Acupuncture Biofeedback Counseling Exercise Family Friends Gaining knowledge Hobbies, volunteer work Laughter Massage therapy Meditation Mini-vacations, healthy denial, and escapism Music, song, and dance Nutrition

Pets Positive thinking and visualization Reading Relaxation training Sleep Snuggles and smooches Spirituality, religious beliefs Support groups Water Writing Stress medications

What can we do?

If fear is not very useful in dealing with cancer, and anxiety and depression pose risks for long-term health problems, what reactions and responses deal effectively with cancer-related stress? And if stress is not linked conclusively to the inception or growth of tumors, and may in fact shrink tumors in some cases, why attempt to reduce the stress that is associated with the cancer experience?

First, most people prefer feeling good to feeling bad. Stress reduction techniques can help you feel better.

Second, increased levels of stress clearly are tied to the worsening of certain illnesses such as upper respiratory infections. If you've decided on a course of chemotherapy or radiation therapy, your immune system may be compromised for a few days or a week during each cycle. It's best to avoid infections, and to minimize those that may arise, during these troughs. Stress reduction techniques may help you keep secondary health problems at a minimum while undergoing anticancer therapy.

Third, high levels of stress for long periods of time can contribute to the development of high blood pressure, gastric ulcers, migraine headaches, certain autoimmune diseases, and other stress-related illnesses.

Fourth, stress may upset the balance you're trying to maintain between constipation and diarrhea.

Behavioral and medical ways to interrupt the worry cycle are discussed next.

Stress reduction techniques

An article of this length cannot do justice to the history of theories of stress and stress reduction, and the ways of life that arose to accomplish this. Nonetheless, stress reduction has always been of interest to humans albeit under different names, and has received close scrutiny in the twentieth century after the chemical link between stress and hormones was delineated. Thus, various ways to reduce stress have been discovered or rediscovered.

Listed below in alphabetic order are techniques that many have found useful for reducing stress. Not all of these will work for any one person; in fact, it's possible that none of these will work for you during particularly stressful times such as during periodic checkups, or if you have a symptom that causes fear of relapse. It is hoped, though, that the following ideas will help you discover your own ways to unwind.

Acupuncture

Acupuncture is a versatile way to reduce stress and pain, and is particularly good at relieving certain kinds of pain.

The ancient Chinese mapped the flow of energy in our bodies through pathways called meridians. These pathways are thought by Western medicine to be neuroelectric, although there continues to be discussion about the exact nature of these meridians. Eastern medicine believes that the stalled or misdirected flow of energy through these meridians accounts for most of the imbalances that occur within our bodies, and that these imbalances cause illness, and can be detected in twelve pulses.

The central nervous system produces hormones for which receptors exist on the surfaces of white blood cells. Recent gains in knowledge regarding this interaction of the central nervous system and the immune system may explain more fully some of acupuncture's mode of action.

An experienced acupuncturist will spend at least an hour taking a comprehensive medical and emotional history; will use few needles, perhaps no more than six; may prefer Japanese to Chinese needles because they're thinner; and will be skilled at using the needles in a way that is not perceptible, or barely perceptible.

The needles come in packets for single use only. You'll be able to see your practitioner opening these packets, which is reassuring if you have well-justified doubts about the reuse of needles. All body surfaces on which needles are used are cleaned first with rubbing alcohol.

If you have asthma or hyper-reactive airway, tell the practitioner. Certain acupuncture treatments call for the burning of an herb called moxa that may irritate your breathing. When moxa is used, only a sensation of warmth is felt on the skin.

Shoes should come off last and go on first. The easiest and most regrettable way to find a tiny, thin, lost acupuncture needle on the floor is with your bare foot.

It's becoming increasingly common for health insurance companies to pay for part or most of acupuncture treatment, although they generally pay less for psychological diagnoses such as stress than they do for medical diagnoses such as migraine or endometriosis.

In some states, an acupuncture practice must be supervised by a medical doctor. Verify the licensing and credentials of your practitioner with your state health department.

