Supporting Pregnant Women With Cancer

GROUP SUPPORT FOR TWO

Group Support for Two:

Support Groups for Pregnant Women With Cancer

Jessie Simmons

Generalist Social Work Practice with Groups SW3052-002

Professor Kinney

University of Cincinnati

April 22, 2016

1


Introduction:

“For some women, the happiest time in their lives [is] complicated by the scariest

time in their lives as some pregnant women are diagnosed with cancer” (Cardonick,

2014, p.1). The supported population in this essay is pregnant women of various races,

ethnicities and economic backgrounds who have been diagnosed with cancer, most often

with breast cancer. “Seven to fifteen percent of breast cancer cases occur in pregnant

women making it the most common [type of’] cancer diagnosed during pregnancy”

(Cardonick, 2014, p. 1).

An optimal support group for pregnant women with cancer would be a revolving

membership support group.

Revolving membership groups generally are more structured and require more active leadership than fixed membership groups. Participation and learning are not highly dependent on attendance at previous sessions. In some settings, new members may be brought in at fixed intervals. In a daily group, for instance, new members might enter once a week. Members who have been in the group for a substantial number of meetings often help to orient newer members. (Substance Abuse Treatment: Group Therapy, 2010, p.1).

In an ongoing revolving membership support group, members are allowed to stay as long

as they desire and are only required to go to group sessions where specific topics relevant

to their needs are covered. A typical location for an ongoing revolving membership group

for this population, would be the outpatient section of hospitals, where patients go for

continuing care (Substance Abuse Treatment: Group Therapy, 2010 p. 1).

Pregnant women with cancer face complicated choices that require them to

balance their own need for treatment with the potential effects of treatment on their

unborn child. These women are dealing with the biological changes brought on by each

2


stage of pregnancy at the same time they are trying to understand and arrest the spread of

cancer within their bodies. One positive impact of a support group for pregnant women

with cancer would be the comfort of having women around who are coping with the same

medical challenges and fears. One issue that clients in this support group will face is the

fact that their cancer is progressing more quickly than that of non-pregnant women with

cancer (American Cancer Society, 2014, p. 1). A support group for pregnant women with

cancer can assist patients with the decision re: what type of treatment they should pursue.

Treatment type usually depends on the size and location of tumors, the size of the breasts

and the pregnancy trimester of the patient. Support groups for pregnant women usually

connect to the following outside resources: professional counselors for women who are

experiencing depression; doctors including oncologists, obstetricians and pediatricians;

breast care nurses for women who are breast feeding their baby after birth; and online

chatrooms for pregnant women who cannot make it to in person meetings (Cancer

Research UK, n.d. p.1). Support groups for pregnant women work with organizations

including the American Cancer Society, Hope for Two and the Cancer Research Center,

in order to find the resources they need.

Literature Review

Oncologist Elise Cardonick’s article, For Pregnant Women Who Find Out They

Have Cancer, in The Cancer Network Journal does not discuss much about how to form a

support group for pregnant women with cancer. Dr. Cardonick’s article is more of a plea

to health care professionals to spend more time working together for the sake of their two

3


patients, rather than acting territorial over who should treat the patient (Cardonick 2014,

p. 1). The article drives home the fact that:

…medical literature currently cannot answer all the relevant questions for the woman facing this cancer or other types during pregnancy. Few oncologists or obstetricians treat more than 2 or 3 patients in this situation in an entire career. The only way to gain the necessary knowledge about cancer found and treated during pregnancy is to gather together experience from various hospitals into one single database (Cardonick, 2014, p. 1).

One might assume that the substance abuse population and pregnant women with

cancer do not have much in common. However, the article Four Group Development

Phase Specific Tasks in Substance Abuse Treatment Methods proves that while the

circumstances of the populations being treated may be vastly different, the support group

process can be applicable to both groups. The article states that all support groups have

the same aims: to survive the turbulent beginning phase; focus on goal accomplishment

and treatment during the middle phase; and establish mental and emotional closure when

an individual leaves the group. The number of pregnant women facing breast cancer is a

slowly growing epidemic, and in order to establish more support groups for this

population, professionals must look to how support groups are run for other populations.

Pregnant women go through many hormonal changes and can experience a vast range of

emotions like those of an addict going through withdrawal. Both populations feel a sense

of isolation because of their circumstances and both populations feel a desire to be around

people who can relate to their circumstances. Pregnant women can look at their lower

survival statistics and give up in the same way that members in drug treatment groups can

be discouraged by the long road ahead and the external odds working against them

4


(Anonymous, 2010, p. 1). It can be inspiring to be part of a group where another

member has survived the same situation they are facing.

