinions of its members. The people within this group often begin to not only talk amongst themselves concerning cancer, but to others in order to learn about cancer. They do this not only for themselves, but also for the patient. This type of learning experience begins with stories of other relatives who had gotten cancer and can expand to full fledged information-gathering efforts by family and friends. This is an important source of cancer support for the patient because of the simple fact that you tend to trust what your family and friends have to say. You often feel as though they have your best interest at heart. This is a direct result of the sociological change that resulted in the “silence” of cancer being lifted. Today we take this sort of thing for granted, but in the past this mini-society learning experience would never happen.

In any discussion of the consequences of cancer, particularly when it comes to the larger society, there comes into play the concept that was mentioned above called the “cost.” Again, there is the strictly monetary cost of healthcare related to cancer that impacts families and their decisions related to the care of a family member with cancer. Those will be discussed later, but there have been attempts to combine the monetary and the social cost of cancer. This is what is called the “psychosocial” cost of cancer and it is an attempt to put a monetary value upon the sociological aspects of cancer. Some of these are physician/nurse fees, cost of end-of-life care, treatment cost of psychological disorders caused by cancer, and the expenses incurred by family members involved with the patient (transportation, child care, and work loss). This list is extensive because many new things are going on within a family that has a member with cancer and they all cost money. In 1975 it was estimated that the social cost of cancer was about one tenth of the US Gross National Product or 138 billion dollars. The problem with studies such as this one is that the monetary cost of not only the areas mentioned above, but almost all of these social expenses incurred by the family are vague and range in value. In addition to this it is very difficult to assign a monetary value to a human life. The only redeeming quality of studies such as these is that they elucidate the enormity of the cancer problem faced by modern society.

The real social costs of cancer are the psychological effects that cancer has on family members and the resulting consequences on society as a whole. For instance while a family member is being treated for cancer changes occur within members of the family. These changes are related to the unpredictability of the treatments and the disease itself such as tension, irritability, and relationship dynamic changes between the members. This is very similar to what happens as outlined in the Individual and Cancer section where the person being treated suffers from a host of psychological effects caused by this uncertainty related to cancer treatment. One of these psychological effects suffered by individual cancer patients as mentioned in the above section, was Posttraumatic Stress Disorder (PTSD). These are symptoms such as anxiety, depression, and what is called “hyper arousal,” which is a heightened sensitivity to negative stimuli. As far as families are concerned, parents of childhood cancer survivors routinely experience PTSD years after the initial treatment of their child. It was found that it was not uncommon for a full 40 to 90% of both mothers and fathers to have experienced these symptoms at some point after the 5-year “cured” period. Psychological counseling has been found to be an effective treatment when these symptoms interfere with the normal functioning of the family. However in real-time, during a family member’s cancer treatment, immediate psychological symptoms within the family (partners/spouses, children, and friends) occur at an increasing rate. Some of the many symptoms include inability to concentrate and loss of confidence. Just these two psychological symptoms can lead to problems with safety in the household, while driving or at work. Often family members had a feeling of not being in control as well as feeling helpless to do anything to help this family member being treated for cancer.

Another psychosocial effect of cancer on families is cancer survival, which was mentioned above. Once a patient is deemed “cured” of their cancer the effects of the disease remain. This is true for not only adult cancer patients, but also children, which is the fastest growing cancer survivor group. One of the strongest disruptors of psychosocial environment of the family is the recurrence of cancer. This can occur at any time after the patient is been deemed cured, which as mentioned above, is usually after five years of being cancer-free. As discussed extensively in the Individual and Cancer section, the re-occurrence of cancer has a devastating effect on the patient, but more importantly family life is also changed dramatically. Just like with individuals who have a recurrence, family members begin to re-live the experiences they had throughout the “cancer experience.” This is more of a traumatic event for siblings of the patient. How old they were when the parent was treated for cancer determines how well they cope with the recurrence. If they were very young and didn’t understand it then, that confusion re-surfaces. Often what accompany those memories are other immature thoughts that are unrelated to the recurrence, but were going on during the initial experience of their parents having cancer. This can lead to behavioral problems. In addition, it has also been shown that the adult family members respond to the family member’s recurrence by demonstrating a more intense effort than was initially demonstrated during the initial cancer experience. However, with that comes more intense impairment in the functions mentioned above related to concentration and confidence.

