Well: Living With Cancer: Chronic, Not Cured

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At the end of yoga sessions for cancer patients, we are told to say to ourselves, "I am whole, healed and healthy in this and every moment." Perversely, since in yoga we express aspirations as if they were already so, the sentence reminds me of people who congratulate me on being "cancer free." Stable disease often goes unrecognized.

Perhaps the concept of chronic cancer has been hard to comprehend because public discussion tends to focus on the initial diagnosis of breast cancer. Early detection of breast cancer yields good survival rates and many patients can consider themselves cured. Often we assume a clear-cut partition between survivors and the terminally ill.

In her book "Cancer Made Me a Shallower Person: A Memoir in Comics," Miriam Engelberg divides a circle into two uneven segments to illustrate a divide in the breast cancer community. The larger part of the circle is labeled "Primary Diagnosis Only," and a cartoon bubble exclaims, "I'm O.K. — Really!" The small section is labeled "Gone Metastatic," with the caption "Damn!"

From the time she got her initial diagnosis in 2001 until her death in 2006, the same year her book was published, Ms. Engelberg resisted pressure to become "someone nobler and more courageous than I was." She followed "the path of shallowness" by producing a series of droll comics on the "insanely cheerful" chemotherapy booklets and radiation technicians she encountered. She mocked her own self-absorption, trepidation and irritation as well as the social quandaries that arose as she, like her cartoon surrogate, plummeted from cancer survivor to terminal patient.

But for some of us, there is a middle stage in this journey. Because of advances in cancer research and the efforts of dedicated oncologists, a large population today deals with disease kept in abeyance. The cancer has returned and has been controlled, but it will never go away completely. Like me, these people cope with cancer that is treatable for some unforeseeable amount of time. Chronic cancer means you will die from it — unless you are first hit by the proverbial bus — but not now, not necessarily soon.

The word "chronic" resides between the category of cured and the category of terminal. It refers to disease that is not spreading, malignancy that can be arrested but not eradicated. At times, the term may seem incommensurate with repetitive and arduous regimens aimed at an (eventually) fatal disease. For unlike diabetes or asthma, cancer does not respond predictably to treatment.

Still, quite a few patients with some types of leukemia or lymphoma, prostate or ovarian cancer live for years. While in the 1970s 10 percent of women with metastatic breast cancer survived five or more years, today up to 40 percent do. Chronic disease may lack the drama of diagnosis and early treatment; even friends can get bored by mounting details. Its evolution does not conform to the feel-good stories of recovery that most of us want to read. But neither does it adhere to the frightfully degenerative plot of quickly advancing tumors.

On a number of websites, people with chronic cancer discuss the succession of therapies in which they enlist. When one drug fails, another combination of drugs begins. Complex dosing schedules, multiple tests and hospitalizations take their toll. No matter how grateful these patients are for their continuing existence, it requires not the spurt of sprinters but the stamina and sometimes the loneliness of long distance runners.

Ms. Engelberg's "path of shallowness" can alleviate strain, especially from disabling byproducts of persistent maintenance: sadness, anxiety, anger and then remorse about all those roiling emotions. When repetitive and arduous regimens weary the spirit, it may be impossible to value the preciousness of life, to adopt a healthy lifestyle, to visualize one's harmony with the universe, to attain loving kindness, to stay positive, to meditate to a state of mindfulness, to greet each day as a prized gift, to enlist the power of now. The social pressure to be upbeat can get anyone down.

The shallow path enables the cartoon character Miriam to circumvent the guilt trips induced by a gaggle of past and present cancer gurus. Instead of going inward, she often distracts herself: zoning out on "Judge Judy" or attaining "trivia nirvana" through crossword puzzles or joking about the need for a support group to cope with the jolly advice of her support group. Eventually she decides to make cartooning her "spiritual practice."

If I am low during a yoga session, if the warrior, the goddess and the star feel impossibly strenuous, I take the shallow path with the supine pigeon and a revision of my wonderful instructor's final words: "I am as whole, healed and healthy as I can be in this and every moment."

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Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of "Memoir of a Debulked Woman," which explores her experience with ovarian cancer.

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The New Old Age: Moving On by Moving Around

Caregiving is a delicate dance, with a gradual shift in who is leading and who is following. One partner is, often, a frail, widowed mother, upended by the loss of her husband and living in the family home, too big, costly and difficult to maintain.

A dear old friend fits that profile: Stooped and finally reconciled to a walker, she grieves a husband lost to Alzheimer's disease while ensconced in a dated four-bedroom house atop a canyon in the Bel Air section of Los Angeles. I've begged her to move more times than I can count, and surely more times than she wanted to hear.

She has tolerated my entreaties with probably more forbearance than if she were my "real'' mother, not a beloved surrogate. Her mind is clear, her will strong, and her way of making decisions — slow and steady — has always worked for her. So she's held her ground.

Along the way, she has taught me two lessons.

– Know when to butt out, because you're not always right.

– Move the furniture.

The latter is useful shorthand, like "shift your weight'' when you get stuck in life. But it's literal advice, too. Some will argue that rearranging the chairs is a superficial response to a deep problem. Lately I'm not so sure.

Up in the hills of Los Angeles, my elderly friend (I'm not going to name her, as I suspect her children might object) has succeeded in making changes to her home that have nothing to do with handicap accessibility (long ago done) and everything to do with emotional well-being.

On a recent visit, I was assigned the master bedroom rather than the small guest room. What's not to like? A king-sized bed. Sliding doors to the patio. Only when the rest of the household was asleep did I permit myself tears.

I loved her late husband, also like a surrogate parent. His favorite books were on the shelves, his swimming goggles still on the edge of the sink. How could I possibly sleep in their bed? And if I couldn't, I realized during my first fitful night, how could she?

