While we hear much about advances in treatments for breast cancer, less is said about the health issues these can trigger. Here Dr Philippa Kaye – a GP with a special interest in women’s health and author of Breasts: An Owner’s Guide – explains how to manage potential side effects to help you live well for longer:
The most common cancer in the UK, one in seven women will be affected by breast cancer at some point during their lives. And while this means that many will be affected, a combination of earlier diagnosis and better treatment pathways mean that there are also many breast cancer survivors, currently an estimated 600,000 in the UK alone, a number that will continue to rise.
But moving from active treatment – be that after surgery, radiotherapy or chemotherapy – to follow up can be difficult to navigate. As a bowel cancer survivor, I know that ending treatment can feel a little bit like falling off a cliff. You go from seeing your medical team extremely regularly, perhaps even once or twice a week, to every three months, six months or even further apart.
As little as anyone enjoys treatment, and as positive as it is to need to be seen less often, there is a feeling of safety from being assessed regularly by your team. The increasing time between appointments can be extremely anxiety inducing. This, combined with “scanxiety”, the worsening of anxiety in the lead up towards scans, can only increase worry.
Breast cancer survivorship is to be celebrated and everyone would hope that over time we will see more people than ever overcoming the disease. But to assume that once treatment is over everything goes back to normal does a disservice to those survivors. Surviving breast cancer or living with it for longer can bring health issues of its own and we need more research into long term health issues related to cancer treatment.
For now, those who are struggling should see their doctor, because there are ways to manage many of the issues which may occur. Here’s my guide to living well after breast cancer.
Menopause symptoms: Breast cancer can occur at all ages and hormone treatments used to tackle the cancer, such as tamoxifen and aromatase inhibitors, can cause symptoms of the perimenopause and menopause. This is because they block the production or effect of oestrogen, which regulates the menstrual cycle. However, even without hormone treatment chemotherapy can affect the ovaries, causing a premature menopause. The ovaries may also be affected by radiotherapy, or removed surgically.
This can leave women battling many physical symptoms including hot flushes and sweats, joint pains and palpitations. Psychological symptoms include low mood, depression and anxiety while issues such as insomnia, loss of libido and fatigue are also common. Infertility can occur after cancer treatment.
Symptoms can also affect the genitourinary system such as vaginal dryness/itching, painful sex and recurrent urinary tract infections, though these are often more common in those having ongoing treatment with aromatase inhibitors such as anastrozole, which lower oestrogen levels.
There has been much written about the menopause and the potential benefits of hormone replacement therapy (HRT) on symptoms. But currently HRT should only be offered to breast cancer survivors in exceptional circumstances, after other treatments have been tried and after discussion about potential risks and benefits.
What some women don’t realise is that this guidance only refers to “whole body” or systemic HRT and not to vaginal oestrogen. Vaginal oestrogen is really effective for the genitourinary syndrome and does not have the same risks as it acts locally rather than being absorbed across the whole body. This means that generally it can be given to breast cancer survivors and can make a significant improvement to symptoms.
There are also non-hormonal treatments available. These include SSRI and SNRI antidepressants and anti-seizure medications such as pregabalin and gabapentin. It doesn’t mean that you have depression or epilepsy, rather that these medications can be helpful for your symptoms.
Non-medication options such as cognitive behavioural therapy (CBT) and lifestyle measures such as exercise are also effective.
Lymphoedema: After cancer surgery there is a risk of developing lymphoedema, a build up of lymphatic fluid which in breast cancer patients which can lead to swelling of the arm, hand and chest on the side of treatment, which may feel tight and uncomfortable, stiff and inflexible or heavy.
The condition can develop rapidly after surgery or take months to occur. Some swelling in your chest and arm in the first few weeks after surgery is common and doesn’t mean that lymphoedema is developing, which affects approximately one in five or six of those who undergo breast cancer treatment and is more common if the lymph nodes in the armpit are removed during the procedure and/or if you have radiotherapy.
To reduce your risk of getting lymphoedema you should
• Exercise and keep active as usual
• Avoid too much salt in your diet and stay well hydrated
• Infection can increase your risk of lymphoedema, so be careful for example to wear gloves during gardening to avoid scratches, use insect repellent to avoid bites and keep cuts clean.
• Sunburn also increases risk, so use sunscreen regularly and keep limbs covered with light fabrics like linen.
• Try to avoid weight gain if possible.
Unfortunately there is no cure for lymphoedema and you are likely to be referred to a specialist lymphoedema nurse for advice and management. There are ways to reduce the symptoms, including
• Keeping the skin well moisturised
• Compression garments such as gloves or sleeves are available through the NHS. Be careful as you put them on that there are no rolls or wrinkles, as this may lead to too much pressure being applied. Alternatively kinesio taping, or K-tape, may be suitable to reduce swelling.
• Manual lymphatic drainage (MLD) is a form of massage which can help drain the fluid from the arm
• Where possible have your blood pressure or blood taken from the unaffected side.
Bone loss: Hormonal treatment used during breast cancer treatment can block oestrogen leading to an increased risk of osteoporosis, which makes bones thinner and more fragile with an increased risk of fractures.
This is most likely if you are on a hormone inhibitor as part of your treatment. If this is the case you may be offered a bone scan and if appropriate treatment.
It is important to take vitamin D, eat a calcium rich diet and remember, weight bearing activity is protective for healthy bones.
Fatigue: Tiredness is extremely common after breast cancer treatment with one in four affected. It is more common among those who have had chemotherapy. There are lots of reasons why this may occur but treatments such as peer support groups and CBT can be useful. Although it sounds contradictory, physical activity actually helps fatigue, and also helps decrease recurrence.
Mental health issues: Developing cancer does not solely affect you physical health, taking its toll on mental health as well. Low mood, depression, anxiety, loss of body confidence and OCD can all occur in relation to a cancer diagnosis. It is so important that you keep talking and get help if you need it. There are lots of treatments available depending on the condition such as antidepressants, anti-anxiety medications and talking therapies.
The terms “brain fog” and “chemo brain” are not medical diagnoses, but used by patients to describe difficulties with memory and concentration, forgetfulness, feeling that their thoughts are murky or muddled.
This can occur when on chemotherapy and beyond. It is not clear why this happens and in particular why it can persist even after treatment is finished. It could be related to the medications used in chemotherapy, the breast cancer itself or menopausal symptoms due to treatment. Talking therapies, exercise, mindfulness and yoga may all be useful.
Breast changes: Treatment for breast cancer generally involves some form of surgery and even if you don’t have a mastectomy, breast conserving surgery can change the shape and size of the breasts.
In addition to scarring, there can be changes such as an indent over the scar where internal scar tissue pulls the skin from underneath. Radiotherapy treatment can also change the breast, making it feel firmer and look smaller than previously.
As you age or go through the menopause the breasts change, becoming softer, or changing size and shape if you gain or lose weight. However a breast which has been exposed to radiotherapy may not alter in the same way, meaning that any asymmetry can become more obvious.
Breasts: An Owner’s Guide, is out now (£14.99, Dorling Kindersley)