The monetary “cost” of cancer and the family

When talking about the cost of cancer in strict monetary sense, the problem is enormous and can have a devastating effect on a family who’s loved one has cancer. A study conducted by the National Cancer Institute, which looked at just cancer patients that were 65 years or older determined that the cost of cancer for just this group would be almost 160 billion US dollars by the year 2020. According to the US Census Bureau in 2010 this group was 13% of the US population and by 2020 twenty percent (US Census Bureau 2010). If one includes the rest of the population it becomes apparent that cancer is one of the most medically expensive diseases in society. The financial aspect of cancer as it relates to the family (and friends) begins with the direct cost of cancer care. These cost are things like the cost of cancer drugs, rehabilitation, psychological counseling, and any expense directly related to patient care. Even with insurance these costs mount-up and can become a financial burden for even financially well-off patients. Eventually, the patient or the patient’s immediate family is unable to afford these expenditures and need help. Other family members and friends may contribute financially to the cost of this care. Many times after this extended family is unable to keep up, they organize fund raising events to offset the cost. The subject of “family fundraising” will be the topic of the next section, but the effect that this financial burden has on the family has other wide-ranging effects on society. For instance the expense of cancer in many cases leads families to alter their economic strategies in such a way as to affect other institutions such as banks. Many families either refinance or sell their homes in order to pay for cancer related expenses. Retirement funds have also been “cashed-in” for this very purpose. There are hidden cost of cancer that relate to simple things such as transportation cost, lodging for the family during hospital visits, food, and other expenses that are all associated with attending a family member with cancer. Hidden types of financial problems associated with visits become known to primary care nurses who interact with visiting family members and are sympathetic to their concerns. Situations like this one and the need to help family members with cancer has become an integral part of society. Cancer is a disease, but now also an industry. Families that wanted to help other families during the crisis of cancer initiated cancer fund raising that was never heard of until the 1990s.

Families and cancer fundraising

There are several very obvious changes in society as far as cancer is concerned. Most of these changes interface with the media in the form of print, TV, and radio. Two of the most prominent indicators of this change are advertisements for cancer treatment centers and cancer fundraising events. Cancer fund raising has become an industry much like cancer treatment centers. Each tends to elicit funds associated with cancer treatment. These organizations actively compete for patients and their healthcare money. As far as cancer fund raising is concerned the question is how did this all start and who is responsible? The answer to these two questions is simple to answer. The answer to the how part begins in the 1980s when the veil of silence about cancer was lifted. This silence about cancer that came from the 1950s was discussed in detail in an earlier section of this report. This silence basically prevented fund raising efforts because the subject of cancer was not talked about. At that time, cancer was ignored because many thought it affected a very small-unprivileged section of society. During the 1980’s it was recognized that cancer affected everyone and the disease was brought out into the light of society. Now the “who is responsible” part of this question mainly has to do with families. As cancer became more prevalent there were some quite famous and wealthy individuals who died because of it. One of the most recognized cases was the death of John Wayne the actor and celebrity. Using funds from his estate John Wayne’s family began to support the John Wayne Cancer Foundation, which supports cancer research and cancer facilities throughout the US. Even though this was the beginning of family-based cancer fund raising, that effort, even on this small scale has changed society.

Today some 30 years later, celebrities such as Fran Dresher are not only using their high visibility in society to raise funds for cancer, but are also warning people of the carcinogenic dangers of food additives. This is an example of a famous individual involved with cancer fund raising, but as far as family efforts are concerned several notable organizations devoted to cancer fund raising have appeared recently. The first and probably most visible is the Susan G. Koman Foundation. Susan G. Komen was a woman from Peoria, Illinois who died from breast cancer in 1980 at the age of 33. Her sister was determined to help other women diagnosed with the disease and created the non-profit organization in 1982. Since then the organization has raised over 1.9 billion for breast cancer research (Susan G. Komen). The next notable family-based cancer fund raising organization is Alex’s Lemonade Stand Foundation, which was started by Alexandra (Alex) Scott who was diagnosed with neuroblastoma and passed away from the disease in 2004 at the age of 8. Prior to her death, Alex decided to set-up a lemonade stand in the families front yard and give the proceeds to doctors to treat other children who suffered from childhood cancer. In 2005 this non-profit organization was founded by her family and has raised over 50 million for childhood cancer research.

These two examples of cancer fund raising, initiated by the family are the most visible, but there are literally hundreds of smaller fund raising organizations that have been initiated by the family of a cancer patient. Most of these fund raising efforts are genuine, but some are not. Unfortunately, some individuals and organizations abuse the fund raising system for personal gain, which cast doubt on legitimate efforts. Fortunately most of this abuse is detected and persons responsible for it have been prosecuted. To a certain extent cancer fund raising has become a lucrative business, which is susceptible to the types of fraud all successful businesses occasionally experience. Despite this, these efforts by family members has not only raised vast amounts of money for cancer research, but also has raised the awareness of the public to cancer. All of this has come about because the stigma of cancer, which was mentioned in the beginning of this section, began to dissipate. This allowed open discussions about cancer and then the willingness to help others, thorough family-based efforts, began in earnest. This area of fund raising for cancer is the most visible aspect of the change in society caused by the continual presence of cancer. It is the result of the power of the family, which is a hallmark of US society. Once an issue is addressed in the context of the “family” it becomes an issue that society as a whole must deal with. The contribution of the family to the recent changes in society with respect to cancer have been enormous and are a direct result of the power of the “family voice” in society.

