This is Breast Cancer Education Week, when the breast cancer support group Just Between Us and the Ministry of Health, Social Services and Housing are mounting a public information campaign and sponsoring several events to highlight the disease and stress the importance of early detection.

In this article, two health care professionals discuss the psychological aspects of having breast cancer, from diagnosis through treatment to recovery, and the effects this trauma can have on the patient and those around her.

Fear.

That is the initial reaction women have to the discovery of a lump, no matter how small, in their breast.

Left unaddressed, fear can have wide-reaching -- and even fatal -- results.

Which is why four health care professionals made the psychological impact of breast cancer the subject of a workshop project during a course they took at the Bermuda College.

"We felt the psychological aspect of breast cancer wasn't being addressed,'' Mrs. Kereen Richards, unit co-ordinator of the King Edward VII Memorial Hospital's Emergency Department, and one of the workshop members, explained.

"The topic arose out of the emotional pain some of our group were experiencing following the death of friends from breast cancer. Because their friends had refused to discuss their illness with them, our members felt they had been shut out of their lives and left them unable to assist.'' During the workshop discussions, the feelings of patients, their relatives, friends and co-workers, and the impact on health care professionals dealing with breast cancer patients, arose.

"We decided it was important to highlight that aspect, as well as other issues which people need to deal with -- the anguish and fear of finding out you have a lump in your breast; not knowing whether it is cancerous or benign; waiting for test results; and thinking you are going to die,'' Mrs. Richards explained.

Reaction to discovery of a breast lump is as varied as the women who experience it.

While some go to their doctor immediately, many more do not. Some become withdrawn as they internalise their "secret.'' Others decide to ignore it, hoping it will go away. Still others put off going to the doctor for as long as possible because they can't face a cancer verdict and all that that entails. Young women -- generally defined as those of child-bearing age -- often go into denial, telling themselves breast cancer is a disease of older women.

Again, fear overrides the facts, for the reality is the majority of breast lumps are not cancerous, but only a physician can make the correct diagnosis.

Since there is no way to prevent breast cancer, early detection is not only vital but can save a life. It may also mean less treatment is required and a better prognosis for survival.

Because time is of the essence, seeking prompt medical attention is doubly important when one takes into consideration the time it takes to complete the necessary diagnostic tests, obtain the results, and determine the course of treatment.

"It is never a case of find the lump, go to the doctor, get the diagnosis all in one day,'' Mrs. Richards warned. "From the time you find the lump to getting it sorted out can be three weeks, with another ten days on top of that before you get the results. This will impact on the time the patient has for surgical intervention. While these cases are treated with some urgency, some delay is inevitable.'' Because the waiting period for test results is an anxious one for the patient, those around need to be sensitive to her feelings.

"One aspect of waiting for test results is that the person becomes irritable and difficult to live with,'' Mrs. Diana Simons, a fellow workshop participant and assistant unit co-ordinator of Recovery at King Edward, said.

"She is anxious all the time and doesn't function that well because the problem is always in the back of her mind. Even though she doesn't say anything, those around her will notice the change in her behaviour, and because they don't understand it, can also become angry with her.'' Women arriving for outpatient diagnostic tests are commonly anxious and apprehensive -- again because of a fear of the unknown.

"It is visible in their approach,'' Mrs. Richards said. "The nurses in the Outpatient Department are sensitive to this and spend time trying to allay their fears. They talk with the patient, try to answer their questions, and generally be there for them, even if it is just holding their hand. All you can do is be a positive influence on their thinking.'' When going to the doctor to get the test results, Mrs. Richards and Mrs.

Simons recommended that the patient take her partner, a close relative or friend along for support.

Should the diagnosis be cancer, the patient would need moral support there and then because such news was often received with shock. Because of this, the patient was also apt not to listen to everything her physician was telling her, whereas the second person was likely to retain more.

How the woman handled such information in the immediate aftermath of being told varied. Some women wanted to go straight home, others felt like going out for a cup of coffee, a long walk, or a quiet sit by the sea.

Whatever the decision, whoever was with her should be there for her.

When discussing treatment options, Mrs. Richards said the patient should seek full details from her doctor, and have all of her questions answered.

"She should ask the doctor anything that is important to her. Put the questions down on paper, no matter how simple or irrelevant she may think they are, because that is how she will learn what is going to happen to her, and what to expect,'' she said.

Treatment options should also be discussed with her partner, and perhaps close family members and friends.

Because the event of cancer impacts directly on the whole family, and not just the patient, it is also important for their questions and anxieties to be addressed by the doctor and possibly a support group.

"It is not just the physical well-being of the patient, but also the family's economic well-being,'' Mrs. Richards said. "Issues like child care, especially for the single parent, have to be considered.'' While in the hospital, the patient should ask medical staff for answers to all their questions. In their turn, staff need to be sensitive to the psychological impact removal of a breast has on a woman -- if that is the course of treatment followed -- and also explain the post-operative effects and limitations she will experience.

Because western society places such emphasis on perfect breasts, some patients suffer emotional trauma at the loss of one or both. They may feel ugly, mutilated, or less than a woman. They also worry that their partner will reject or leave them.

Reassurance from partners, family, friends, and support groups is therefore important.

Where radiotherapy is required, this is another potential source of stress because treatment must be carried out abroad.

"Radiotherapy means heading into the unknown, leaving family and friends behind, and not knowing what to expect. Medically, it means nausea following treatment and skin changes. All in all, it is quite an emotional overload,'' Mrs. Richards said.

Again, medical staff, family and friends, need to be very supportive and sensitive to the patient's anxieties and needs.

But the bottom line is the patient herself. While a diagnosis of cancer is not -- as most people believe -- an automatic death sentence, no-one is considered "cured'' until five years has passed without a recurrence of the disease following the initial treatment.

"The patient must take responsibility for her life,'' Mrs. Simons said. "She must have a plan and think about her family and her will because she doesn't know for five years if she is going to be cured or not.

"Taking action means the patient is maintaining some control over her situation, and having some say in what is happening in her life. I think that probably does more for encouraging positive attitudes and positive thinking than anything else.'' Both Mrs. Richards and Mrs. Simons said evidence shows that patients who take control of their lives generally do better than those who don't.

However, the onus for recovery is not all up to the patient. Society also has an important role to play.

"As a society we very much need to remind the patient that we are around, and they are part of our lives. It helps them to have a positive attitude, knowing that they are important to others,'' Mrs. Richards said.

Keeping Abreast of your Feelings, a special presentation by Mrs. Richards, Mrs. Simons, Mrs. Sonia Stowe (assistant director at St. Brendan's) and Ms Patrice Dill (Co-ordinator of Community Health Services at KEMH), will take place this evening at St. Paul's Christian Education Centre in Paget. See the Bermuda Calendar for further details.