So she'd moved down the hall, to the narrow bed in the guest room where I'd slept so many times. Now the room had an easy chair and ottoman, piled with the books and magazines she was reading. The desk was reorganized so she could do her bookkeeping. The closet held her clothes. The walls were hung with pictures from her life, including a poster from her college reunion: Tufts, class of 1947.

Elsewhere in the house, I found, the changes were less dramatic but numerous. The living room had always been used less than the family room. Now the furniture in the two had been reversed. The "nicer" couch, formerly in the living room, now was enjoyed daily, not just once in a blue moon. It looked brand new, its leather unscuffed, and it was set at a fashionable angle rather than up against the wall.

In front of it, a huge glass coffee table, also from the living room, replaced the narrow wood-slatted one that had been there before.

The dining room table was laid with rush place mats, nothing fancy but a freshening touch. In the kitchen, new appliances gleamed in economical white rather than pricy stainless steel. A new filter basket to make coffee was metal mesh rather than stained plastic. The silverware drawers had been rearranged. Cookies and cereal were stored where pots used to be, and vice versa.

As a longtime guest, it took some getting used to, and I fumbled to find things. Still, I came to marvel at her good sense. Most of these changes were less dramatic than the bedroom switch, I realized, but all in service of the same principle: Not to forget a dead husband, but to remember and move forward at the same time.

My first morning there, I screwed up my courage to tell her how wrenching it had been to sleep in "their" bed. And how disconcerting to find so much in the house changed.

"I have to go on," she told me. "It will never be the same, and I don't want it to be, but I need reminders that this is my life now, physical reminders, and all this helps."

And so I have learned yet another thing from her: To be more humble giving advice to the elderly about their homes, and to keep my big mouth closed unless and until I see they're at risk.

It's a lesson that doesn't come naturally.

Before leaving, I observed that a trellis attached to the house was rotting. "Find out if it's termites,'' I told her, "and if the exterminator can't totally get rid of them, tear it down before they find their way into the house.''

Oops.

But since then, despite high temperatures and high winds in Southern California — fire weather in the canyons — I've resisted calling to say, as I have so many times before, that it's not safe to be in a house with a shake roof.

She's doing fine figuring things out on her own.

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Well: The Workout: Becoming Rocky Balboa

Not many Broadway stars have to dodge punches on stage. But for Andy Karl, it is all in a night's work.

Mr. Karl, 39, plays the title character in the musical "Rocky," a high adrenaline show based on the original 1976 film written by and starring Sylvester Stallone. To prepare for his role, Mr. Karl devoted himself to a grueling gym routine devised by a personal trainer.

But his workouts do not end at the gym. The role requires the actor to go through the punishing training routine of a boxer every night, along with four choreographed fights that include some full-contact punches.

For his efforts, Mr. Karl was nominated in April for a Tony award for best actor. The winners will be announced on Sunday night.

Recently, we caught up with Mr. Karl at his gym in Manhattan to learn about training to play the iconic boxer, his exercise and diet strategy for achieving "the Rocky look," and why black eyes and bruises are part of the job. Here are edited excerpts from our conversation.

Can you tell us about your physical preparation for the show? What goals did you have in mind?

Rocky is a fighter. He's in great physical shape, and Sylvester Stallone has always been in great shape. So I had someone to look up to and a movie to judge my own physical attributes. The goals were basically to keep my stamina up and also to put on some more mass, which is hard when you're doing eight shows a week under hot lights.

Were you always a fit person?

I had always gone to the gym but never taken on a trainer. I knew I had some goals to put on some mass, but to do that, my trainer and I worked on intrinsic muscles – the ones underneath the big muscles that can actually build those larger muscles. Just going to the gym and doing a couple of bicep curls and bench presses doesn't quite do it, so my trainer and I worked on a lot of core, and we worked on shoulders, because a boxer has to have good shoulders.

How did you build muscle?

We do a mix of things. We do many kinds of circuits to strengthen my core. We use the TRX straps, which allow you to use your body weight in different ways. We do a lot of unique training with kettlebells so you can strength-train in ways that keep you limber. And we also use weights.

Do you train every day?

We try to find as many days as we can. With the show there's a lot of press, and there's an award season that's coming up. But I know how important it is to get in here and work out. It makes me feel much better to do the show after I've worked out because things are pumping and things are good. So I do get in here every day either by myself or with my trainer, and maybe take one day off. But when I do take a day off I feel guilty about it.

How much time do you spend working out?

I spend a good hour working out. It's a pretty intense hour. But working out in that condensed amount of time and hitting a lot of muscles pushes your stamina. It's imperative for what I do every night, and to understanding Rocky's mentality. Rocky gets the offer of a lifetime to fight the heavyweight champion of the world, so he has to put the extra time into working out and getting mentally prepared and strong.

Are you taking a beating in this role?

Pain has become a part of my life, but one that I actually like now. We're doing full-contact punching. I'm getting hit in the head a lot. Rocky takes a lot of punches, so I've had black eyes. I've had bruises. I've had a sore neck. But it's taken me to another level and I feel great.

Can you tell us about the big fight scene at the end of the show?

It's the most epic part of our show. I finish a song basically talking about how I've got to push through and keep on standing, and then the whole place lights up like it's Madison Square Garden. The ring comes down from the ceiling and out into the audience. We have a huge Jumbotron come down, we have screens, we have all sorts of amazing things to make the audience feel like they're watching a real live fight.

It's a unique part of our show that our director came up with, and it works every time. I see all the faces out there in the audience because the entire place lights up. I see everyone wide-eyed and cheering.