Number 12 Families and cancer

The plan is for me to write a series of blogs about cancer. You will read this small paragraph every time you read one of these blogs because it is an explanation and a disclaimer. First of all, why should I do this and what qualifies me to do so? The answer to the second question is that I am a cancer immunologist with a PhD from the University of Pennsylvania and have 30-years experience in not only research, but also in the experiences of cancer patients. I have published numerous articles and a book about immunity to cancer and have two other books about my experiences with research and cancer patients as well as a fictional account of the final cure for the disease. However, none of this experience allows me to give advice or otherwise tell people what to do if they have cancer. I can be viewed as a participant/observer who will be relaying current and past observations about this world called “cancer”, which many people do not understand. That’s the answer to the first question, which is why I should do this. The first step in overcoming anything is to understand it first. With that being said, here they are:

Number 12 Families and Cancer

II. Families and Cancer

G. Unmarried couples and cancer

There is a definite paucity of information about couples that are not married and are involved with one of the partners having cancer. Long-term couples that are not married tend to behave as married couples, but don’t have the same legal rights as married couples until seven years have passed. This is the case in many States in the US. Despite this, they still suffer the same fate as married couples and either one of them can be diagnosed with cancer. The emotional responses can be slightly different when compared to married couples and this has to do with the bond the partners have in their relationship. For instance it was found, when studying heterosexual partners where the male partner had prostate cancer, that the mental aspect of the couple, but not the physical aspect, determined the quality of life of the patient (Bergelt 2008). This is very similar to married couples where the spouse has breast cancer and it’s the support and recognition of the disease by the partner that improves the survival of the patient. Furthermore, daily contact between the couple was the most important factor in this improvement of survival and increased quality of life (Belcher 2011). As a matter of fact the mental attitude of the partner who doesn’t have cancer is a determining factor in how that patient survives the disease. If the partner decides to ignore the other’s serious health problem (cancer) then the patient’s outlook on their ability to survive is diminished. This fact spans all types of cancer when couples are involved. Here, the idea is to get not only the cancer patient to participate in a psychologically based analytical program, but also the partner of that person because the patient’s well being and quality of life during the experience depends on the bond the patient has with their significant other (Gustavsson-Lilius 2007).

This situation between unmarried couples and cancer, as mentioned previously, can be just as difficult a situation that married couples face. The mental aspect of how the non-cancer partner has to be involved with the plight of their significant other is important, but the non-cancer partner can develop serious psychological issues during the period where their partner is being treated for cancer. As mentioned previously with prostate cancer, couples have difficulties associated with the treatment period of the disease. Incontinence and loss of sexual function are the major problems that occur during and after prostate cancer treatment. Just these two problems can cause both emotional and social distress for the unaffected partner. The main reason is that they are “private” issues that often come to light in the social sphere of friends and family. Until recently, it was thought that each partner equally shared this psychological distress. However, studies revealed that it was more stressful for the unaffected partner (woman) than the patient. It was shown that this distress experienced by the woman could be lessened by a willingness to help her partner by seeking psychological counseling in order to understand why she is experiencing so much distress (Couper 2006).

In many respects the treatment for prostate cancer is similar to those associated with ovarian and breast cancer in terms of the psychological impact on the patient. All three of the treatments for these cancers may alter the “body image” of the patient and for this reason they can cause personal turmoil that affects their partner. One particular case, which was written about in a popular magazine, that turmoil was averted by a new type of prostate cancer treatment and it started when a woman’s fiancée was diagnosed with prostate cancer. Initially the woman was concerned with the results of the primary treatment for the disease, which is surgery that can cause the previously mentioned problems of sexual dysfunction and incontinence. However, they were able to have available to them another kind of treatment that uses focused radiation, which can kill the cancer cells. It was clear in this case that the female partner’s optimism and willingness to find other alternatives to surgery made a major difference in the outcome of the treatment. In this case, the psychological distress associated with an altered body image was avoided (Eberhardt 2005). Often what happens in these cases where there is an unmarried couple going through this experience, the unaffected partner may distance themselves from involvement with the patients treatment problems. This severely limits the willingness of the patient to not only seek life-saving information, but also to have a positive attitude. A positive attitude (discussed in the Individual and Cancer section of this report) is an essential ingredient in maintaining a high quality of life before, during, and after cancer treatment, as well as maintaining good health in general (Bruckbauer 1993). Despite the fact that this group is not bound by the legalities of formal marriage, unmarried couples are susceptible to not only the same types of cancers as other family units, but also suffer from similar psychological difficulties brought about by having the disease.

