Breast Cancer Survivorship Care

This section reviews long term issues after the primary treatment in breast cancer survivors including:

1. Physical adverse effects

Physical adverse effects of primary therapy:

This section reviews long-term physical adverse after primary therapy in breast cancer survivors.

1. Lymphedema:


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2. Pain management and comfort measures:

Pain can be caused by all treatments for breast cancer and by the cancer itself. Pain is varies depending on the individual and type of treatment. For example, some patients have relatively little discomfort with lumpectomy and require mild analgesics medication1. Others may moderate to severe pain after mastectomy and reconstruction that require stronger medication1. Speak to your doctor as the plan for post-operative pain is best individualised between clinicians and patients with regular monitoring for pain relief. Good communication is essential to getting continuous relief for any pain you may experience due to breast cancer or its treatment. The nature of your pain can change over time, and this may require a change in your treatment.

Chronic pain can also be caused by mastectomy and radiation to tissues causing permanent tightness and shrinkage2. Treatment include pain medication, physiotherapy, massage therapy2. Further, our doctor or pain specialist can help you manage your symptoms so you can continue your cancer treatments.

Further, women may experience post-operative muscles tightness, difficulties in lifting of the arm, soreness around shoulders. Gentle stretching exercise can be usually beginning soon after surgery (usually within 24hr hours), to maintain adequate range of motion. Your oncology team may refer you to physiotherapy.

3. Fatigue:

4. Neuropathy

It can be a side effect of chemotherapy, radiation or surgery. Neuropathy may present with loss of sensation, numbness, tingling, burning, decreased feeling of hot and cold, discomfort when touched, muscle weakness and cramping. This can involve your upper and/and lower limb3.

Treatments for neuropathy include medications, massage, and transcutaneous electrical nerve stimulation (TENS)4.  Strategies that you can try for managing neuropathy include Regular exercise, avoiding tight fitting shoes or socks and extreme hot and cold temperatures4,5. During the chemotherapy administration, keeping your hands in an ice bath, or frozen gloves may help you. Speak to your oncologist team as they consider changing the dose of treatment. Further, it is important to also take safety precautions as the decreased feeling in your hands and feet may increase the risk for injury

 

5. Skin changes

Radiation induced skin effects range from slight peeling, dryness, itchiness skin darkening, breast fullness and heaviness6.  To manage skin changes, wear loose-fitting clothes; wash with mild soap and lukewarm water; moisturize your skin twice a day with a thick cream that contains no alcohol, perfume or dye; you can also use gentle laundry detergents that are free of perfumes or dyes; and protect your skin from the sun. Your doctor may prescribe corticosteroid cream if needed. For breast fullness and heaviness, you can use firm, athletic bra6.

 

6. Bone health

Women who are treated with aromatase inhibitors (AI)s can experience joints and muscle pain as a side effect7. Additionally, AIs can increase the risk of osteoporosis and subsequently the risk of fracture7.  Therefore, if a bone density scan shows signs of bone loss, your doctor may prescribe a bone-modifying agent.  To promote good bone health, get enough calcium and vitamin D, and maintain a healthy weight. Perform weight-bearing exercises, such as walking, dancing and climbing stairs, which stimulate the production of bone-forming cells. Also, help prevent falls by wearing shoes that fit well and by avoiding clutter and small rugs in your home

 

7. Cognitive dysfunction (brain fog)

Data suggest that cognitive dysfunction related to chemotherapy may be an issue for breast cancer survivors8. Cancer-related brain fog is the feeling you get when your mind is hazy or cloudy. You can’t quite concentrate like you used to, multi-tasking has become more challenging impaired verbal and visuospatial abilities or you have difficulty remember things that occurred recently9. While it’s most commonly known as a side effect of chemotherapy, many patients who don’t get chemo complain of similar symptoms10. It might be related to other drugs you’re taking, the cancer itself, fatigue, low blood count, stress or hormone changes.

