Breast cancer and the couple relationship

Breast cancer, as with many life crises, often draws couples closer together. However, the illness is not without its challenges. The likelihood that breast cancer will be a bonding experience for couples is increased by four things:

1. Having insight into attitudes and ways of being that are more and less helpful to your partner
2. Becoming aware of common traps that intimate partners can get caught in during breast cancer
3. The ability for both partners to communicate openly and effectively about their experiences in relation to the illness
4. Working together as a team in relation to the illness

What follows is a summary of how breast cancer commonly affects couples. In conveying this information we understand that not all of the points will apply to all relationship partners at all times. However, as you reflect on the points, you may catch glimpses of yourself or your relationship in them, and we hope that this awareness may enhance your understanding of how to best support one another through this stressful period.

In this resource, we refer to people diagnosed with breast cancer as women. We also acknowledge that people who are diagnosed with breast cancer include men, transgender people and people who are non-binary.

Supporting each other effectively

Rarely is anyone prepared for a diagnosis of breast cancer, particularly when it happens at a relatively young age. It catches couples blind and is a shock to the relationship system. During the diagnosis, treatment, and recovery phases of the illness, many of your usual relationship roles, routines, and responsibilities get shaken up and redistributed. Furthermore, the illness itself creates new roles, routines, and responsibilities that both partners have to rise to. The woman with breast cancer must summon the strength to undergo invasive treatments and cope with their side effects; the well spouse will often have to pick up the slack around the house and with the family. Added to these stressors may be additional financial strain due to some loss of income while the woman goes through treatment.

When you really stop and think about it, the burden that breast cancer places on both partners by virtue of how intertwined your lives are - is astounding. Then consider that intermingled with the practical challenges of the illness are the emotional and existential ones. Your relationship is changing and mobilizing in order to accommodate the impact of the illness on your shared life. For all of these reasons, coping with breast cancer as a couple is like having to rebuild the ship while navigating a turbulent sea. The metaphor could be extended further to include an unfamiliar sea, at night, with rocks and shoals to be mindful of. It is understandable that at certain times during the illness, partners may find themselves in the dark, misunderstanding one another, or not knowing how to help the other person. Even partners that are very satisfied in their relationships and strongly committed to one another may have a tenuous moment or two when faced with the extraordinary stress of breast cancer.

Giving and receiving support during the illness is more complicated than most people realize. First of all, although women in general are often very familiar and comfortable with being caregivers, they are often equally as uncomfortable with being care-receivers. They struggle with the loss of independence imposed on them by the illness and are sometimes hesitant to ask directly for assistance from their partners. The need for assistance may be more concrete, such as receiving help dressing a surgical wound, or more emotional, like simply wanting an empathetic ear. Sometimes a woman rebels against this feeling of lost independence by putting on a strong front and resisting her partner's attempts to help her. Sometimes she may become overly critical and nit-picky when her partner tries to help but fails to live up to her expectations or standards. Without sufficient guidance, a spouse caregiver may feel at a loss for how to be supportive, or worse, he may feel helpless or woefully inadequate. If his support attempts are consistently spurned, the well spouse may feel shut out all together from the women's illness experience. In this situation, a loss of closeness between partners is inevitable.

On the other side of the fence, male caregivers are often very capable of providing practical help for example, by attending medical appointments with his ill partner, or with assuming more household chores. When men fall short, according to women with breast cancer, it is usually in the area of being emotionally supportive or available. This drawback is more due to habit than to any absence of empathy. Men tend to fall into a common trap of responding to their partners' emotional needs by offering advice or solutions as though feelings associated with breast cancer were a practical problem to be solved. For example, a commonly voiced anxiety for women is the fear that the cancer could come back, and an equally as common response for male partners is to minimize or dismiss such concerns outright. However, women often just want their feelings to be heard, acknowledged, or validated rather than changed. Paradoxically, when a woman has an opportunity to process her emotions fully in the relationship, and she feels understood by her partner, only then do troubling thoughts and feelings evolve into a more constructive or hopeful direction. Following such supportive conversations, women are better able to determine for themselves, what if any action needs to be taken, and such active coping when self-determined - can enhance her feelings of personal control and empowerment.

Open and effective communication

Unknowingly, sometimes both relationship partners collude in ensuring that difficult feelings are not directly expressed. We refer to this as under-burdening. On a conscious level, couples are typically concerned with the possibility of overburdening the other person. Male caregivers are acutely aware of their partner's vulnerability and do not want to unduly add to her burden with their own concerns; women going through treatment are often determined to "hold it all together" for their partners and families, and therefore keep their struggles to themselves. For as well intentioned as under-burdening often is, it ironically puts partners at risk of drifting apart because couples refrain from communicating about significant issues. As a consequence, each is denied the opportunity to really understand what the other is going through.

Complicating the issue is that for many men, under normal circumstances, their primary confidant is mainly their spouse and, unlike women, they often do not have many other people in their lives that they can turn to for emotional support. And even if they did, there are often strong messages that doing so is a sign of weakness and so they may not take the initiative to seek help from friends, siblings, parents, or mental health professionals. So what happens to men's worries and apprehensions? Sadness and grief? Do these feelings get expressed and dealt with? According to one man who supported his wife through breast cancer, these emotions get "stuffed." This tendency to not reveal feelings of vulnerability or perceived weakness outside of the relationship, rooted in how men are socialized, adds an extra layer to the dynamic of under-burdening.