H. Gay and lesbian families and cancer

To a certain extent this is the most unique family unit that will be examined in this investigation of families and cancer. Many of these couples, which will be discussed in this section neither have children, nor are legally married. This is due to the social stigmas associated with homosexuality. Regardless of that, they pass the definitions of family as defined in the introduction of this section and will be considered as such. The fact is that they, like the rest of humanity, suffer from cancer. The types of cancer sometimes are specific for their lifestyle, but many times typical of the general population. Because of the social factors that affect their lives, a cancer diagnosis may be viewed in a different light with these couples. There is another issue concerning the healthcare of gay and lesbian individuals. This has to do with the responses they get from healthcare workers. This issue is important as far as cancer is concerned because early detection is dependent on cancer screening. If an individual has a problem making routine doctor visits, some cancers may go undetected and when they are found, it’s too late for successful treatment. There is evidence of blatant discrimination in healthcare systems against Gay and lesbian individuals, which are not commonplace occurrences, but exist nonetheless (Kendall-Raynor 2007). However, what is more prevalent is a negative emotional response directed towards them by doctors and nurses that the have to see on a routine basis (Saulnier 2002). So to some extent this “discrimination factor” is a major problem when it comes to the incidence of cancer in gay and lesbian individuals. This is the backdrop of any discussion of cancer and gay and lesbian couples. It is an emotional issue that needs to be addressed because they represent a major percentage of our society.

One of the encouraging aspects of this situation is that healthcare treatment of gays and lesbians is improving because of acceptance and recognition of not only homosexuality in general, but the lifestyle of gay and lesbian couples. Within the healthcare system itself, there are indications that when a gay or lesbian couple seeks cancer treatment for one of the partners the reactions of healthcare workers has been described as almost “gay neutral.” Despite the fact that this response is not “gay acceptance” response it is a good thing for these couples who have to deal with one of them having cancer. However, there is a problem with support groups. In this situation the majority of participants are heterosexuals who are from the general population that have issues related to cancer that are dealt with in this type of group therapy. Often what happens is that these couples are exposed to the same homophobic attitudes, which were encountered in the outside world. This is in contrast to the healthcare system, which actually has to conform to some type of acceptance of gay and lesbian couples for legal reasons. These couples, if they go to these meetings, leave out the fact that they are partners and often portray themselves as just “friends.” Sometimes, if they admit they are a couple they only attend one meeting and then stop. This is a major problem for gay and lesbian couples because group therapy can alleviate the stress of cancer these couples encounter and without it, the quality of live and potential survival of the patient is diminished. Another aspect of gay and lesbian couples experiencing cancer is a sexual one. To a certain extent, sexual organs such as the breast and penis are viewed differently in homosexual couples versus heterosexual couples. Homosexual relationships tend to be more dependent on sex than heterosexual relationships are. Therefore, the loss of a breast or dysfunction of a penis is more of an emotional crisis for homosexual couples. This fact is almost completely unknown by heterosexual healthcare workers such as doctors and nurses (Katz 2009).

Most of the information about homosexual couples and cancer is focused on prostate cancer. There are a combination of problems associated with gay men and prostate cancer. First of all in the general population there is a tendency to not talk about prostate cancer. The second part of this has to do with the fact that the heterosexual society avoids talking about gay men. So therefore because of this “silence” many gay men do not submit to prostate cancer screening. After diagnosis, many of these men slip into deep depression, which is associated with the fact that they have to enter a healthcare system that is not always ready to deal with gay men. Other factors such as those mentioned above about sexual organs and the sexual dysfunctions, which were talked about in the Prostate cancer section, may contribute to this depression that many gay men experience after diagnosis. Often the partner of the patient is at a loss at what to do to help him. Again, Psychological counseling, specific for gay couples can alleviate the emotional problems associated with this situation (Pearlman 2005). As mentioned above, sexual functioning and the organs that facilitate it are viewed in a different light for homosexuals. Prostatectomy removes the entire prostate gland containing the tumor, but as a result of that the man who experiences this often cannot ejaculate. For heterosexual couples this may not be a problem because the man can still satisfy his female partner with an erect penis. However, the erection and ejaculation is important for gay men and sometimes neither can be achieved after surgery. This is a major psychological dilemma for these patients because it impacts their lives on may different levels. After prostatectomy a man has to become reacquainted with his “new sexual body”, where an orgasm is possible without an erection or ejaculation. There is a tendency for these men to feel as though they were not only cursed, but also victims of a vicious disease called prostate cancer (Martinez 2005).

