Breast Cancer Awareness Month

Each October, I usually share a little blurb in my newsletter to remind readers about National Breast Cancer Awareness Month and the importance of screening and early detection. I was content to leave it at that until two recent events prompted the desire to share more information: the announcement from Beyoncé’s father, Mathew Knowles, that he had been diagnosed with breast cancer and the news that a dear family member is experiencing a recurrence of her breast cancer after being in remission for about 10 years.

Men and Breast Cancer

According to the CDC, about 2,200 cases of breast cancer in men are diagnosed in the US each year – compared to about 245,000 cases in women. So, although breast cancer occurs mainly in women, men can get it, too. Many people do not realize that men have breast tissue and that they can develop breast cancer.

Men have much less breast tissue compared to women and thus, are not routinely screened for breast cancer. Breast cancer screening is only recommended for some men at higher than average risk due to:

  • an inherited gene mutation (either they have the BRCA2 or BRCA1 gene mutation themselves or an immediate family member has the mutation), or
  • a strong family history of breast cancer, such as a mother and/or sister diagnosed at age 40 or younger

For these men, screening may increase the chances that breast cancer is found early, when the chances for survival are highest. The National Comprehensive Cancer Network (NCCN) recommends men at higher risk for breast cancer, starting at age 35:

  • have a clinical breast exam every year
  • learn how to do breast self-exam

Men at higher risk for breast cancer should also be aware of the warning signs of breast cancer, including:

  • a lump, hard knot or thickening in the breast, chest or underarm area (usually painless, but may be tender)
  • any change in the size or shape of the breast
  • dimpling, puckering or redness of the skin of the breast
  • itchy, scaly sore or rash on the nipple
  • pulling in of the nipple (inverted nipple) or other parts of the breast
  • nipple discharge (rare)

Any man noticing these signs or other changes in his breasts or nipples should see a health care provider right away. Mathew Knowles said he noticed a recurring dot of blood on his shirts and his wife saw the same on their bed sheets. Fortunately, he contacted his doctor, was diagnosed quickly and underwent treatment immediately. He emphasized the importance of early detection to increase the chances of survival.

Click here to learn more about male breast cancer – and ladies, please share this information with the men in your life.

Women and Breast Cancer

Unfortunately, despite all of the advances of modern medicine, there is no sure way to prevent breast cancer – or its recurrence. Therefore, emphasis is still placed on understanding the risk factors and promoting screening and early detection.

There are some risk factors that are out of your control, such as being female and getting older (it’s more common in women 55 years and older). You are also more at risk if there is a family history of breast cancer or if you have an inherited mutation in the BRCA1 or BRCA2 gene. However, there are other lifestyle-related risk factors which you can modify to help lower the risk of developing breast cancer. I thought it would be helpful to highlight some of the ways you can do so, including:

  • Maintain a healthy weight – being overweight or obese after menopause increases breast cancer risk. Having more fat tissue after menopause can raise estrogen levels and increase your chance of getting breast cancer. Also, women who are overweight tend to have higher blood insulin levels, which have been linked to some cancers, including breast cancer.
  • Exercise regularly – evidence is growing that regular physical activity reduces breast cancer risk, especially in post-menopausal women. The current recommendation is that adults get at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity (or a combination of these) each week, preferably spread throughout the week.
  • If you drink, limit alcohol to no more than one drink per day – drinking alcohol has been linked to an increased risk of breast cancer. The risk increases with the amount of alcohol consumed. Alcohol is also linked to an increased risk of other types of cancer.

Understanding and modifying your behavior-based risk factors is important, but at the end of the day, finding breast cancer early and seeking treatment immediately are the most important strategies to prevent deaths from breast cancer. Getting regular screening tests is the most reliable way to find breast cancer early. For women of average risk for breast cancer, the gold standard for screening is the mammogram, which is a low-dose x-ray of the breast. A mammogram can often find breast changes that could be cancer years before physical symptoms develop. Women at high risk for breast cancer are often urged to undergo a breast MRI as well as a mammogram. An MRI uses magnets and radio waves to take pictures of the breast.

At this time, there are some differences in the breast cancer screening guidelines recommended by some of the leading organizations, such as the American Cancer Society and the US Preventive Services Task Force. Therefore, it is best to talk to your health care provider about the most appropriate  screening options for you.