Biofeedback

Biofeedback is a way to relearn how to relax, usually monitored by a psychiatrist or psychologist.

During initial biofeedback sessions, sticky sensors are attached to various muscle groups on the part of your body that seems tense or is in pain, and a graph of muscle tension is displayed on a screen that is similar to a home computer screen. Relaxation tapes or the guiding voice of a therapist are used to establish a calm atmosphere.

When you have relaxed these muscle groups, you can tell you've succeeded because the indicators on the screen have changed.

After a few sessions with the sensors and the screen, you no longer need them for echoing success, and you switch to doing relaxation exercises on your own. It is important to rehearse this stage of independence over and over with a therapist so that soon you can do the exercises independently in any setting.

As with acupuncture, it's becoming increasingly common for health insurance companies to pay for part or most of biofeedback treatment, although they generally pay less for psychological diagnoses such as stress headache than they do for medical diagnoses such as migraine.

Counseling

Counseling sessions with a mediator or therapist who is experienced in cancer survivorship issues have proven very helpful to many people. Three randomized studies, including Dr. David Spiegel's work with breast cancer survivors, have shown increased survival among melanoma, colorectal cancer, and breast cancer survivors who received counseling.

Counselors might be a psychiatrist, a psychologist with a PhD or a master's degree, or a licensed social worker. Some insurance companies pay a larger percentage of the cost for sessions with a psychiatrist or psychologist, but often social workers charge less to begin with.

Group counseling or support with other cancer survivors is a wonderful way to reduce stress. The group generates camaraderie, reduces feelings of isolation, offers practical as well as sympathetic support, and can become the source of many new friendships.

See Support groups for more information.

Exercise

Modest regular exercise is a wonderful, well-documented way to reduce stress as well as improve overall health. Exercise also generates endorphins, the body's natural opiates, which reduce pain and ease depression.

Be careful, though, not to be too strenuous, for very strenuous exercise, such as training for a marathon, can lower white blood cell counts for about 24 to 48 hours. Do only what feels good, stopping before the point of exhaustion. Check first with your oncologist before starting a new exercise regimen, especially if you have had radiation therapy in the chest area. This treatment, if given in high doses, entails a risk of cardiac damage. The same is true for very high doses of 5-FU.

Family

Of all social support factors that appear to contribute to the positive outcome of an illness, including cancer, the support of family or very close friends appears to be highest. This effect has been shown most clearly in studies of white males recovering from heart conditions. The beneficial effect is less clear when other illnesses, females, and members of non-white ethnic groups are studied.

I am blessed to have a wonderful supportive family with the most positive outlook. That is the advice my surgeon gave me, "Surround yourself with positive people, just walk away from the negative ones, they'll only drag you down."

Most people are both blessed and cursed with family. Cancer survivors report family members who range from saintly, indispensable soulmates to those seemingly hatched by Fate as an example of how not to behave. Nonetheless, at times, there's something uniquely comforting about being surrounded by those who resemble you, share your body language and your mother tongue, regardless of their inclination, or lack of inclination, to offer support. If nothing else, the less helpful ones can unintentionally provide wry entertainment.

Occasionally people have family members who need more support than the cancer survivor does, or who are tooth-grindingly insensitive to what they're going through. And once in a while, stories surface about family members who actually blame the cancer survivor, or family "rivals" such as a daughter-in-law, for the cancer.

Don't berate yourself if you find you frequently need a vacation from family members who put themselves first at all costs. Often these unhealthy imbalances in family dynamics were present all along, but remained subtle and bearable until the cancer experience highlighted them.

Friends

Few other stress reducers are as good as having sympathetic, listening friends.

When friends offer to help, don't be too noble to say yes. Keep in mind that often they don't know quite what to say when they learn of your cancer, especially at first, so they may prefer to act instead.

The journey isn't over yet, but I have so many delightful friends to help me along the way. I have to say I have never been happier in my life. I have learned not to sweat the small stuff, to embrace life and enjoy every minute of it.