Had you ever boxed before this show?

I had been working with the show for about three years before it got to Broadway. I'd done some preliminary workshops, and the producers made sure I got some boxing training so I knew my fundamentals. I appreciate any fight I see now because you can tell that everyone has a different style. Rocky fights low and slow, and he hits to the body a lot. But Apollo [Rocky's opponent] hits to the head and gets a lot of points that way.

We heard you got some tips from Stallone himself?

Yes. One of the things he said to me was to make sure you throw your punches from your shoulders. So I try to incorporate that into the choreography as much as I can. I take a lot of pride in him offering this role to me because it came down to his decision. It's a great honor, and it's a challenge. I grew up watching the films, and I want to honor the guy who's at the helm of the ship.

Do you follow a special diet?

My biggest thing is trying to eat as clean as possible. That helps me with my performance as well because the cleaner you eat, the better your voice is going to sound. If you eat a lot of cheese and dairy it's going to affect your voice. The other part is making sure that I'm feeding the muscles to help with the weightlifting that I'm doing. I think I've lost and gained about 15 pounds since I started rehearsals back in December. Its just one of those things where you're going to sweat a lot, you're going to work out a lot, and so you have to eat. And I'm starving half the time.

What does "eating clean" mean for you?

For me it's keeping away from a lot of bread and milk and trying to eat chicken and vegetables and not a lot of extra products thrown on top of everything. Right now, I need all the help that I can get just getting through these workouts and the show.

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Well: The Great Hamstring Saver

This article appeared in the June 8, 2014 issue of The New York Times Magazine.

Talent and tactics aside, the 2014 World Cup could be won or lost by hamstrings, those long, stringy muscles and tendons that run along the backs of the thigh from the hip to the knee. The most common injury in soccer, hamstring strains and tears democratically strike high-school players, adult-league hobbyists and such luminaries as Argentina's Lionel Messi and Spain's Diego Costa. Anyone, in fact, participating in a sport involving high-speed striding — whether track and field, football, ultimate Frisbee, basketball, dance, baseball, marathons or even brisk walking — is at risk of a hamstring injury. The hamstrings decelerate the leg as it swings forward. So, near the end of each running stride, especially during sprints, they are under considerable strain, and if insufficiently strong, may rip.

Enter the Nordic hamstring exercise. According to at least half a dozen recent studies, almost two-thirds of hamstring injuries might be prevented by practicing its simple steps: After warming up, kneel on the ground, with a spotter securing your ankles. Then, as slowly and smoothly as possible, lean forward so that your chest approaches the ground. Use your hamstrings to put the brakes on your forward momentum until you can no longer resist gravity. Put out your arms at that point to stop your fall. Allow your chest to touch the ground, then push yourself upright to repeat the exercise.

In a 2011 study, 942 Danish soccer players were randomly assigned to either an off-season program of the Nordic exercise or normal training. In the subsequent season, those following the Nordic exercise program experienced 70 percent fewer injuries than the control-group athletes. Players who had previously suffered hamstring damage saw 85 percent fewer injuries.

The Nordic exercise works, the study researchers conclude, because of its eccentricity. Eccentric muscle contractions occur when a muscle extends as it contracts. Lower a weight during a biceps curl, for instance, and your forearm muscles lengthen at the same time as they clench. Raise that same weight upward, and the contractions become concentric, shortening as they contract. In general, eccentric contractions require more energy than concentric ones. If you run hills, it's the downhill portion of the workout that leaves your muscles twinging the next day, not the ascents. But, once those muscles heal, usually within a few days, they become stronger than before. Eccentric exercises also seem to spark changes in the nervous system that result in improved coordination between brain and muscles.

Some physical therapists have expressed concern that the Nordic exercise, if practiced without adequate healing time between sessions, could weaken tissue and lead to a hamstring tear. But researchers at the Sports Orthopedic Research Center in Copenhagen, who led the 2011 study, documented no related injuries. It is important, though, to ease in, said Dr. Jesper Petersen, the study's lead author. One weekly session is plenty at first; you might easily complete it during the United States vs. Ghana halftime break.

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The Program

Week 1: 1 session; 10 repetitions

Week 2: 2 sessions; 12 repetitions each

Week 3: 3 sessions; 18 to 24 repetitions each

Week 4: 3 sessions; 24 to 30 repetitions each

Weeks 5: 10 – 3 sessions; 30 repetitions each (divided into 3 sets of 12, then 10, then 8 repetitions)

After 10 weeks, try to perform one weekly maintenance session of 30 repetitions.

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Well: Think Like a Doctor: Arachnophobia

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you solve the medical mystery of a woman who develops a sore on her leg and then fever, nausea and chest pain?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 36-year-old stay-at-home mom with a sore on the back of her knee who also develops a fever, night sweats, diarrhea and chest pain. I have provided the only information that was available to the doctor when she was finally able to make the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, "Every Patient Tells a Story," and the satisfaction of solving a difficult but really cool case.

The Patient's Story

"She thinks I have some kind of cancer," the 36-year-old woman said to her husband as she hung up the phone. She looked pale, and her eyes were shiny with tears.

Her primary-care doctor had just called to say that the CT scan the woman had had the day before showed something worrisome — so worrisome that she needed to go to the local cancer center the next day.

I don't know what's wrong with me, she told her husband, but I know it's not cancer. It can't be. It just doesn't make any sense.

A Funny Bump

Two weeks earlier, the woman had noticed a strange bump on the back of her knee. About the size of a nickel, it was red, firm and a little tender. She didn't give it much thought.