Finally, I think its important to end with a note about breast exams. For years, women were urged to perform monthly breast self-exams. Recent studies have not shown a clear benefit of regular physical breast exams done by either a health professional (clinical breast exams) or by women themselves. Unfortunately, there is very little evidence that these tests help find breast cancer early when women also get screening mammograms. However, women are still encouraged to be familiar with how their breasts normally look and feel and to report any changes to a health care provider right away. All of the women I know who were diagnosed with breast cancer felt something in their breast that prompted them to seek further testing. That’s enough to make me continue with regular self-breast exams.

Choosing a focus area and exploring readiness to change

So far, I have covered the first three stages of the health coaching process:

  • identifying the client’s vision for optimal health and wellbeing
  • exploring values and what is important to them about their health
  • assessing current health through Current and Desired States questionnaire and other available data such as lab and diagnostic tests or a health risk assessment

At this point, the client is usually ready to identify a focus area, i.e., a part of their vision of health they want to begin working on. This can be a particular domain from the Wheel of Health, such as nutrition or exercise, or it may be something like weight loss, which can encompass several areas of the Wheel. There are several factors that may influence where a client chooses to start, including:

  • the long-term importance of the focus area to them
  • the immediate benefits of making the desired change
  • the client’s current willingness to take on the challenge of the desired change

In my experience, that last factor typically plays a key role in how successful the client will be in making the change. That is why the next step in the process is so critical: assessing the client’s readiness to change. Just because a client has prioritized a focus area does not mean they are fully ready to make the change.

A client’s readiness to change can be influenced by many potential factors, but the two primary factors tend to be importance and confidence. Ideally, we want both of those factors to be relatively high before moving into goal setting and action steps. Oftentimes, clients want to jump right into action, but it will increase their chances of success to slow down and explore readiness to change before moving into action.

Typically, a client chooses a focus area because it is important to them at some level, but there may be other competing values or priorities that could interfere with the client’s attempt to change. And even if the selected focus area is of high importance, the client may have doubts about their ability to change. Perhaps they have tried in the past and failed, or they are not sure what steps they need to take to achieve the desired change. There are a number of strategies that coaches can use to assess readiness to change. Typically, we explore the importance of making the change before assessing confidence. After all, if it’s not important to the client, it is not really worth spending a lot of time on their confidence to change.

One of my favorite tools for exploring importance is a 1-10 number scale (with 1 being low importance and 10 being high). Asking the client to place the importance of making the change on a number scale allows them to think about all the factors that go into selecting the number. In general, a client is usually ready to move forward if they rank themselves as a 7 or higher. If a client ranks themselves lower than a 7, there are follow up questions I usually ask to explore the reasons why it is important for them to change. For example, if a client ranks themselves a 5, I may ask “What makes it a 5 versus a lower number like 3?” This allows the client to verbalize the reasons why they rated it as high as they did while also acknowledging any competing priorities that may keep it from being the most important area for change.

Another strategy for assessing the level of importance is to help the client explore the pros and cons of changing vs. staying the same. Having a client verbalize the pros and cons of changing may help them identify the positive benefits they will experience if they change. On the other hand, it may bring to light any competing priorities that could make it difficult for the client to change. All of this information is critical to helping the client determine if the focus area is of high enough importance to address at this time.

When the client determines that the change is important enough to move forward, the next step is to assess and support their confidence to make the change. In my work with clients, I have often found that importance is typically high, but confidence is usually on the low side. If a client is lacking in confidence around making the change, it can make the rest of the change process quite challenging. Thus, it is critical to adequately assess and help build the client’s confidence before moving into action. Lack of confidence often comes from the client’s previous attempts to change without success. For this reason, it is beneficial to acknowledge when the client has had at least partial success and more importantly, to help the client learn from the times they were both successful and unsuccessful.

Coaches use some of the same or similar strategies and tools to assess client confidence. For example, I often use the 1-10 number scale to assess confidence level (with 1 being low confidence and 10 being high). Again, we typically want the client’s confidence to be a 7 or 8 before moving into action. If a client ranks themselves lower, I will often ask one of the following questions:

  • “What makes it a {6} versus a lower number?”
  • “What would it take to increase your confidence from a {5} to a 7 or 8?”
  • “What number would it have to be for you to begin making the change?”