The subject of cancer in gays and lesbians is a complex one as evidenced from the information above. Despite the fact that gays and lesbians make up 40% (~20 of males and 20% of females) of our population, general and specific information about what occurs during the “cancer process”, such as diagnosis, treatment, psychological effects, medical effects, and quality of life is limited. It is very difficult for healthcare professionals to gather this information in order to give their gay and lesbian cancer patients the best care. Several studies have been done to determine exactly how much of this information is available and why. One of these studies examined information related to lesbians and cancer. The first thing they noticed was that there was a large disparity in not only the amount of information, but also its quality when compared to the heterosexual female cancer patient population. For instance there was information about lesbians and cancer screening/prevention, breast cancer, and cervical cancer, but very little information about other cancers. In addition, there was almost no information lesbian cancer incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality (Brown 2008).

The lack of this information, which should be available to healthcare workers who treat gay and lesbian cancer patients, may lead to patients to receiving inadequate or inappropriate treatment. It appears that gay and lesbian cancer patients are not considered when it comes to compiling information for cancer surveillance programs. The reasons for this more than likely have to do with the slowly changing attitude that society has about homosexuality in general. In support of how valuable the above information is to the health and well being of gay and lesbian cancer patients, recent studies have revealed that there is a vast difference in not only cancer survival, but also the quality of life in these patients. Recent information concerning the fact that gay men have a higher rate of cancer as compared to their straight male counterparts is useful because it should lead to increased cancer screening (Boehmer 2011). Again this is an important issue that has to be rectified because it not only negatively affects these patients and their partners, but also the patient’s parental heterosexual family. Often, but not always, parents and heterosexual friends put aside their differences and offer support to these patients. However because of inadequate care brought about by the lack of information about homosexuals and cancer, these families and friends end-up suffering as well as the patient from psychological distress, poor quality of life, and premature cancer death. There are particular treatments and techniques available to alleviate the suffering in this particular situation, but first they have to be tailored to the gay and lesbian cancer patient and then made available to them in a non-bias way. Unfortunately, the information that was mentioned above that would allow these treatments to be effective in gay and lesbian cancer is sparse and unavailable to be used to help these patients. Because gays and lesbians make-up 40 percent of the population they are one of the largest minority groups in the country. It is difficult to believe that proper cancer statistics do not exist for such a large percentage of our society. This is another area where cancer is changing society because of its ever increasing recognition of the fact that gay and lesbian patients should have cancer care treatments that are just as effective as they are for the rest of society.

Number 11 Families and Cancer

The plan is for me to write a series of blogs about cancer. You will read this small paragraph every time you read one of these blogs because it is an explanation and a disclaimer. First of all, why should I do this and what qualifies me to do so? The answer to the second question is that I am a cancer immunologist with a PhD from the University of Pennsylvania and have 30-years experience in not only research, but also in the experiences of cancer patients. I have published numerous articles and a book about immunity to cancer and have two other books about my experiences with research and cancer patients as well as a fictional account of the final cure for the disease. However, none of this experience allows me to give advice or otherwise tell people what to do if they have cancer. I can be viewed as a participant/observer who will be relaying current and past observations about this world called “cancer”, which many people do not understand. That’s the answer to the first question, which is why I should do this. The first step in overcoming anything is to understand it first. With that being said, here they are:

Number 11 Families and Cancer

II. Families and Cancer

A. Introduction

The family dynamic or interactive responses between individuals in any given family unit are quite variable during average day-to-day happenings, but in a “crisis situation” that dynamic changes quickly. There is a reorganization of responsibilities, which may lead to some members of the family taking on more responsibilities, and some less. In a situation such as this, the lines of communication between family members is realigned and focused on the situation at hand. When a family member gets diagnosed with a life-threatening disease such as cancer it is a crisis situation that affects every family member. There is not only a change in responsibilities, but also a wide spectrum of emotional responses related to the uncertainty of cancer. This uncertainty concerning cancer has to do with the type of cancer, whether the treatments will work, and if death may be involved. Obviously the above information is complex, variable, stressful, and difficult for a family to manage. How traditional and some non-traditional families deal with a member getting cancer is the subject of this investigation. Initially, there will be a description of the family structures that will be examined in this situation. Next, a brief description of the types of cancers used as examples. The reason for this is that many times the type of cancer that is diagnosed can illicit it’s own unique emotional response and responsibility based on its biologic behavior. Then the consequences of the cancer treatment, which are related to decision-making by the physician, patient and the family, will be examined. This will include an unfortunate consequence of cancer, which is death. This will lead to the ultimate goal of this investigation, which is to identify the contributions of the family to the recent changes in our society concerning cancer. The changes that will be focused on are fund raising events and organizations, cancer support groups, and changes in medical ethics surrounding family involvement such as a patient’s right to die.