With a year-old toddler to care for, the woman didn't have time to worry about little things. But late that afternoon she started feeling ill. Her body ached, and there was a strange throbbing behind her eyes. By dinnertime she was shivering, with a chill that didn't make sense given the mild summer day. She took her temperature: it was 102.5. Her husband brought her some Tylenol and sent her to bed.

The next morning her fever was even higher. It wasn't flu season, but it felt like the flu. Her entire body ached. Her stomach warned her against eating. And she was so tired she could barely get out of bed.

Her husband stayed home from work to take care of their child, and she spent the day in bed. She felt miserable, sometimes drenched with sweat, other times shaking with violent chills. The lump on the back of her leg was dark red, and red streaks climbed up from the wound. When she was no better the next morning, she called her doctor.

Visiting Her Doctor

That afternoon she was seen by one of the nurse-practitioners in her doctor's office. Could this be a spider bite, the patient asked?

The nurse wasn't sure about that, but was pretty sure that antibiotics would help. The patient took the pills for the next three days but felt no better.

She went back to the doctor's office, saw another nurse-practitioner, and got another type of antibiotic.

That didn't help either. She still had high fevers every day. She also had terrible diarrhea. She lost over 10 pounds. The wound on her leg had become worse; it throbbed and exuded a hideous yellow pus. She was so tired that just getting out of bed seemed an insurmountable task.

Then her chest started to hurt whenever she took a breath. Any exertion caused a stabbing, aching pain on the left side of her chest. Coughing just about killed her. That's when she went to the emergency room of her local hospital in Frederick, Md.

An E.R. Visit

After spending the entire night in the bright, noisy emergency room, having dozens of tubes of blood taken as well as an X-ray and EKG, she was seen by an infectious disease specialist. He asked her no questions but simply looked at the sore on her leg.

"That little thing?" he remarked dismissively. He told her it was healing nicely and sent her home.

The woman was finally able to see her own primary-care provider after she'd been sick for over two weeks. The doctor examined her carefully. She grimaced as the doctor probed the left side of her abdomen. That hurts? the doctor asked.

The patient nodded, a little surprised by the sudden pain. That's when the doctor ordered the CT scan. And it was what she saw on the scan – an enlarged spleen – that made her think the patient might have cancer.

Cancer Scare?

What about the sore on my leg? the patient asked after the doctor mentioned cancer on the phone. The doctor wasn't sure what to make of that – maybe it was a spider bite. She was much more concerned about the enlarged spleen and wasn't sure the two problems were related. The doctors at the cancer center will help us figure it out, she told the patient, then hung up.

The woman's husband put his arm around her and drew her close. I think it's time to call your brother, he told her.

His wife's brother was a physician who had trained at Johns Hopkins Hospital in Baltimore, just over an hour away from where they lived. After hearing about her illness and her repeated visits to her local doctors, he urged them to get a second opinion at Hopkins.

Up to now she'd felt too sick to want to drive that far when her own doctor was just up the street. This phone call made a second opinion sound like a good idea.

And so the next day, the patient left her toddler with her husband and drove to the Baltimore suburb of Lutherville to see Dr. Heather Sateia, an internist in the Hopkins system. She had only just checked in with the front desk when the young doctor came to the waiting room to bring her in.

Another Opinion:

The doctor listened as the patient carefully retold her story. She had brought a DVD of the CT scan but had no other records. You can see the CT scan image of the spleen below.

As Dr. Sateia examined the patient, she felt for the enlarged spleen she had seen so clearly on the scan. The patient squirmed with discomfort as the doctor felt for but did not find the enlarged organ.

The most common cause of splenomegaly, or an enlarged spleen, in a young healthy woman was mononucleosis. This patient had had a febrile illness – though her temperature was normal in the office – and that fit the picture of mono as well. An in-office test for mono was negative, but since that test is less accurate later in the infection, Dr. Sateia ordered a different test to look for the presence of the Epstein-Barr virus, which causes mono.

Cat scratch fever was also possible. Although the patient didn't have a cat, her neighbor did, and she often played with it while visiting. Cancer, too, was a possibility. Splenomegaly is often seen in the so-called liquid tumors — leukemia and certain lymphomas. Dr. Sateia ordered tests to look for these possibilities and explained her thinking to the patient.

What about the sore on my leg? the patient asked. No one seemed to be able to link that to any of the other problems she had. Like the doctors before her, Dr. Sateia wasn't sure how to connect those dots. But, she told the patient, she would read up on spider bites to see if she could link the small open sore to the rest of her symptoms.

A few days later Dr. Sateia called the woman, who reported that she still felt awful. The fevers weren't as high, and the diarrhea was gone. But she was so fatigued and her chest hurt so much that it was almost impossible for her to pick up her child.

Did the doctor have any answers for her? Well, the doctor answered, all the tests she had done were negative. However, she'd been reading up on spider bites and made an important discovery. The sore was probably not caused by a spider. Spider bites can cause terrible tissue injuries, but the wound on her leg didn't look at all like the kind of lesion caused by spider venom.

However, she had read up on a close cousin to the spider that was known to carry a wide variety of infections. Had she seen a tick on her leg at any time during the summer?

A tick! The very idea of it horrified the patient. She had never found a tick anywhere on her body, nor on the two chihuahuas her family had.

Perhaps not, the doctor told her, but several of the tick-borne diseases she'd read about could have caused both the sore and the rest of her symptoms. Lyme disease was the most well known of these, but there were others – a disease called anaplasmosis and another called babesiosis. All three were carried by the same tiny deer tick. All caused awful febrile illness, and all three were becoming more and more common. The patient needed to go to her local lab; Dr. Sateia had already sent an order for her to get tested. She was convinced that this was the right direction.

The patient went to the lab the very next day. A few days later the results were back – all negative.