If they're good listeners, let them know if you do, or do not, feel like talking about cancer today--and that tomorrow might be different. Undoubtedly there will be days when reducing stress means talking about cancer, and other days when one more word about cancer will make you want to run for cover. Try to sense or ask if they feel like listening, too.

Far too many cancer survivors report that friends, even very good friends, disappear when cancer appears. These friends are speechless, sad, frightened, or guilty that they're healthy--never mind that perhaps we're much more sad and frightened than they are.

Each of us has to decide on a way to handle this abandonment that meshes with our system of ethics. Many cancer survivors say that they just don't need additional sources of sadness and stress in their life, and they move on to find new friends, often in cancer support groups. Other cancer survivors try to keep their old friends by never talking about cancer. Bear in mind, though, that for those who are very fearful about cancer, just being around someone with cancer might be frightening.

If you have healthy friends who have remained a presence in spite of cancer--lawn-mowing, grocery-buying, baby-sitting friends, friends who have listened to you when you're scared, or friends who have just spent time with you if talking about cancer is not your style, you're very lucky. Show them that you're glad they're around. The harmony that results is a guaranteed stress-reducer.

Take solace, too, in the goodwill of those you may never meet. The daffodils that appear in hospitals during the American Cancer Society's Daffodil Days in March, for instance, are from someone who wants you to feel better.

Gaining knowledge

Not surprisingly, a book such as this supports the belief that gaining knowledge about your cancer, and thus gaining some control over your cancer experience, is an excellent coping mechanism. Learning about your illness and your options has been proven to reduce anxiety and stress, and may be the crucial factor in your illness and its outcome. Not only can obtaining a correct diagnosis and learning about new, more effective treatments result in sound choices, but animal studies have shown that those who perceive that they have a means to escape stressful situations maintain higher white blood cell counts than those who perceive otherwise. Bear in mind as well that, while our doctors often must master information about a broad variety of cancers, or are immersed deeply in their own research projects, we have the luxury of going narrow and deep, learning a great deal about our own illness.

If your doctor seems unreceptive about things you've learned, seek a second opinion or consider changing doctors. An excellent book on this topic, Working with Your Doctor, by Nancy Keene, is available.

Worthy of mention is the observation that some doctors react badly to the idea that their patients find information on the Internet, because the information available on the Net ranges from abysmal to superb. If you use the Internet to research your illness avoid using the word "Internet" when discussing your findings with your oncologist. Instead, use terminology that credits the sources on which your findings are based: Medline, the PDQ database of the National Cancer Institute, Cancerlit, certain reputable medical journals, and so on.

Hobbies, volunteer work

As a form of healthy denial and, in some cases, a form of exercise, hobbies are an excellent stress reducer. Immersed in an activity you enjoy, you're likely to forget cancer, breathe and laugh more easily, and feel capable. Hobbies are especially important for reducing the stress that may be linked to the lowered self-esteem of those who are temporarily or permanently unable to return to work.

Laughter

In his book Anatomy of an Illness as Perceived by the Patient, Norman Cousins says we should take humor seriously. Cousins was diagnosed in 1964 with ankylosing spondylitis, a degenerative disease of the connective tissue that causes disability and pain. He undertook to improve or cure his condition by focusing on positive, happy thinking, and he believes he succeeded.

Funny friends, books, and movies are good ways to forget about cancer for a while, and can invoke some of the healthy bodily changes that come about when we laugh and relax. Two studies have found that mirthful laughter reduces blood levels of the hormones associated with stress.

Sue Browne shares a way she and her sisters used humor and distraction to ease her husband's worry while he was hospitalized:

To help ease some of the stress of this nightmare and hopefully cheer Steve up a bit, my sisters and I put on a little performance for him. Since he is an avid fisherman, we each picked out a fishing hat and made up our own words to, "Row, Row, Row Your Boat," singing it in a round harmony. The poor guy had to hold his pillow tight to his stomach to laugh--we about busted his stitches wide open! We even made the surly old man in the bed next to him smile for a brief second.