B. The family unit and cancer

One simple definition of the family is a group of people, who are affiliated by consanguinity, affinity, or co-residence and another obvious one is the fact that it involves more than one person. Beyond this simplistic view of the family lies a multitude of variations, which are too numerous to delve into for the purposes of this investigation. However, four representative family units will be examined in this situation where one of the members is diagnosed with cancer. There will be one pre-condition and is that the age of the primary couple will not be included in this examination in order to limit the variables of this analysis. The first family unit examined in this setting is the traditional family, which is composed of a married couple with or without children. Next would be single parent households where there are children under the age of 18 who live in households headed by an adult (male or female) without a spouse present. Another common family unit would be co-habiting couple families, which have been an increasing type of family unit in society. Finally, the last family unit examined in this context will be families of lesbians and gay men. These family units are included in this study because they have been recognized by family-oriented literature as viable families and are a significant percentage of family units in society. The various types of cancer (breast, prostate, leukemia, etc.) will be used to examine these family units. In addition, these four family units will be used to examine similar characteristic emotional responses and responsibilities of the members as they relate to a family member with cancer.

The types of cancers examined will represent members of a traditional family, where there is a father (prostate cancer), mother (breast cancer), and children (childhood leukemia). As mentioned previously, each type of cancer engenders somewhat different emotional responses based on the nature or lethality of that particular type of cancer. Most of the emotional responses within the population come from either personal experience with someone who had that type of cancer or from reports in the media. For example how a diagnosis of a particular type of cancer such as pancreatic cancer, is a death sentence for the patient. In terms of strong emotional responses to a type of cancer elicited from not only society, but also the family, childhood leukemia would have to be at the top of the list. Despite the fact that today the 5-year survival rate of the three (AML, ALL, and APL) major types of childhood leukemia is 80%, diagnosis of a child with leukemia elicits a strong emotional response. This is a very difficult disease for a family to cope with because of the unpredictability (uncertainty) of the remission period, which is defined as the minimal residual disease after treatment. Generally, the emotional response of a family to a child who has been diagnosed with leukemia is similar to that family’s response to a natural disaster, which can cause both physical and emotional distress. Breast cancer is the next type of cancer to be highlighted in terms of the family because it affects women, can be deadly, and has a powerful effect on the family dynamic. This again is one of those types of cancers that have affected almost every level of society as far as the other people (family and friends) involved and social awareness of the disease. Prostate cancer is also in this category because it affects men, who in many cases are the main provider for the family. To have this person side-lined by cancer can dramatically change the family dynamic. The emphasis on emotional responses has to do with change. Cancer-induced changes in society are, for the most part, driven by the emotional responses of the patient, their families, and friends and healthcare workers (doctors and nurses). Particular attention will be paid to those emotional responses that have directly influenced change. In this way a true understanding of how cancer has changed our society can be revealed.

C. Families and childhood cancer

Childhood cancer is one of the most emotional cancer-related events known to us as a society. It has had an impact on several very important aspects related to the change in society with regards to cancer. Because of the way these types of cancers affect not only the immediate families, but also the general population, there has been a major effort to solve many of the problems associated with children getting cancer. Two of the major problems have been the type and nature of these cancers and funding to do research to cure them. The major types of cancers children get are brain and nervous system tumors such as neuroblastoma, wilms tumors, bone cancer, lymphoma, retinoblastoma, rhabdomyosarcoma, and leukemia. There are several others, but the one that has had the greatest impact on change is leukemia. Part of the reason why is emotional, but another part has to do with the biology of the disease itself and it’s control of the emotional response. It’s important to understand the facts about leukemia in order to get an idea of the magnitude of change in our society that this disease has caused.

Leukemia is a malignant proliferation of blood leukocytes, usually characterized by leukocytosis (increasing number of white blood cells) and the infiltration of other organs by leukemic cells, ultimately causing death. This is the standard dictionary definition of leukemia, but leukemia is much more than this definition. It’s impact on our society as a form of cancer has been formidable. There are magazines and scientific journals just about leukemia. There are also societies, patient groups, and survivor reunions, all associated with getting leukemia. Leukemia is one of many types of childhood cancers, but it has permeated our society in such a way that sets it apart from all other forms of cancer. There are many reasons for this. For one thing it is a very difficult type of cancer to treat because of its nature. One of the other reasons is that during treatment for leukemia there is a level of anxiety experienced by the childhood patient, their family, and the attending physician that is somewhat different from other cancer treatments. Perhaps it’s the length of treatment or the constant remission/relapse cycles the children and their families go though. Actually, more adults are stricken with leukemia. It accounts for only 30 percent of childhood cancers, but leukemia is the number one cause of cancer deaths for children. However, when the children suffer we suffer.