It’s important to give yourself time to heal. Over time, most patients find that their cognitive abilities improve9,10. These symptoms improve with time and can be stabilised after 6 months from the therapy completion9. But for some, symptoms can continue long after treatment ends. Strategies to compensate for these difficulties include is a side effect of systemic cancer therapies. Strategies you can use to cope with brain fog include use a calendar to keep all your important information in one place; exercise your brain with crossword puzzles, games, get proper sleep, physical activity, and nutrition and keep a record of your cognitive difficulties to share with your doctor, who may have other solutions. Sign up for mindfulness meditation classes. Meditation can help you focus your thoughts and improve your attention.

 

8. Menopausal symptoms

Endocrine and/or chemotherapy may induce temporary or permanent ovarian failure.  Symptoms include, hot flashes, dry vagina night sweats, sleep problems, mood changes, weight gain and slowed metabolism, thinning hair and dry skin11. Hormone therapy (HT) has been studied in breast cancer survivors, but safety has been questioned11. Ask your doctor for safer alternative medication to treat menopausal symptoms.

There are many strategies that you can do to improve your symptoms. For example, Physical exercise, particularly aerobic exercise (walking, running, bike riding, swimming), can help reduce hot flashes, sleep disturbances and mood swing11. Other strategies to manage hot flashes include wearing cotton, keeping ice water nearby to drink, taking a cool shower before going.  Limiting alcohol and Caffeinated beverages may also help with these symptoms.

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Related websites:

 

References:

  1. Poleshuck, E. L., Katz, J., Andrus, C. H., Hogan, L. A., Jung, B. F., Kulick, D. I., & Dworkin, R. H. (2006). Risk factors for chronic pain following breast cancer surgery: a prospective study.The Journal of Pain, 7(9), 626-634.
  2. Andersen, K. G., & Kehlet, H. (2011). Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention.The Journal of Pain, 12(7), 725-746.
  3. Speck, R. M., DeMichele, A., Farrar, J. T., Hennessy, S., Mao, J. J., Stineman, M. G., & Barg, F. K. (2012). Scope of symptoms and self-management strategies for chemotherapy-induced peripheral neuropathy in breast cancer patients.Supportive Care in Cancer, 20(10), 2433-2439.
  4. Bandos, H., Melnikow, J., Rivera, D. R., Swain, S. M., Sturtz, K., Fehrenbacher, L., & Ganz, P. A. (2018). Long-term peripheral neuropathy in breast cancer patients treated with adjuvant chemotherapy: NRG Oncology/NSABP B-30.JNCI: Journal of the National Cancer Institute, 110(2), djx162.
  5. Hadji, P. (2009). Aromatase inhibitor-associated bone loss in breast cancer patients is distinct from postmenopausal osteoporosis.Critical reviews in oncology/hematology, 69(1), 73-82.
  6. Tesselaar, E., Flejmer, A. M., Farnebo, S., & Dasu, A. (2017). Changes in skin microcirculation during radiation therapy for breast cancer.Acta Oncologica, 56(8), 1072-1080.
  7. Hermelink, K., Bühner, M., Sckopke, P., Neufeld, F., Kaste, J., Voigt, V., … & Harbeck, N. (2017). Chemotherapy and post-traumatic stress in the causation of cognitive dysfunction in breast cancer patients.JNCI: Journal of the National Cancer Institute, 109(10).
  8. Biglia, N., Bounous, V. E., Malabaila, A., Palmisano, D., Torta, D. M. E., d’Alonzo, M., … & Torta, R. (2012). Objective and self‐reported cognitive dysfunction in breast cancer women treated with chemotherapy: a prospective study.European journal of cancer care, 21(4), 485-492.
  9. Lange, M., & Joly, F. (2017). How to identify and manage cognitive dysfunction after breast cancer treatment.Journal of oncology practice, 13(12), 784-790.
  10. Crandall, C., Petersen, L., Ganz, P. A., & Greendale, G. A. (2004). Association of breast cancer and its therapy with menopause-related symptoms.Menopause, 11(5), 519-530.
  11. Rosenberg, S. M., & Partridge, A. H. (2013). Premature menopause in young breast cancer: effects on quality of life and treatment interventions.Journal of thoracic disease, 5(Suppl 1), S55.