The humor we have been able to share also has a lot to do with our faith. Friends ask us how we can be so calm and joke around about this, and we just tell them that humor has replaced the anger and fear that would be there in its place. We used to always tell our kids, "You can do this hard, or you can do this easy," meaning that you have choices in how you deal with life's situations. Keeping busy also helps especially when you are waiting for the next milestone.

Massage therapy

The back-rubs and neck-rubs given to you by loved ones will release endorphins that reduce pain and depression.

The lymphatic strokes practiced by massage therapists, on the other hand, are location-specific and utilize a lot of pressure. Always check with your doctor before having deep massage therapy, because massage may hasten the spread of colorectal cancer through lymphatic vessels.

Your doctor may determine that professional therapeutic massage of certain parts of the body, those that appear unaffected by colorectal cancer, is acceptable.

Massage therapy is licensed by some states, and recognized by a national organization, the American Massage Therapy Association (AMTA). In some states, massage therapy can be performed only under the supervision of a doctor, nurse, physical therapist, or chiropractor. Your local phone book will list the nearest chapter of the AMTA for verifying your practitioner's credentials, or you can contact the national office at (847) 864-0123 or www.amtamassage.org.

Meditation

Meditation is a way to interrupt negative, cyclic thinking by focusing on one soothing word or peaceful scene. Those who practice meditation regularly eventually are able to lower their blood pressure and levels of stress hormones. These reductions persist beyond the end of the meditation session, and sometimes well beyond.

Lowering of blood pressure is beneficial for those who have cardiac or vascular damage following radiation therapies.

One study has shown that those who meditate have higher levels of melatonin in their urine, and another study has shown that higher levels of melatonin are found naturally in those with certain cancers. The significance of higher levels of naturally produced melatonin, or melatonin supplements, on colorectal cancer survivors is not fully understood, but a few studies have shown that melatonin can increase the growth of myeloma cells in the test tube. (Myeloma is a cancer of the blood and bone marrow related to leukemia.)

Owing to this unquantified risk, the FDA requires a warning on melatonin dietary supplements made or distributed in the US about possible health risks for those with white blood cell disorders such as ulcerative colitis or Crohn's disease.

It is likely that naturally elevated levels of melatonin associated with meditation do not have an undesirable effect on tumor growth, and that only the higher doses associated with dietary supplements do. It is also possible that all relaxation efforts, not just meditation, increase urinary levels of melatonin, and that future studies will demonstrate this--or that blood levels, not urinary levels, are significant for an effect on cancer. Clearly, more research on melatonin's effects on the colorectal cancers is needed, but it's not likely that meditation will harm you.

Mini-vacations, healthy denial, and escapism

Denial is a healthy coping mechanism as long as is doesn't cause us to neglect the care we need for cancer. Some healthy ways to take a mini-vacation from cancer are:

• Drive to work along a prettier route.
• Schedule day trips away from daily stress.
• Buy your favorite author's latest hardcover edition instead of waiting for the paperback or library version.
• Grant yourself permission not to worry for one hour, one day, one week, and so on.
• Take a nap on your lunch hour.
• Buy a pair of wild golf pants, or lipstick that "isn't your color" and wear it anyway.
• Spend all day Saturday in your bathrobe reading old New Yorker cartoons.
• Write a limerick and mail it anonymously to a friend.
• Odd as it may sound, you might enjoy celebrating the parts of your body that still work. Most of them still do work, of course, and rejoicing in this and using our bodies may have healing effects as yet unknown to medicine.

One of the highlights of my day is to gaze out the patio window at my lovely flowers, hummingbirds, butterflies, and many birds and squirrels. God has created such a beautiful world for us, we often forget to stop and savor it.

Music, song, and dance

Dr. Albert Schweitzer once said that he couldn't imagine life without music or cats. Schweitzer was an extremely productive, altruistic, humorous man who lived and worked in a difficult setting well into old age. He was a strong believer in the doctor within each of us, and thought of himself as only the facilitator of his patients' own healing processes.