Technically there are two stages to leukemia. First is the chronic stage where

abnormal white blood cells (leucocytes) can still function and there is a slow onset of the

disease. Many people who are in this stage do not know it because there are no symptoms. The next stage is acute leukemia, where the leukocytes cannot function

normally. In addition, their numbers rapidly increase to the point where they begin to cause spatial problems, which can cause system-wide inflammation. This stage of leukemia can worsen quickly. Symptoms such as fatigue, due to the lack of red blood cells, easy bruising due to low numbers of platelets (that control bleeding), and the recurrence of minor infections because of low numbers of functioning white blood cells, occur rapidly.

Leukemia affects white blood cells in the bone marrow where these cells are born.

The two major types of white blood cells in the bone marrow are the lymphoid (lymphocyte) and the myeloid (myelocyte) types. There is acute/chronic lymphocytic and acute/chronic myelogenous leukemia. There are about 200,000 people living with leukemia and in 2008 there were an estimated 50,000 newly diagnosed cases in the US. As mentioned previously, leukemia is actually diagnosed in more adults than children at a ratio of 10 to 1. There were about 20,000 deaths from leukemia in 2008. The five-year survival rate (cure rate) today, as mentioned above is about 80% up from 15% in the 1960’s. This is due to dramatically improved treatments for this type of cancer. What causes leukemia is not completely understood. It is known that job related exposure to benzene and exposure to ionizing radiation can cause leukemia, but this does not explain the vast number of cases. What is important is that as the number year’s progress so does the cure rate. A contributing factor to this increase in the cure rate is the continuing development of new therapeutic treatments for leukemia (Alexander 2011).

These facts about childhood leukemia are in a way, typical of all childhood cancers. These cancers in children can have a devastating effect on not only the child, as they grow-up, but also the families. There is a vast array of long-term emotional effects for both. The effect on the parents can cause marital instability and sometimes complete disruption of the family unit. This effect occurs in stages. Amazingly enough, the first stage is anger. This is not only experience by the parents, but also the siblings. The parents feel as though they were singled out unfairly to have a child with cancer. The siblings really have a hard time because all of a sudden the attention is draw away from them and directed to the sick brother or sister. The next stage is usually denial, which is similar to how individuals who get diagnosed respond. Grief and then depression follow. The potential loss of a child or sibling intensifies the last two emotional states. This has to do with the “innocence” of childhood and how everyone clings to those memories as adults. One good thing that occurs is that a family unit can be resilient and often can recover from an experience such as this. One of the things that are not readily apparent is that having leukemia as a child and surviving it as an adult, has consequences. Throughout that person’s life there are some lingering medical and psychological effects, which have to be dealt with on a long-term basis.

D. Breast cancer

Breast cancer has had a significant impact on how society views cancer. Aside from the disruptive nature of childhood cancer, breast cancer is second in family disruption. Most of this has to do with the fact that a mother is a central figure in the family unit and usually the emotional anchor. When a life-threatening disease affects this person it affects everyone in the family. Many times the news of the diagnosis is concealed from the children, but eventually everyone in the family is informed. Children, and especially the youngest, have a hard time dealing with the news. A diagnosis of breast cancer can completely split-up the family or make it stronger. It is quite disruptive of the day-to-day functioning of the whole family. However, advances in the treatment of the disease have rendered the diagnosis of it as potentially survivable. Unlike years ago, now a diagnosis of breast cancer does not mean a death sentence. Despite this, a breast cancer diagnosis is a serious and life-altering event that often leads to death.

One of the aspects of breast cancer is that it can be inherited. This is a family issue because there is a family of genes called BRCA that gets passed from mother to daughter. There are several of them and they’re recessive genes, which means that you can have the gene and pass only one copy to your sibling. One copy of this gene is benign, but when there are two copies there is a high likelihood that the recipient will get breast cancer. These genes not only cause breast cancer, but also ovarian cancer. Generally, if a daughter is diagnosed with breast cancer and gets tested for the BRCA gene and is positive, her mother feels as though it was her fault. There is a significant amount of guilt generated in these situations. This is a major issue, but one that has to do with biology, yet it is an emotional event that can fracture families. Another aspect of this genetic component of breast cancer is that often after a woman is tested positive for these genes a decision has to be made about preventative mastectomy. This is a very difficult decision for someone to make, but many times these decisions involve the rest of the family. As a matter of fact families are usually involved with major aspects of breast cancer treatment such as what to do about the diagnosis, treatment, and prevention of recurrence. Breast cancer is another cancer that has had a major impact on society and the way we view cancer because of it’s impact on the family.

E. Prostate cancer

Prostate cancer is another form of cancer that affects families because it is a cancer of men and fathers are involved. It is the leading form of cancer in men and originates in the prostate gland. This gland is about the size of walnut (normally) and is located near the rectum. The prostate gland makes the seminal fluid, which eventually contains the sperm during ejaculation. For an unknown reason, in older men (40-years old), the fluid builds-up, which causes inflammation of prostate cells. Eventually those cells become cancerous. As cancers go, prostate cancer is slow growing. The problem is that there are few symptoms until the cancer has advanced to its later stages and has spread throughout the body. Generally, if a man is in his later 50s or mid-60s and is diagnosed, he’s just as likely to die from natural causes in his 70s or 80s than from the cancer itself. It is not known what causes prostate cancer, but there is a genetic link to it and inherited form of the disease.