 

2. Psychosocial issues

This section reviews psychosocial issues in breast cancer survivors.
1. Fear of recurrence :

2. Anxiety

Approximately 18 to 25 percent of long-term cancer survivors report anxiety.1 Reasons of heightened distress after breast cancer diagnosis include fear of recurrence, concerns about family, changes in self perceptions and body image, increase awareness of vulnerabilities.2Several factors have identified as risk for anxiety for survivors including, advanced disease, present of long-term physical symptoms that are related to treatment, lack of social support, a previous history of mental condition.2

Physical and psychological symptoms of anxiety include insomnia, hypervigilance to symptoms or event, shortness of breath, jitteriness, distractibility, worrying thoughts apprehensive, low concertation emotional numbness and fatigue.1 If these symptoms interfering with your quality of life and the ability to carry out daily activities, further evaluation and treatment may be required. Speak to your doctor if you are experiencing these symptoms. Treatments include talk therapies, either individually or in a group, and anti-depressants. You may try relaxation exercises that can help improve your mood Yoga, Meditation, Massage2.

 

3. Depression

In breast cancer survivors, depression is less common compared with anxiety1. However, it’s associated with a twofold increase for all cause of mortality2. Symptoms of clinical depression include at least two weeks of unusual sadness or decreased pleasure in daily activities, a decline in functioning, as well as five of the following; a significant change in weight or appetite, change in sleep (this can include either lack of sleep or excessive sleepiness), Fatigue or loss of energy, Guilt/worthlessness, low Concentration or more indecisive Suicidality. It may be something you notice yourself or observed by your friends and family.3

While some sadness or anxiety is normal when you have breast cancer, mood disturbances require treatment if they are severe, persistent, or accompanied by thoughts of death and dying. If this is the case for you, ask your oncology team or your family doctor. Treatments include talk therapies, and anti-depressants or anti-anxiety agents designed to lift mood disturbances. You may try relaxation exercises that can help improve your mood Yoga, Meditation, Massage.

It is important to get help immediately if you are experiencing thoughts of suicide.

 

4. Survivor guilt

It’s a complex psychological condition that is described as a sense of blame for the diagnosis, loss and grief. Additionally, feeling that they have done something wrong that can be never corrected as a result of having survived cancer3. This can lead to mood disturbance. However, survivors may use this guilt to giving back participation in advocacy activities, positive health changes in health (diet, exercise and smoking cessation).

5. Social issues:

Cancer and its treatment can have a broad reach into the lives of cancer survivors and their caregivers and their social network (eg, friends, community, church). Specific issues that have been evaluated are discussed below.

  • Caregivers

Breast cancer exerts its effects on the spouse or significant other particularly during the active treatment. Caring for a cancer patient can take a toll on the caregiver’s health. Available data has suggested that caregivers experience distress, anxiety and depression. Sharing thoughts and feelings about cancer experience of both the patient and caregivers is found to decrease distress and/or depression4.

  • Children

Mother with breast cancer report various concerns about their children range from their daily disruptions to questions about dying and leaving children behind. How to talk to children about breast cancer. Children of parents who are breast cancer survivors may face psychosocial issues. These include feelings of uncertainly, anxiety and isolation A child age, cognitive capacities, strengths and gender may influence of children response’s to mother’s breast cancer. Recent studies have showed that adolescent5. females were found to be the most negatively impacted5. One study demonstrated that among adolescent daughters of breast cancer survivors, those exhibiting greater anxiety had mothers who demonstrated greater anxiety in their relationship7.

  • Adjustment to work:

Work issues can be major hurdles in adjustment after breast cancer. Returning to work can be difficult for many survivors as they are recovering from the physical and psychosocial issues related to cancer and its treatment. Worry about health insurances and benefits poses a Hight priority concern. Other challenges include fatigue, physical limitations (difficulties with range of motion), psychological issues including anxiety and depression, and also menopausal symptoms. Self-employed survivors also have a more difficult time returning to work. 