According to the Cancer Research UK article, Breast Cancer During Pregnancy,

breast cancer in pregnant women is uncommon right now, with only one in three

thousand women experiencing this situation (Cancer Research UK, n.d. p.1). However,

since women are having children later in life, they are now at increased risk of getting

cancer while pregnant. While the majority of pregnant women with cancer are able to

have their babies, some decide to terminate their pregnancy because simultaneously

fighting a life threatening disease while carrying a child is too a heavy burden to carry.

Pregnant women typically receive a later diagnosis, because OBGYNs and general

practitioners are more focused on caring for the pregnancy than diagnosing the woman

for other medical conditions. The article discusses the main treatment for breast cancer,

which is surgery and provides a great deal of insight on what the pregnant cancer patient

could be feeling.

The American Cancer Society’s article, Finding Breast Cancer During Pregnancy,

goes into more detail about how to definitively tell if a woman has breast cancer and

identifying the next steps. Breast biopsies are the best way to know for sure if a woman

has breast cancer. Biopsies are typically outpatient procedures where the area of the

breast is numbed and a needle biopsy is performed to determine if there are any

cancerous cells. If the needle biopsy does not reveal anything, a surgical biopsy must be

done where a small incision is made in the breast to remove and test a piece of tissue.

If breast cancer is found, other tests may be needed to find out if cancer cells have spread within the breast or to other parts of the body. This process is

5


called staging. Staging is very important for pregnant women with breast cancer because their cancers tend to be found at a more advanced stage (the tumor is likely to be bigger and to have spread beyond the breast). (American Cancer Society, 2014, p.2).

The American Cancer Society article goes into detail about what will happen during

surgery. A neonatal surgeon often works with the oncologist to determine which stage

during the pregnancy would be the best time to do the surgery and then monitors the

well-being of the fetus during the surgery. Chemotherapy is usually used as an adjuvant

treatment for pregnant women with cancer, after they get a lumpectomy or partial

mastectomy. The article does an excellent job at realistically telling individuals about the

prognosis for pregnant women surviving cancer. In general, pregnant women with breast

cancer are twice as likely to die from breast cancer as other women with breast cancer.

Group Process Selected and Reason for Selecting Process:

The processes described in this section relate to use of a revolving membership

support group model. This model was selected because it allows for flexible entry, exit

and attendance, depending on the member’s needs and health complications. It also

balances teaching structured content with providing an emotionally supportive

environment. Before establishing a group, planning and prescreening must be done.

Prescreening potential members before they enter a group can be helpful because

revolving membership groups usually have limited space of up to fifteen people

(Substance Abuse Treatment: Group Therapy, 2010, p. 1). Social workers may be able to

assist a facilitator with a non-social work background in deciding what personalities

would contribute to group cohesion. Next it is important to prepare potential members

6


for what is entailed in joining the group. Clients who have been prepared for treatment

are more likely to stay in the group.

Another potential challenge that should be addressed in the planning phase of this

support group is maximizing retention. The first month that a client attends a group is the

most crucial time, because it is during that period that the client is more likely to drop

out. Reasons for premature termination include stress from outside life; feeling

uncomfortable; inability to share with group facilitator; conflicts about intimacy and

disclosure; and inadequate preparation. Retention rates are affected positively by client

preparation, maximum client involvement during the early stages of treatment, the use of

feedback, prompts to encourage attendance, and the provision of wraparound services

(such as child care and transportation) to make it easier for clients to attend regularly

(Substance Abuse Treatment: Group Therapy, 2010, p. 2).

Another hurdle in the planning phase is establishing a set of agreed upon rules for

the group. “A group agreement establishes the expectations that group members have of

each other, the leader, and the group itself” (Substance Abuse Treatment: Group Therapy,

2010, p. 3). One way to help encourage compliance is for facilitators to ask members to

recall the agreed upon rules at the beginning of every meeting. Some examples of

common group rules are: 1) that attendance is mandatory and if a member cannot make it

they must notify the facilitator twenty-four hours in advance; 2) that members make an

initial three-month commitment; 3) rules regarding touch and physical contact; and

4) confidentiality rules that often state that group members not present should not be

discussed (Substance Abuse Treatment: Group Therapy, 2010, p. 3).