Music can lower stress and enhance emotions. You can experiment with music to see which type suits your needs at different times. Some people find the relaxing or soul-thrilling effects of classical music best; others find that loud pop or rock music numbs pain, and that its relatively simple, repetitive rhythms and singable melodies interrupt incessant worries. Still others enjoy rediscovering the ethnic music they may have abandoned in the past. Listening to a type of music we've never heard before, such as the Australian didjeridu or Tibetan chord-singing, might distract us from the worries of cancer.

Singing can release cares from your soul, and may realign anxious breathing. Singing out loud in the car when you're alone, like screaming, can lower tension levels.

Classes in dance for people of all ages and both genders are available in many community centers. If you feel that you need greater control in your life, ballet's discipline, controlled breathing, and classic beauty may make you feel better. If, on the other hand, you feel there's too much control in your life, jazz dance or aerobics may allow you to set free some inhibitions. Flamenco might help you rediscover the sexuality that may have gone to sleep when you heard the word "cancer." Yoga, t'ai chi (an Asian discipline), and Feldenkrais movement, all of which span the disciplines of exercise and dance, are fine ways to stretch and relax.

Nutrition

In general, the diet that is recommended for those without cancer--a diet high in vegetables, fruit and grains--remains the best diet for those with cancer, although those who are losing weight, suffering from loss of appetite, or recently recovering from colon surgery should consult their oncologists before substituting vegetables for meat.

A few nutritional factors seem to have some effect on mood:

• A diet high in animal protein has been linked to anxiety and panic attacks. Other studies have found that certain flavonoids, compounds found in plant but not animal tissue, are similar to Valium in their relaxing action. This might mean that it's not reducing meat intake, but increasing vegetable intake, that lowers anxious episodes in some people. If you're suffering from severe anxiety symptoms related to your cancer diagnosis, you might try modifying your diet to contain more vegetables and grains--but check first with your oncologist.
• Drinking milk at bedtime, or eating turkey for dinner are known to help with relaxation. These foods are high in tryptophan, an amino acid that aids sleep. Tryptophan is used by the body to make serotonin, a neurotransmitter that affects mood and is the target of many of the newer antidepressants.
• Low blood levels of zinc have been correlated to treatment-resistant depression, and to an increase in the undesirable immune system inflammatory response sometimes seen in depressive patients.
• Cachexia, the weight loss experienced by some cancer patients, has been linked to depression, which is thought to be triggered by nutritional deficits, or by the tumor's commandeering of dietary substances otherwise needed for the manufacture of brain neurotransmitters.

Always verify a change in diet first with your oncologist.

Pets

You may find that your pets, considered family members by some, are a unique solace to you through the cancer experience. Animals seem to have a knack for knowing when we need help, and they don't care if we smell funny or if our hair is missing. They don't become instantly bashful because of our diagnosis, and they aren't afraid they'll catch cancer from us. How many humans will sit by us for an hour in the bathroom while we're sick, as our dogs will? And who's funnier than the cat who thinks the bathtub filling with water must be a sign from the gods? Or the puppy who barks at the wig on the dresser?

Positive thinking and visualization

Positive thinking and visualization have been shown to increase immune system function in some studies. Oddly, one study has shown that when cancer survivors visualize an immune system attack on the tumor, using attack images that are incorrect according to what is known today about immune system function, immune system parameters still improve. This may reflect the "taking charge" phenomenon: the belief that you can escape stress tends to lessen the effect of stress on the immune system.

Visualization can be used as described above, to attempt to direct inner forces against the cancer, or to relax by calling to mind pleasant experiences, places or dreams. Initially it might be useful to practice visualization in a quiet, relaxed atmosphere, but eventually you can do it anywhere.

Reading

As a form of escapism, reading is a good way to reduce stress.

As a means of learning more about your illness, reading may make you feel more stressed temporarily, but this may be offset by long stretches of peace of mind after you're able to make better medical decisions based on what you've learned by reading.

If you have a personal computer, reading from and writing to the various cancer discussion groups on the Internet can provide a cathartic outlet for you.

See Support groups.

Relaxation training

This technique is similar to Biofeedback, described earlier, and incorporates visualization techniques, described previously under Positive thinking and visualization.