If under-burdening creates an emotional pressure-cooker in the relationship; open communication is the release valve. Couples often avoid discussion of 'hard' topics such as the possibility of dying from cancer. Understandably, couples don't want to venture there the thought is simply too inconceivable and overwhelming. The problem is that both partners often share similar concerns but in maintaining a 'code of silence' they are never able to address the issues constructively. We have found that when couples do share disturbing thoughts and feelings, rather than feel worse because of the disclosure, they are often relieved to get the concern out in the open and discover the other person can relate.

However, there is one important qualifier in relation to open communication: Couples who communicate most effectively about sensitive issues are discerning about when and how they approach the other person for such a conversation. They do not adopt a 'tell everything all the time' approach. They choose their moments well. For example, the woman should not approach her partner when he's obviously preoccupied by a stressful episode at work. Where effective communication is concerned, timing is crucial. So is your intricate understanding of your partner and your knowledge about when he or she is in a more and less receptive frame of mind.

More generally couples might fall into a trap of communicating too little or too much about the illness. One way of mitigating this risk is to agree to a time of day, and day of the week when both of you give yourselves the space to discuss all concerns related to cancer. At the same time, you can also agree to times when cancer conversations are 'off-limits' for example, not just before you go to bed, or not over the weekends these times are reserved for more 'normal' or light-hearted, enjoyable activities. By carving out a space for cancer-related conversations you accomplish the outcome of having an outlet for these issues, while not permitting them to overtake your life.

Common challenges and pitfalls of breast cancer

There are some issues specific to breast cancer that many couples struggle with. Although commonly experienced, these challenges and pitfalls are easy to get caught in if you are unprepared. The purpose of this section is to alert you to these so you can either look-out for and avoid them, or be ready to work them through.

One major challenge, especially for younger couples, is coping with the sexual disruption that frequently occurs during and after treatment. Depending on the treatment received, a woman may go through periods of feeling a loss of libido, soreness and tenderness, or pain with intercourse. She may feel more inhibited or self-conscious about her body because of weight gain, or due to the loss of one or both breasts. She may feel disfigured and less attractive. An imbalance is created when there are all these changes are occurring for the woman, while the man's sex drive remains generally intact. Compounding the issue is that this imbalance may be present for several months. From a relationship perspective, it is important to remember that for most couples sex is a bonding as well as a pleasurable activity. Physical, sexual, and emotional closeness go hand-in-hand. Therefore, although your usual sexual scripts and routines may be put on hold for a period of time, it is nevertheless important for couples to strategize creatively around other ways to express physical affection and intimacy. (For more information, please refer to section on Sexuality and Breast Cancer).

Another common source of strain on the relationship occurs just as the woman is completing the active phase of her treatment. By this point in time, often several months have passed and both partners feel worn down by the imposition of the illness, and the emotional, physical, and practical toll it has taken on their life. Everyone, including friends and extended family, just want things to be 'back to normal.' It often comes as a surprise to couples to learn that the illness does not end with the completion of active treatment. To begin with, women often feel a renewed sense of fear and uncertainty at this time precisely because they are no longer aggressively treating the disease and are afraid that the cancer could come back. Moreover, couples have to plan for a period of recovery and rehabilitation following treatment (loosely gauged as a month of recovery for every month that the woman has been in treatment). Initially after treatment women will experience excessive fatigue, loss of energy, and/or a loss of mental alertness. These symptoms gradually improve over time, but it is important for both partners to recognize the need for time, and to not expect an immediate resumption of previous roles and responsibilities.

Not only is post-treatment crucial to physical recovery, but this is also the point at which the woman starts to realize that the illness has had an enduring impact on her life; that there really is 'no turning back' completely. Once the responsibility of treatment is behind her, the woman has time to stand back and make meaning of everything she has been through, to integrate cancer into her sense of self and personal history. For example, she may experience a change in her priorities and become more involved in personally rewarding endeavours such as volunteering. Or she may choose to pursue a lower paying job to reduce the stress in her life. Although the post-treatment period can be psychologically rich and meaningful, couples can run into trouble if the partner has difficulty accepting, supporting, or feels threatened by the fundamental changes occurring for his spouse. By the same token, it is important for the woman to be frank with her spouse about these shifting priorities and changes, and willing to discuss the broader implications of any new directions she wants to pursue.

Facing breast cancer as a team

Couples who cope best with breast cancer are able to tackle the illness as a team with a shared sense of purpose and responsibility. Perhaps the most damaging thing that a spouse can do to a woman with cancer is to view the disease as only belonging to her. At the same time, the most damaging thing that a woman can do to herself is to see the disease as her doing, as something she has brought upon herself and her partner. Some male partners go through periods of feeling angry at their spouse for having cancer. Some women on the other hand, feel intense guilt over the perception that they somehow allowed cancer to happen.

As irrational as such thoughts and feelings are, they are in fact extremely common. The problem with these reactions is that on some level they imply that that the illness is solely the responsibility of the woman. However when you are in a long-term, committed relationship, the illness is a shared experience. Although you may have separate roles and functions in relation to the illness, the responsibility for the illness is shared between both partners. Breast cancer is a 'we disease.' Couples who are able to put their relationship on one side of the fence and face the illness as a united front, fare the best. In being mindful of the points presented in this section of trying your best to support each other, of being alert to common relationship challenges and pitfalls, and of being open and honest with each other you will both be better able to work together as a team in facing breast cancer.