The first family aspect to be focused on is how married couples deal with prostate cancer. In many respects this is a difficult issue for a couple to deal with because of this “uncertainty” factor related to almost all cancer diagnosis. It has been found that couples in this situation (prostate cancer diagnosis) use something called “collaborative coping.” This involves the couple pooling their resources and problem solving abilities to deal with problems associated with the cancer. Problems such as incontinence and impotence can be very stressful for a couple, but this coping technique helps both individuals deal with that stress. However there are problems with this situation if the couple’s relationship was tenuous before the diagnosis. Couples have what is called “relational resources”, which is defined as the total reservoir of emotional coping a given couple has. With some couples the disease uses that up and this is where “emotionally focused couple therapy” comes in. It is a way to shrink the emotional load that each individual has to deal with. In addition to this, studies suggest that in order to cope with the disease, couples have to successfully exchanged responsibilities. In this way the couple can maintain control over the disease and their lives. An unfortunate aspect of not only prostate cancer, but also other cancers is what happens to family caregivers when the cancer is in its advanced stages. It’s been found that the caregiver, in this case the spouse, can suffer from both mental and physical fatigue that has to be addressed. Again, many of these issues between couples and prostate cancer can be dealt with in a clinical psychology setting. As mentioned previously, this type of treatment can be just as important as the treatment of the disease itself because cancer affects not only the body, but also the mind.

F. Cancer and single parent families

A lot of the information about this topic has to do with how a single parent deals with a child who has cancer. However, the fact is that just like every other family, the child may have to deal with a parent that’s been diagnosed with the disease. The interactions of individuals in this situation can be more intense than usual because there is not a larger family unit to absorb the significant amount of stress that cancer causes. Large family units can often disperse the stress by having various individuals take turns with the responsibilities related to what happens when there is a cancer diagnosis. They also tend to sequentially address the emotional needs of those involved. However, single parent households are often cut-off from these extended family relationships because of factors such as divorce and relocation. When cancer happens in this small family unit it can have a profound effect on both the parent and child. There is one major benefit to this situation when a child of a single parent gets diagnosed with cancer. This has to do with that same lack of extended family involvement. What happens is that there is a singular focus that is brought about by the lack of distractions from other family members. Single parents are often more emotionally strong than their couple counterparts because of the situation that they’ve found themselves in. In addition to this, there is often a special bond between the parent and child for the very same reasons. Because of the lack of distractions, these parents tend to be able to access information quickly and they can focus on what they have to do as a parent with a child that has cancer. They tend to draw on different resources that are available to them because they are single parents.

This situation does raise some other issues related to time spent by a single parent focusing on being involved with their child who has cancer. In the majority of single parent households the mother is in control. Often she’s a working mother, but now she has to take time off from work to deal with this situation. Unfortunately, women who are absent from work tend to loose their jobs at a disproportionally higher rate than men. However, there is a federal law called the Family Leave Act that allows family members to be absent for 12 weeks and still retain their jobs. The 12-week period is unpaid leave. The bad thing about this law is that it applies to companies with 50 or more employees. This added to the fact that most employment is in the small business sector, a woman in one of these small businesses and with a child that has cancer is still faced with loosing her job. There are resources available to single mothers in this situation that have to do with social services and insurance providers. In addition, there is financial aid from local, state, and federal sources. While all this is going on the child with cancer sometimes feels guilty because they feel that they are a burden on the parent. These feelings were usually in place before the cancer because of the experience, which maybe related to divorce or separation.

Several years ago a survey of literature related to single parents with children who had been diagnosed with cancer was conducted. The authors of the study admitted that there was a paucity of information about the subject, but came to several important conclusions. First, and what was mentioned previously, was the psychological effects on the child in terms of them being even more of a burden on the parent because they had cancer. Secondly, it was pointed out that this is a very stressful situation for the parent. It is so stressful that it can impact the life expectancy of the person, as evidenced by the scientific data related to telomeres and their length. Telomeres are stretches of DNA found at the end of chromosomes and their length is a predictor of life expectancy. Shorter telomeres are indicative of a sorter the life expectancy. It was found that single parents that went through the experience of childhood cancer had significantly shorter telomeres when compared to those single parents that did not. As has been discussed previously in this investigation, the authors of this study recommended psychological evaluations of both the child and parent. The reason for this was that therapeutic treatments could be tailored to address their specific psychological needs based on their individual personality profile.