Sleep

Research shows that even one night of missed sleep lowers levels of natural killer (NK) white blood cells that attack tumors. Although NK counts recover quickly once sleep is restored, persistent lack of sleep is an opportunity for illness.

Animal research on the artificial shifting of the phases of light and darkness shows that the immune system is depressed by the shifting. Fish that occupy parts of the ocean that receive low light in winter experience an additional breeding cycle if artificial light is increased, and simultaneously their white blood cell counts decrease.

Snuggles and smooches

Being kissed, hugged, and patted by people who love you causes endorphins to be released within the central nervous system. Endorphins are natural opiates produced by our bodies, capable of reducing pain and depression, and producing feelings of well-being.

Hugging, kissing, snuggling, and giggling with a child who has cancer has been shown in several nursing studies to lower the child's pain and anxiety levels.

Hugging and kissing your partner can be enjoyable and healthy, even if you're feeling too tired at the moment to enjoy all of the sexual activities you enjoyed before diagnosis.

Spirituality, religious beliefs

Your religious beliefs may provide comfort when little else is making sense. Some people find that their spiritual beliefs sustain them in spite of a seemingly arbitrary infliction of suffering, either because their religion provides answers for the question of human suffering, or owing to theological beliefs they have developed independently.

I am 48 years old--too young to have this disease. I know I cannot control the cancer. I can just fight it, but that's me. There are times when I need my faith to carry me through. We are all different, and we find what we need--and maybe that's a doctor telling us everything will be all right ( just like our moms used to when we were little).

Other cancer survivors, however, experience a crisis of faith after their cancer diagnosis. They find it difficult, for instance, to reconcile the emergence of a seemingly undeserved, life-threatening illness with their belief in a kind, nonpunitive deity.

On a more human level, the support that fellow church or temple members furnish to those who need help is clearly an asset in stress reduction. Support might take the form of emotional support (cards, calls, hugs, visits), prayer, practical support (drives to and from the doctor, or casseroles for supper), or financial support for someone who is underinsured.

The May 1995 issue of the Journal of the American Medical Association contains an article showing a correlation between religious practice and prayer and increased good health. At least one other study has shown that a person who is prayed for improves when ill, even if he or she is not aware that prayers are being said.

Sue Browne describes her reliance on faith to keep her and her husband on an even keel:

Without our faith, I don't believe that we would be at peace with all that this disease has thrown at us. You go through lessons in humility you never would have had to go through, or at least not until you were very old and senile. As a relatively young man, Steve has been poked, prodded, and shaved by good-looking, young-sweetie nurses, had his wastes monitored, and his hair fall out. We pray all these are "costs" for his survival.

Support groups

For some of us, support groups can be the difference, literally, between life and death. The opportunity to exchange information with those who have already weathered colorectal cancer can provide you with everything from emotional support to knowing when to question your treatment and seek medical help elsewhere. Support groups are an immeasurably useful way to do this, bringing together a variety of skills, sometimes including medical and legal knowledge.

Moreover, Dr. David Spiegel's work with breast cancer survivors shows longer survival among those who are part of support groups, a serendipitous finding from a study intending to highlight other aspects of survival.

Support groups are offered locally in many areas by organizations such as the American Cancer Society, the Wellness Community, or local hospitals.

If you have Internet access, support groups are also available on the Internet.

Water

In the 1930s, marine biologist Sir Alister Hardy noted that humans have features in common with water mammals, features not found in any other primates, such as a subcutaneous layer of body fat, hair that grows in one direction to reduce water resistance, a protective dive reflex within the respiratory system, a nose that blocks water during a dive, residual webbed toes, and fully webbed toes in 7 percent of humans. He argues that we humans may have spent a period of our evolution in water.

Anthropologists may settle this point eventually, but for our immediate use, it means that, for some of us, water is a wonderful way to relax. A good swim or a warm tub with salts and a good book can make you briefly more than just human.

Discuss swimming or bathing first with your oncologist if you have an ostomy. Some water activities might entail a risk of introducing bacteria at the stoma.