The doctor didn't give up. She had some ideas and figured out the answer.

You can see Dr. Sateia's notes here:

You can view the patient's lab results here:

You can read more about the imaging results here:

Solving the Mystery

What about you? Do you have any ideas about what this patient might have?

Post your guesses in the comments box. I'll post the answer on Friday.

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Personal Health: New Therapies for Bowel Diseases

Correction Appended

Personal Health

Jane Brody on health and aging.

Decades ago, I met a surprisingly quiet, withdrawn young man. Surprising because I knew his bright, vibrant wife and wondered what had attracted her to him. He barely participated in conversations even at friendly family gatherings.

Some years later, the same man seemed to have undergone a personality transplant. He was forthright and funny, intelligent and interesting. I asked a mutual friend what could have accounted for the apparent transformation.

The answer: surgical removal of his chronically inflamed colon to treat ulcerative colitis. Once free of painful abdominal cramps, persistent diarrhea, fatigue, nausea and the depression and anxiety that can accompany these symptoms, he came to life. Even having to cope with a colostomy bag did not dampen his newly awakened spirit.

Today, this rather draconian treatment is reserved for the very few patients with inflammatory bowel disease — Crohn's and ulcerative colitis — whose debilitating symptoms don't respond to a growing number of less invasive modern therapies.

Although many people with chronically inflamed bowels still have surgery, it is nearly always less aggressive, rarely requiring an external pouch to replace a surgically removed colon and rectum.

Today in 98 percent of patients with ulcerative colitis in whom the colon must be removed, it is replaced by an internal pouch, creating a reservoir for stool that is sutured directly to the rectal canal, said Dr. R. Balfour Sartor, chief medical adviser to the Crohn's and Colitis Foundation of America.

"This approach decreases urgency, enabling patients to defer the need to evacuate, and reduces the number of stools per day," Dr. Sartor said in an interview.

Inflammatory bowel diseases afflict 1.4 million Americans, typically starting in the teenage years and lasting a lifetime. But treatments for these chronic conditions are being transformed, spurred by the decoding of the human genome and a growing understanding of the balance of microbes in the gut and why it goes awry in some people.

As with operative changes for ulcerative colitis, in recent decades, surgery for Crohn's disease has become less disruptive of normal digestive function. Instead of removing diseased sections of the intestine, Crohn's patients can have a procedure called strictureplasty, better preserving the body's ability to absorb nutrients. Strictureplasty involves cutting the diseased area at its midpoint, stacking the two pieces on top of each other, then cutting and reconnecting them lengthwise.

The technique, known as Michalessi strictureplasty for the Weill Cornell surgeon Dr. Fabrizio Michalessi, has been shown to encourage regression of the disease in the treated area. "Surgery doesn't cure Crohn's," Dr. Sartor said, "but this technique preserves most of the natural function of the small intestine, where nutrients are absorbed."

Dr. Ellen J. Scherl, gastroenterologist at Weill Cornell Medical Center in New York, emphasized in an interview that "surgery is a therapy, not a failure of therapy."

She added, "If doctors persist with medical therapy to avoid surgery, they may be subjecting patients to chronic flare-ups."

At the same time, however, improved medical remedies are fast emerging. Experts in inflammatory bowel disease are working on treatments based on a patient's genetic makeup, an approach now increasingly used to treat cancer.

Dr. Ramnik J. Xavier, chief of gastroenterology at Massachusetts General Hospital in Boston, said that after determining the genomic regions associated with inflammatory bowel diseases (163 genes have been linked to the ailments), "we're now looking individually to identify certain genes that affect inflammation and the failure of ulcers to heal."

There are also genetic changes that protect the gut, Dr. Xavier said, and targeted molecules could be designed to both treat the disease and prevent relapses.

"Ulcerative colitis and Crohn's are in many ways the poster child for which sequencing the genome is having a tremendous impact," Dr. Xavier said in an interview.

Equally important to improved treatment has been understanding how environmental factors like diet and antibiotics can disrupt the balance of microbes in the gut. Some bacteria are protective and keep the gut healthy, while others result in chronic inflammation.

"Antibiotics, which alter the gut microbiome, may be helpful or not," Dr. Scherl noted. Tailor-making antibiotics that attack only harmful bacteria could give protective microbes a chance to dominate. And altering the diet to deny harmful microbes the nutrients they prefer can curb inflammation.

Dr. Scherl said that sugars, other carbohydrates and fats can lead to uncontrolled inflammation in the gut of people genetically predisposed to inflammatory bowel diseases. When a flare-up occurs, she said patients "must step back and eat simpler food — a so-called white diet — until the inflammation subsides.

Dr. Sandra C. Kim, pediatric gastroenterologist at Nationwide Children's Hospital in Columbus, Ohio, treats flare-ups in children with what is called enteral therapy, in which they consume a formula that deprives harmful bacteria in the gut of the nutrients they need to produce substances that foster inflammation.

Although Dr. Kim acknowledges that the diet is not easy to stick to, when pursued for eight to 12 weeks it can induce remission of the disease, reduce the risk of relapse and enable the child to grow normally.

Another new approach aims at gut-specific transport of inflammatory cells from the blood into the gut. The Food and Drug Administration just approved a drug called vedolizumab, which blocks the movement of those cells.

"This is a completely new strategy for treating Crohn's and ulcerative colitis," Dr. James D. Lewis, professor in the gastroenterology division at the University of Pennsylvania Perelman School of Medicine, said in an interview.

Perhaps most important for people with an inflammatory bowel disease, Dr. Scherl said, is to be cared for by a specialist "who understands its complexities and nuances and listens to patients who are living with it."