These questions can help a client verbalize what makes them confident about making the change as well as what challenges they believe may get in their way.

If a client’s confidence is low and they are not feeling ready to move into action, there are strategies a coach can use to help build their client’s confidence level. One of the most effective ways to do so is to explore the client’s strengths and past successes. Perhaps they have lost weight in the past and can tap into the tools and resources they previously used. Or this may be an opportunity to look at a client’s successes in other areas of their life and how those strengths and skills can apply to the current focus area.

If a client has made several attempts to change in the past without success, they may feel discouraged about attempting to change one more time. In a case like that, it is beneficial to have the client think about the time when they had the greatest amount of success, even if they did not accomplish all they hoped. If the client is concerned about barriers that prevented their success in the past, the coach can help the client strategize how to overcome those barriers should they arise again (this will be done in the action planning stage as well). Having a plan for addressing barriers may help increase the client’s confidence in attempting the desired change one more time.

After thoroughly exploring importance and confidence, the client and coach together will determine if the client is ready to move forward into Goal Setting and Action Steps. If confidence is still low, the client may want some time to think about it between sessions and then revisit confidence the next time. Or it may be that they need to consider a different focus area at this time. Even if the client and coach decide that moving forward with the current focus is the way to go, importance and confidence can shift throughout the coaching process. Thus, the coach may revisit either or both if they sense changes based on the client’s words or actions.

Assessing current health

Once a client has identified their vision of optimal health and wellbeing and why it is important for them to make changes in their health behaviors, it is helpful to perform a more comprehensive health assessment. This assessment can include input from a number of different sources including medical lab tests and diagnostics, a health risk assessment, recommendations from healthcare providers as well as any number of self-assessments around physical and mental health.

Even if a client comes to coaching with a specific focus area in mind, I find it is beneficial to have them complete a comprehensive self-assessment. Doing so may clarify what area(s) they most want to work on, or it may provide insight into areas that they did not realize were impacting their health. So many of our health behaviors are inter-connected, so taking a step back to look at the big picture can actually help a client identify the most important area(s) in need of change.

The self-assessment tool that I use with clients is the Current and Desired States Questionnaire. This self-assessment asks clients to rate their current and desired states of health on a scale of 1-10 for each area of the Wheel of Health. Doing so provides valuable input to clients as they prepare to select an area of health and wellbeing to focus on and set specific goals. In addition to rating each area, clients can document the reasons why they chose their current rating as well as what changes they could make to help them get to their desired level.

I usually give clients the questionnaire prior to our first meeting so they have time to complete it beforehand. This allows us to discuss the results in our time together. Before jumping into the specifics, I often begin with questions that ask the client about their experience completing the assessment and looking at their health in this way. For example, I may ask:

 

  • What was your experience in completing this assessment? What stood out most to you?
  • What, if anything, surprised you about your responses?

 

After discussing the general experience of completing the questionnaire, I then help the client explore specific areas on the assessment to help them prepare for the next step in the process, which is choosing a specific focus area. We often don’t have time to review each question in detail, so I typically use more general inquiry such as:

 

  • What are the areas in which you feel strong? What supports those areas of strength?
  • What are the areas where you would like to see some improvement or change?

 

Many times, clients will have more than one area in which they would like to improve. Given that behavior change takes time and can be difficult, I emphasize to clients that they do not have to take on all of their desired changes at one time. In fact, clients are strongly encouraged to work on only one area at a time. Studies have shown that the greatest success comes from choosing a focus area where the client will achieve results that are important to them and they are most likely to do well. Achieving a series of small wins in the early stages of behavior change can help a client stay motivated on their path to improved health and wellbeing.

As you can imagine, health assessment is not a static part of the coaching process. Depending on how long a client stays engaged in coaching, I will have them revisit and reassess their status along the way. Repeating the Current and Desired States Questionnaire at the end of the coaching process is also a wonderful way for the client to assess and celebrate the progress they have made and look at what changes they may want to continue with in the future.

Using one or more assessment tools is an excellent way to help clients clarify and prioritize what area of their health they want to focus on, particularly if there are multiple areas they want to change or improve. Self-assessment can also be an insightful part of the self-discovery journey that unfolds as part of the coaching experience.

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