Writing

If you have an urge to write, you'll be encouraged to know that those who write very honestly and emotionally about their frightening, negative experiences increase the function of their white blood cells. Writing can be in a range of formats. You can write for yourself in a journal, write letters to friends, write letters for your children to be read when they're older, or write email to cancer discussion groups on the Internet.

Stress medications

Stress associated with cancer responds well to anti-anxiety and antidepressant medication. Research has shown, though, that these medications are most effective when used in combination with counseling and behavior modification training.

There are many drugs to choose from to ease anxiety or depression, or to aid sleep. The newer drugs available today have fewer side effects, and are less likely to be addictive than drugs used just a few years ago.

All medications prescribed by any physician, including a psychiatrist, should be reviewed first by your oncologist for their effect on your digestive system.

Anti-anxiety medication

Anti-anxiety drugs (anxiolytics) fall broadly into two groups, the fast-acting drugs and the slower-acting drugs. The fast-acting benzodiazepine drugs such as Valium, Ativan, or Xanax are potentially addictive, and can cause rebound anxiety when they're stopped. The newer anti-anxiety drugs such as Buspar (buspirone) cross the boundary between anti-anxiety and antidepressive drugs, are not addictive, and can be stopped abruptly with no ill effect. They take two to three weeks to work.

The mood change following use of the older anti-anxiety drugs in the Valium family is pronounced and rapid, similar to the effect of alcohol. It's unwise to drive or operate heavy machinery when using drugs in the benzodiazepine family.

The mood change following use of newer anti-anxiety drugs such as Buspar is more subtle and gradual, and sleepiness, if present, is less pronounced than with the benzodiazepines.

The anti-anxiety drug Ativan, a benzodiazepine, is often used just prior to chemotherapy to control nausea.

Antidepressant medication

The availability of today's more effective, safer antidepressants is a blessing for those coping with cancer. Unlike the antidepressants of a few years ago, which caused sleepiness, weight gain or other undesirable side effects, today's antidepressant medications are far safer and less disruptive of weight and sleep patterns.

Some of the newer antidepressants can cause restlessness and insomnia for the first two or three weeks they are used. You might discuss with your doctor the temporary use of a sleeping pill until your body has adjusted to the antidepressant.

Antidepressants are also good pain relievers, although their mechanism as such is not entirely clear.

Improvement in mood is gradual with most of the antidepressants used today, changing slowly over a few weeks or months. The fullest effect is gained if the drugs are used continuously for months. Always check with your doctor before stopping an antidepressant lest gains in improved mood be lost.

The best source for antidepressant medication is a psychiatrist. This specialist is the one most likely to be familiar with all antidepressants and their side effects, and can rotate you through several until the best one for you is apparent.

Sleep medications

Sleep medications range from the very mildest, including over-the-counter antihistamines and Tylenol, to the stronger medications necessary for those using prednisone, or those coping with moderate to severe anxiety.

The anti-anxiety drugs in the benzodiazepine family, such as Ativan, are also used as sleep aids. See "Anti-anxiety medication," earlier in this article, for cautions about these drugs.

One of the newest sleeping pills available is Ambien, a drug that aids those who have trouble falling asleep. It's cleared very rapidly from the body, so it's less useful for those having trouble staying asleep. When Ambien first was approved by the FDA, it was marketed as a nonaddictive sleeping pill, but post-market experience has shown that, for at least some people, it may be addictive.

Drugs prescribed for severe pain, such as codeine and morphine, also induce sleep.

Some people use melatonin, a substance marketed as a food supplement, to aid sleep. Melatonin has been shown to increase the quantity of white blood cells. This is a risky phenomenon for a person with a gastrointestinal cancer linked to an autoimmune disorder such as ulcerative colitis, because the white blood cells increased by melatonin or another immune-system enhancer could stimulate undesirable gastrointestinal activity. Accordingly, the FDA requires a warning on melatonin dietary supplements made or distributed in the US about possible health risks for those with white blood cell disorders. Always consult your oncologist before using any drug, whether prescription, nonprescription, or a "natural remedy" marketed as a food supplement.