This is the second of two columns about inflammatory bowel diseases. Read the first, "Speaking Up About an Uncomfortable Condition."

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This post has been revised to reflect the following correction:

Correction: June 2, 2014

An earlier version of this article misidentified a treatment used by Dr. Sandra Kim to treat flare-ups of bowel disease in children. It is enteral therapy, not an elemental diet.

Correction: June 3, 2014

An earlier version of a capsule summary with this article misstated the name of the condition being discussed. It is inflammatory bowel disease, not irritable bowel disease.

A version of this article appears in print on 06/03/2014, on page D7 of the NewYork edition with the headline: New Therapies for Bowel Diseases.

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Well: A Tattoo That Completes a New Breast

Kassie Bracken/The New York Times

FINKSBURG, MD. — A tattoo parlor here has become a mecca for an unlikely crowd: women with breast cancer.

Little Vinnie's Tattoos offers designs ranging from swordfish and skulls to intricate Japanese-style art. But women who have undergone treatment for breast cancer do not typically come for traditional ink. They flock here seeking one thing — a three-dimensional nipple tattoo by the owner, Vinnie Myers.

"Nobody really talks about the areola and nipple area, but it's so important," says Kimberly Winters, 44, a human resources benefits administrator from Wooster, Ohio, who underwent a mastectomy and reconstruction of her left breast two years ago. This spring Ms. Winters traveled nearly 400 miles to Finksburg seeking a realistic nipple tattoo from Mr. Myers.

Word of his skill has spread among women who have undergone surgery for breast cancer. More than 5,000 women have traveled from as far away as India to have their reconstructed breasts tattooed by Mr. Myers.

After a woman undergoes a mastectomy and breast reconstruction, the new breast is a blank canvas. While the operation can recreate the size and shape of the patient's natural breast by using her own body tissue or implants, the darker, sensitive skin of the nipple and areola is usually removed entirely.

Skin grafts can recreate the look of the original nipple, but the procedure isn't popular because "most patients don't want to have another surgery and another scar," says Dr. Leo Keegan, an assistant clinical professor of surgery at the Icahn School of Medicine at Mount Sinai.

Instead, many doctors and patients choose a tattooed rendition of a nipple. In most cases, the procedure is performed by a breast surgeon with only a few hours of tattoo training. The result is usually a passing resemblance to the real thing — a one-dimensional, reddish, pink or brown circle inked onto the tip of the breast.

Mr. Myers originally specialized in colorful, one-of-a-kind tattoos. But at a party in 2001, he struck up a conversation with a woman who worked with a plastic surgeon.

"She told me they were having problems tattooing their breast cancer patients and asked me if I would come in and help correct some of them," Mr. Myers said.

After doing a few jobs, he quickly recognized the need for trained tattoo artists to be involved in breast reconstructions.

"I would never advise anybody to come to me for surgery, but in the same vein nobody should go to a surgeon for a tattoo," he said.

As Mr. Myers developed his technique, word spread and his business grew, giving him little time for other tattoos. Mr. Myers said that in 2010 he decided to stop doing nipple tattoos.

"The morning that I planned on telling the guys to stop taking appointments for them, my sister called to tell me she had breast cancer," he recalled.

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He took it as a sign. Today, he is busier than ever, with a waiting list of four to six months. He has recruited his daughter, Anna, 19, to help with his business. When she graduates with an art degree from Towson University in 2017, Anna plans to learn nipple tattooing from her father.

"I get to see tattoos done by different doctors from all over the world, and it never ceases to amaze me how bad most of them are," Mr. Myers said. "I've seen tattoos that don't match a woman's skin tone or her existing areola, nipples that are so large and out of proportion they take up half the breast, or nipples that are positioned so far on the sides they are almost in the armpits. Doctors have really dropped the ball on this."

I recently decided to make my own trip to Little Vinnie's. After two years of breast cancer treatment, including chemotherapy, a double mastectomy and four additional surgeries, I also wanted to have breasts that at least appeared normal and had the most realistic-looking nipples possible. After talking to my doctor, I made the four-hour drive from my home in New York to the tattoo shop in Finksburg.

Inside Little Vinnie's, butter-yellow walls are decorated with mounted antlers, traditional Asian face masks, and hanging tattoo display racks that offer hundreds of design ideas, from butterflies to tribal bands. A pet iguana basks under a sun lamp in a glass cage. A pool table sits at the center of the main room.

Tall and lean, wearing a fitted houndstooth vest, tailored jeans and navy and cognac-hued wingtips, Mr. Myers had me stand in front of a mirror as he drew — freehand — the outline of my tattooed areola. As he pulled pigments from his inventory — Kelly green, dark purple, pink and black — he saw the terrified look on my face. He explained that he would combine certain colors to complement the undertones of my pale skin. Mixed together they would form a natural-looking nipple color.

He dipped his finger into the ink and streaked it along my chest. I wanted it lighter, more pink. He added three drops of white and then tested the color again. Perfect. The machine began to buzz and in less than an hour, my tattoos were done. As I looked in the mirror, I was shocked by how real my nipples appeared. The pale pink hue was perfect, and the shading mimicked the imperfections of a natural nipple.

Mr. Myers charges $600 to $800 for his nipple tattoos. Some insurance companies reimburse patients, while some, including mine, refuse to pay because Mr. Myers is not a licensed health care provider.

Ms. Winters, who is African-American, traveled to Little Vinnie's to correct a peach-colored tattoo that didn't match her skin. "It looked like the areola of a white woman," she said.

Mr. Myers created a nipple with subtle brown shading and a three-dimensional effect to match the natural nipple on Ms. Winters's other breast.

"He created the illusion of a real nipple and areola," she said. "It's amazing."