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Related links:  

References:

  1. Baqutayan, S. M. S. (2012). The effect of anxiety on breast cancer patients. Indian journal of psychological medicine, 34(2), 119-123.
  2. Tsaras, K., Papathanasiou, I. V., Mitsi, D., Veneti, A., Kelesi, M., Zyga, S., & Fradelos, E. C. (2018). Assessment of depression and anxiety in breast cancer patients: prevalence and associated factors. Asian Pacific journal of cancer prevention: APJCP, 19(6), 1661.
  3. Cvetković, J., & Nenadović, M. (2016). Depression in breast cancer patients. Psychiatry research, 240, 343-347.
  4. Telling your children. (2020). Retrieved March 25, 2021, from https://www.cbcn.ca/en/children_and_breast_cancer
  5. Di Wei, X. Y. L., Chen, Y. Y., Zhou, X., & Hu, H. P. (2016). Effectiveness of physical, psychological, social, and spiritual intervention in breast cancer survivors: An integrative review. Asia-Pacific journal of oncology nursing, 3(3), 226.

 

3. Promoting a healthy lifestyle

Healthy eating and physical activity after treatment are important as you recover from treatment and begin your life beyond breast cancer. Learn how to improve your overall outcome from breast cancer. Studies have demonstrated that interventions targeting weight, diet, and physical activity are feasible, can improve quality of life (QOL), and may minimize disease and treatment-related side effects for cancer survivors

1. Physical activity:

Evidence has suggested that moderate intensity exercise can improved survival and outcomes in breast cancer survivors. Physical activity can help to improve mental health conditions (anxiety, depression), physical function, health related quality of life, body size and image1.

Additionally, upper body strength training can improve mobility and lymphoedema. Although there is no clear consensus on the “best” type of physical activity for breast cancer survivors, the general recommendation would be at least 30 minutes of aerobic exercise three times per week and resistance training twice a week2. Additionally, supervised resistance training led to reductions in lymphedema symptoms in breast cancer survivors.

 

2. Diet:

The existing data is also inconsistent to recommend upon intake of specific dietary nutrients. However, the general recommendation is to focus on specific dietary nutrients that are fruit and vegetables base and, avoiding processed foods, red meat and fat. A few observational studies have shown that ingestion of a diet rich in fruit and vegetables and low in meat and process food have decreased the overall mortality rate. Further, alcohol use after breast cancer diagnosis was also associated with an increased risk of breast cancer recurrence.

 

3.Obesity

Obesity is a well-established risk factor for breast Cancer diagnosis. Weight gain after a breast cancer diagnosis may be associated with an increased risk of recurrence, although the available data do not consistently report this association3. Despite the abundant data linking obesity and poor prognosis in early breast cancer, there have been relatively few studies evaluating the efficacy and potential benefits of weight loss interventions in breast cancer survivors

 

4. Complementary therapies

Complementary therapies, including acupressure and mindfulness, music therapy, and yoga have been explored as treatments in cancer survivors4. While there is no evidence that these interventions decrease recurrences, they may improve quality of life and mood.

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Related link:

References:

  1. Kim, J., Choi, W. J., & Jeong, S. H. (2013). The effects of physical activity on breast cancer survivors after diagnosis. Journal of cancer prevention, 18(3), 193–200. https://doi.org/10.15430/jcp.2013.18.3.193
  2. Pinto, B. M., Papandonatos, G. D., & Goldstein, M. G. (2013). A randomized trial to promote physical activity among breast cancer patients. Health Psychology, 32(6), 616.
  3. De Cicco, P., Catani, M. V., Gasperi, V., Sibilano, M., Quaglietta, M., & Savini, I. (2019). Nutrition and breast cancer: a literature review on prevention, treatment and recurrence. Nutrients, 11(7), 1514.
  4. Ecker, B. L., Lee, J. Y., Sterner, C. J., Solomon, A. C., Pant, D. K., Shen, F., … & Chodosh, L. A. (2019). Impact of obesity on breast cancer recurrence and minimal residual disease. Breast Cancer Research, 21(1), 1-16.
  5. Brems, C., Barnett, J., Parret, V. C., Metzger, J., & Johnson, M. E. (2013). Alternative and complementary treatment needs and experiences of women with breast cancer. The Journal of Alternative and Complementary Medicine, 19(7), 657-663.