7


When members are selected and ground rules are established, the beginning phase

of the group process can commence. During the beginning phase of a support group,

issues arise around topics such as orientation, beginners’ anxiety, and the role of the

leader. “The purpose of the group is articulated, working conditions of the group are

established, members are introduced [and] a positive tone is set for the group” (Substance

Abuse Treatment: Group Therapy, 2010, p. 4). Before cohesion can be established,

introductions must be made. It is important that facilitators and members acknowledge

that each member of the group is in their own phase. In long term revolving membership

groups, it can be hard for new members to find their place, particularly when people are

constantly coming and going (Substance Abuse Treatment: Group Therapy, 2010, p. 4).

One person’s role can be instantly taken over by another after they leave. These changes

can be difficult for veteran members. It is the facilitator’s job to build relationships

between old and new members. This can be particularly important because pregnant

women with breast cancer will be at different stages in their pregnancy, treatment and in

the group process. Some women will be at the beginning of their pregnancy and have just

been diagnosed with cancer; other women will be in the middle to later stages of their

pregnancy and just diagnosed. Since there are so many possibilities, it can create tension

within the group, however the facilitator could work with a social worker to help

participants talk out these budding tensions and create a more supportive environment.

It is inevitable that group members will establish their own social and mental

routines or norms. The facilitator should make sure that the roles and norms being

generated are healthy. When it comes to breaking down harmful routines, social workers

8


may have an advantage because members may look to them as professional role models

(Substance Abuse Treatment: Group Therapy, 2010, p. 5). It may prove more challenging

for a non-social worker to break down harmful social norms if they are a part of the target

population. They may feel an allegiance with the members, not want members to feel

betrayed and, as a result, may overlook harmful routines. An example of a harmful norm

would be the formation of cliques within the group. This can happen in revolving long

term membership groups because veteran members may seek to cling to each other.

Another surprisingly unhelpful norm occurs when the facilitator and members have such

a close bond that they are unwilling to criticize or advise other members (Substance

Abuse Treatment: Group Therapy, 2010, p. 5). Group cohesion is established by the

healthy push and pull of nurture and conflict. It is through nurture and conflict that group

work, discussion and goals can be accomplished. If participants survive the turbulent

beginning phase of becoming a part of a support group, it is likely that they will stick

with the group, because the hardest part is establishing cohesion and a sense of

connection and trust.

It is during the middle phase that a support group accomplishes most of the

therapy and work. “During this phase, the leader balances content, which is the

information and feelings overtly expressed in the group, and process, which is how

members interact in the group” (Substance Abuse Treatment: Group Therapy, 2010, p. 5).

One of the main mistakes new group facilitators make is focusing just on the content.

Many people attend support groups because they want a space to voice their feelings and

opinions, therefore facilitators need to find a way to balance process and expression. For

9


pregnant women with cancer, there will be a lot of anxiety, excitement and sadness and

many may be attending the group for the sole purpose of discussing their feelings and

meeting other women who feel the same way. It is important that support groups for

pregnant women with cancer make an extra effort to provide a nurturing environment for

these women.

The final phase of the group process is the end phase. “Termination is a

particularly important opportunity for members to honor the work they have done, to

grieve the loss of associations and friendships, and to look forward to a positive future”

(Substance Abuse Treatment: Group Therapy, 2010, p. 6). Termination occurs at

different points for different people. Sometimes members can resent the fact that another

group member has reached the point where they want to move on. The process of

leaving a group is a time for members to: discuss their feelings about leaving; share their

plans for moving forward; and reflect upon the impact their fellow members made on

them (Substance Abuse Treatment: Group Therapy, 2010, p. 6). According to Hope for

Two, a support group for pregnant women with breast cancer, members are allowed to

attend meetings and receive therapeutic services and doctors’ appointments for up to five

years during their remission (Hope for Two, 1997, p. 4).

Methods of Best Practice

A best practice that can be used in the prescreening phase is asking analytical

questions to help determine if a potential member will be an appropriate asset to the

group. Some suggested prescreening questions include: What do you think you can

contribute to this group? How do you think you would feel in a group in which your

10


opinion differs from other members? How would you cope with another member in the

group who believes in a higher power when you do not? (Substance Abuse Treatment:

Group Therapy, 2010, p. 1). Asking a set of prescreening questions and analyzing

responses can help a facilitator visualize how the candidate would fit in with the other

members. Facilitators should also conduct prescreening interviews, because they allow

the patient and facilitator to form a therapeutic alliance, to reach consensus on what is to

be accomplished, to educate the client about group therapy, to allay anxiety related to

joining a group and to “explain the group agreement” (Substance Abuse Treatment:

Group Therapy, 2010, p. 1).