A version of this article appears in print on 06/03/2014, on page D6 of the NewYork edition with the headline: Tattoo Therapy After Breast Cancer.

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Well: Losing Weight May Require Some Serious Fun

Phys Ed

Gretchen Reynolds on the science of fitness.

If you are aiming to lose weight by revving up your exercise routine, it may be wise to think of your workouts not as exercise, but as playtime. An unconventional new study suggests that people's attitudes toward physical activity can influence what they eat afterward and, ultimately, whether they drop pounds.

For some time, scientists have been puzzled — and exercisers frustrated — by the general ineffectiveness of exercise as a weight-loss strategy. According to multiple studies and anecdotes, most people who start exercising do not lose as much weight as would be expected, given their increased energy expenditure. Some people add pounds despite burning hundreds of calories during workouts.

Past studies of this phenomenon have found that exercise can increase the body's production of appetite hormones, making some people feel ravenous after even a light workout and prone to consume more calories than they expended. But that finding, while intriguing, doesn't fully explain the wide variability in people's post-exercise eating habits.

So, for the new study, published in the journal Marketing Letters, French and American researchers turned to psychology and the possible effect that calling exercise by any other name might have on people's subsequent diets.

In that pursuit, the researchers first recruited 56 healthy, adult women, the majority of them overweight. The women were given maps detailing the same one-mile outdoor course and told that they would spend the next half-hour walking there, with lunch to follow.

Half of the women were told that their walk was meant to be exercise, and they were encouraged to view it as such, monitoring their exertion throughout. The other women were told that their 30-minute outing would be a walk purely for pleasure; they would be listening to music through headphones and rating the sound quality, but mostly the researchers wanted them to enjoy themselves.

When the women returned from walking, the researchers asked each to estimate her mileage, mood and calorie expenditure.

Those women who'd been formally exercising reported feeling more fatigued and grumpy than the other women, although the two groups' estimates of mileage and calories burned were almost identical. More telling, when the women sat down to a pasta lunch, with water or sugary soda to drink, and applesauce or chocolate pudding for dessert, the women in the exercise group loaded up on the soda and pudding, consuming significantly more calories from these sweets than the women who'd thought that they were walking for pleasure.

A follow-up experiment by the researchers, published as part of the same study, reinforces and broadens those findings. For it, the researchers directed a new set of volunteers, some of them men, to walk the same one-mile loop. Once again, half were told to consider this session as exercise. The others were told that they would be sightseeing and should have fun. The two groups covered the same average distance. But afterward, allowed to fill a plastic bag at will with M&M's as a thank-you, the volunteers from the exercise group poured in twice as much candy as the other walkers.

Finally, to examine whether real-world exercisers behave similarly to those in the contrived experiments, the researchers visited the finish line of a marathon relay race, where 231 entrants aged 16 to 67 had just completed laps of five to 10 kilometers. They asked the runners whether they had enjoyed their race experience and offered them the choice of a gooey chocolate bar or healthier cereal bar in consideration of their time and help. In general, those runners who said that their race had been difficult or unsatisfying picked the chocolate; those who said that they had fun gravitated toward the healthier choice.

In aggregate, these three experiments underscore that how we frame physical activity affects how we eat afterward, said Carolina O.C. Werle, an associate professor of marketing at the Grenoble School of Management in France, who led the study. The same exertion, spun as "fun" instead of "exercise," prompts less gorging on high-calorie foods, she said.

Just how, physiologically, our feelings about physical activity influence our food intake is not yet known, she said, and likely to be bogglingly complex, involving hormones, genetics, and the neurological circuitry of appetite and reward processing. But in the simplest terms, Dr. Werle said, this new data shows that most of us require recompense of some kind for working out. That reward can take the form of subjective enjoyment. If exercise is fun, no additional gratification is needed. If not, there's chocolate pudding.

The good news is that our attitudes toward exercise are malleable. "We can frame our workouts in different ways," Dr. Werle said, "by focusing on whatever we consider fun about it, such as listening to our favorite music or chatting with a friend" during a group walk.

"The more fun we have," she concluded, "the less we'll feel the need to compensate for the effort" with food.

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Well: New Therapies for a Debilitating Condition

Personal Health

Jane Brody on health and aging.

Decades ago, I met a surprisingly quiet, withdrawn young man. Surprising because I knew his bright, vibrant wife and wondered what had attracted her to him. He barely participated in conversations even at friendly family gatherings.

Some years later, the same man seemed to have undergone a personality transplant. He was forthright and funny, intelligent and interesting. I asked a mutual friend what could have accounted for the apparent transformation.

The answer: surgical removal of his chronically inflamed colon to treat ulcerative colitis. Once free of painful abdominal cramps, persistent diarrhea, fatigue, nausea and the depression and anxiety that can accompany these symptoms, he came to life. Even having to cope with a colostomy bag did not dampen his newly awakened spirit.

Today, this rather draconian treatment is reserved for the very few patients with inflammatory bowel disease — Crohn's and ulcerative colitis — whose debilitating symptoms don't respond to a growing number of less invasive modern therapies.

Although many people with chronically inflamed bowels still have surgery, it is nearly always less aggressive, rarely requiring an external pouch to replace a surgically removed colon and rectum.

Today in 98 percent of patients with ulcerative colitis in whom the colon must be removed, it is replaced by an internal pouch, creating a reservoir for stool that is sutured directly to the rectal canal, said Dr. R. Balfour Sartor, chief medical adviser to the Crohn's and Colitis Foundation of America.

"This approach decreases urgency, enabling patients to defer the need to evacuate, and reduces the number of stools per day," Dr. Sartor said in an interview.