To help individuals prepare to become members of the group, it is suggested that

facilitators utilize role induction strategies. One role induction technique, vicarious

training, utilizes lectures, films, and interviews to teach clients how to set achievable

goals for group therapy and about expected behaviors (Substance Abuse Treatment:

Group Therapy, 2010, p. 2). Vicarious training can be done through roleplaying among

the facilitators, so that members can witness what appropriate behaviors look like. A

second best practice technique is motivational interviewing. This listening technique uses

specific questions to help clients realize the benefits of making changing in their lives

(Substance Abuse Treatment: Group Therapy, 2010, p. 2). Other best practices that could

be utilized include follow up appointment reminder phone calls; appointment cards with

the date of the next of the meeting; and provision of wraparound services such as

transportation and childcare.

11


A best practice technique for creating cohesion among group members in the

beginning phase is creating a supportive environment. One way that the facilitator can

help develop a supportive environment is by utilizing group bonding activities. Ideally,

group-bonding activities will focus on similarities between the members. For example,

the round robin technique of group communication can give group members the chance

to express their feelings. Asking other members to react to what another member has just

shared can also help form connections among members (Substance Abuse Treatment:

Group Therapy, 2010, p. 6). If the facilitator does not have a social work background and

is not used to creating bonding activities, social workers can serve as consultants for

facilitators.

Ethical Concerns, Cultural Diversity and Influences

Social workers who are facilitators of support groups or are working with support

groups on a consultation basis are not supposed to become friends with their clients

(Substance Abuse Treatment: Group Therapy, 2010, p. 3). Social workers can maintain

positive, productive and supportive working relationships with clients without becoming

their friend or social media buddy. The job of the social worker is to be a positive,

professional mentor and guide. The role of a non-social work facilitator, who could be a

breast cancer survivor, may be different however, because they are not bound by a code

of ethics and they have been through experiences similar to those of other group

members.

One of the biggest ethical concerns in working with pregnant women with breast

cancer is supporting them whether they chose to terminate or go through with their

12


pregnancy. Some women decide that going through the stress of cancer treatment is all

that they can handle without having to worry about how it will affect their baby. For

women who do decide to keep their baby, it is imperative that the facilitator and group

members help guide the mother-to-be in her decision about what treatment route she

should chose. The social worker must make sure that the client does not receive radiation

therapy because it can cause birth defects or cancer in the baby (Cancer Research UK,

n.d. p.1.). Furthermore, the social worker should caution a pregnant woman with breast

cancer that chemotherapy, given during the first trimester, can cause a miscarriage

because the fetus is just beginning to develop (Cancer Research UK, n.d. p.1.). It is vital

that a specialist “examine the baby [because many] women worry about the effect of the

breast cancer on the baby. [In addition] A pathologist will examine the placenta because,

although very rare, it is possible for cancer cells to spread there” (Cancer Research UK,

n.d. p.1.).

Conclusion/Summary

Pregnant women with breast cancer are a small population. However, they are

slowly growing and our healthcare system is still learning how to support these women.

Support groups for pregnant women with breast cancer are few and far between, but it is

important to study other support groups as a template for how establish more competent

and comforting support groups for this population. Social workers cannot let their own

personal beliefs influence the way they advise these women during a very vulnerable and

confusing time of their lives. Furthermore, it is extremely important that support groups

for pregnant women with cancer create a supportive, welcoming and inclusive

13


environment, which is often challenging for long-term revolving membership groups. For

some group members, termination of membership in this support group means death and

that is a very difficult concept for facilitators and members to endure. Thankfully, there

are activities that facilitators can introduce to help break down emotional barriers. It can

be hard to let new members in emotionally, while grieving the loss of another member.

But maintaining a welcoming environment can shine a bright light on a very difficult and

turbulent chapter in lives of pregnant women diagnosed with cancer.

14


References

American Cancer Society. (2014). Finding Breast Cancer During Pregnancy. Cancer Network

Journal, 1-7. Retrieved April 15, 2016.

Breast Cancer During Pregnancy. (n.d.). Cancer Research UK, 113(1), 1st ser., 1-15.

Cardonic, E. (2014). For Pregnant Women Who Find Out They Have Breast Cancer. Cancer

Network Journal, 1-20. Retrieved April 14, 2016.

Four Group Development Phase Specific Tasks. (2010). Substance Abuse Treatment

Methods, 4(6), 6th ser., 1-22. Retrieved April 14, 2016.

Hope For Two. (1997, October 1). Retrieved April 14, 2016, from http://www.hopefortwo.org/

15

Documents

Supporting Pregnant Women With Cancer