Inflammatory bowel diseases afflict 1.4 million Americans, typically starting in the teenage years and lasting a lifetime. But treatments for these chronic conditions are being transformed, spurred by the decoding of the human genome and a growing understanding of the balance of microbes in the gut and why it goes awry in some people.

As with operative changes for ulcerative colitis, in recent decades, surgery for Crohn's disease has become less disruptive of normal digestive function. Instead of removing diseased sections of the intestine, Crohn's patients can have a procedure called strictureplasty, better preserving the body's ability to absorb nutrients. Strictureplasty involves cutting the diseased area at its midpoint, stacking the two pieces on top of each other, then cutting and reconnecting them lengthwise.

The technique, known as Michalessi strictureplasty for the Weill Cornell surgeon Dr. Fabrizio Michalessi, has been shown to encourage regression of the disease in the treated area. "Surgery doesn't cure Crohn's," Dr. Sartor said, "but this technique preserves most of the natural function of the small intestine, where nutrients are absorbed."

Dr. Ellen J. Scherl, gastroenterologist at Weill Cornell Medical Center in New York, emphasized in an interview that "surgery is a therapy, not a failure of therapy."

She added, "If doctors persist with medical therapy to avoid surgery, they may be subjecting patients to chronic flare-ups."

At the same time, however, improved medical remedies are fast emerging. Experts in inflammatory bowel disease are working on treatments based on a patient's genetic makeup, an approach now increasingly used to treat cancer.

Dr. Ramnik J. Xavier, chief of gastroenterology at Massachusetts General Hospital in Boston, said that after determining the genomic regions associated with inflammatory bowel diseases (163 genes have been linked to the ailments), "we're now looking individually to identify certain genes that affect inflammation and the failure of ulcers to heal."

There are also genetic changes that protect the gut, Dr. Xavier said, and targeted molecules could be designed to both treat the disease and prevent relapses.

"Ulcerative colitis and Crohn's are in many ways the poster child for which sequencing the genome is having a tremendous impact," Dr. Xavier said in an interview.

Equally important to improved treatment has been understanding how environmental factors like diet and antibiotics can disrupt the balance of microbes in the gut. Some bacteria are protective and keep the gut healthy, while others result in chronic inflammation.

"Antibiotics, which alter the gut microbiome, may be helpful or not," Dr. Scherl noted. Tailor-making antibiotics that attack only harmful bacteria could give protective microbes a chance to dominate. And altering the diet to deny harmful microbes the nutrients they prefer can curb inflammation.

Dr. Scherl said that sugars, other carbohydrates and fats can lead to uncontrolled inflammation in the gut of people genetically predisposed to inflammatory bowel diseases. When a flare-up occurs, she said patients "must step back and eat simpler food — a so-called white diet — until the inflammation subsides.

Dr. Sandra C. Kim, pediatric gastroenterologist at Nationwide Children's Hospital in Columbus, Ohio, treats flare-ups in children with what is called an elemental diet, involving a liquid in which the nutrients are completely broken down. The diet deprives harmful bacteria in the gut of the nutrients they need to produce substances that foster inflammation.

Although Dr. Kim acknowledges that the diet is not easy to stick to, when pursued for eight to 12 it can induce remission of the disease, reduce the risk of relapse and enable the child to grow normally.

Another new approach aims at gut-specific transport of inflammatory cells from the blood into the gut. The Food and Drug Administration just approved a drug called vedolizumab, which blocks the movement of those cells.

"This is a completely new strategy for treating Crohn's and ulcerative colitis," Dr. James D. Lewis, professor in the gastroenterology division at the University of Pennsylvania Perelman School of Medicine, said in an interview.

Perhaps most important for people with an inflammatory bowel disease, Dr. Scherl said, is to be cared for by a specialist "who understands its complexities and nuances and listens to patients who are living with it."

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This is the second of two columns about inflammatory bowel diseases. Read the first, "Speaking Up About an Uncomfortable Condition."

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Well: Ask Well: Exercise After Knee Replacement

Q

Can I hike and cross-country ski again after knee replacement surgery?

What is the best exercise for someone with a partial knee replacement? Can I walk too much?

I've had a TKR (total knee replacement), and it's been wonderful. My doctor says no to my returning to running, but the arc of professional opinion seems to be tending toward greater exercise latitude. Has it come far enough to allow me 10-15 mi./week? (I'm 70 and fit.)

A

The idea that we should burn at least 2,000 calories a week during exercise seems to have originated in data gathered decades ago as part of the Harvard Alumni Study. That study followed male Harvard graduates for as long as 50 years, tracking how they lived and died. One of the first publications based on the data, appearing in 1978, showed that the older alumni who expended less than 2,000 calories a week in exercise were at 64 percent higher risk of suffering a heart attack than those who burned 2,000 calories a week or more during exercise. It's worth noting that the researchers' definition of exercise in this study was generous, including climbing stairs and walking around the block, as well as playing sports or jogging.

Widely reported at the time, the 2,000-calorie guideline still gets bandied about today. But the current exercise guidelines from the federal government, based on a large body of recent scientific evidence, emphasize time, not calories, and recommend that healthy adults engage in 150 minutes per week of moderate-intensity exercise, such as brisk walking or cycling.

Adhering to these guidelines means that most of us would burn about 1,000 calories per week in planned exercise, said Michael J. Joyner, an exercise researcher at the Mayo Clinic. And with the stairs we climb and chores we do, we come closer to that 2,000 calorie a week number, he said.

But we don't have to fret about actually reaching it. Meeting the current guidelines for 150 minutes or five brisk 30-minute walks per week is enough, he concluded. "The added health benefits start to level off after that."

Do you have a health question? Submit your question to Ask Well.

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