Published: Thursday, May 03, 2007
- Major needs of patients after treatment
- Helping patients after treatment
- Timing of recurrence
- Recommendations for follow-up after breast cancer treatment
- Role of hormone replacement for women who have a history of breast cancer
- Guidelines for contraception following a breast cancer diagnosis
- Guidelines for prevention of osteoporosis
- Roll of exercise following a breast cancer diagnosis
- Nutrition guidelines following a breast cancer diagnosis
- Foods to avoid - about flax, soy and alcohol
- Vitamins or supplements that should be avoided
- Resources for patients after treatment
1. Major needs of patients after treatment
"At the end of treatment for breast cancer, whether it is surgery, radiation or chemotherapy, most women experience a mixture of elation, fear, and uncertainty (reviewed in Rowland and Massie, 1998). Although they have mastered the many aspects of their treatment regime, they have little preparation and information to guide them in their recovery from treatment. This is coupled with their planned discharge from intensive interaction with the health care system. No longer do they have daily or periodic visits to the treatment centre. In fact, they may not have a scheduled return visit for several months after the completion of therapy. In most cases, a woman is referred back to her primary care physician and may have no further contact with the oncology treatment team."1
During this transition or re-entry period, a woman may have questions about her symptoms and their care. Who will she talk to about the non-specific joint pains that are bothering her, or the fatigue and difficulty sleeping she is still experiencing? Could these be signs of recurrence? Why is she still experiencing so much fatigue when her treatments ended several weeks ago? Why is her family not paying as much attention to her, and why do they expect life to go back to normal when for her it has been changed forever? The post treatment transitional period is a time of considerable psychosocial distress. The paradoxical increase in anxiety has been observed at the end of both radiation and systemic chemotherapy (Holland and Rowland, 1991). Nevertheless, many women find positive meaning and describe post traumatic growth for the cancer experience (Ganz et al., 1996). Nevertheless, fear of recurrence is frequently a dominant emotion that is difficult to control, especially before or during the follow-up visits."1
"There has been a growing interest in the late effects of breast cancer treatment and the quality of life of long-term survivors beyond the acute phase of treatment. Several studies have compared breast cancer survivors to healthy, age-matched populations of women and have found few differences in their long-term physical and emotional well-being (Andersen et al., 1989; Dorval et al., 1998; Ganz et al., 2002, 1998a). A recent study of long-term adjustments of women 20 years after treatment in a large multi-centre clinical trail found cancer worries to be negligible; however, 18 percent of women had posttraumatic stress symptoms, and many reported lymphedema (27%) and numbness (20%) as persistent problems (Kornblith et al., 2003). There is some evidence that women who receive adjuvant therapy may have more physical disruption than those who receive no further therapy, and that women who receive chemotherapy may have more cognitive dysfunction than survivors who did not receive similar therapy (Ahles et el., 2002; Brezden et al., 1999; van Dam et al., 1998). With the growing number of breast cancer survivors, as well as increased research funding targeting this population, new evidence will be forthcoming regarding these cognitive and psychosocial concerns (Gotay and Muraoka, 1998). Nurses can play an important role in ensuring that patients have the information they need and providing reassurance and validation about their feelings after treatment is complete."1
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2. Helping patients after treatment
- Ensure that patients are aware of their follow-up plan as outlined by their oncologist. This information should be provided in written format using the BC Cancer Agency pamphlets "Follow-up Program after Breast Cancer Treatment"-English, "Follow-up Program after Breast Cancer Treatment" -Chinese or "Follow-up Program after Breast Cancer Treatment" - Punjabi or can be recorded in the "Breast Cancer Companion Guide" contained in the Breast Cancer Information Kit
- Encourage patients to review appropriate sections in their "Breast Cancer Information Kit" for further information on life after breast cancer
- Ensure that patients are aware of who will be responsible for their follow-up care, how often they are to see them and what should happen at those visits
- For women who will still have regular mammograms, explain that they are no longer eligible through the Screening Mammography Program. Mammograms will need to be booked by their family doctor through a Diagnostic Breast Imaging Service
- Explain that fear of recurrence and fatigue are very common responses to the end of treatment. Direct patients to the Awareness Guide: "After Breast Cancer Treatment: What Next?" contained in the Breast Cancer Information Kit to learn about common issues after treatment and ways to help themselves
- Teach breast self- examination techniques to patients who are interested
- Encourage regular exercise, healthy nutrition, and stress management strategies
- If emotional distress levels are high, encourage counselling, support group involvement or CancerConnection programs
- Inform patients of dragon boating activities in their communities
3. Timing of recurrence
Learn about the risk of locoregional and systemic recurrence.
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4. Recommendations for follow-up after breast cancer treatments
For the rest of their lives, women with a history of breast cancer are at risk for recurrence. Most recurrences are detected within five years, but recurrence can occur up to 10 years after diagnosis, and later recurrence is not uncommon. Because many long term follow-up studies have shown that more than 75 percent of recurrences are heralded by symptoms or findings on physical examination, any of the following symptoms should be investigated thoroughly: changes in the breast or chest wall, adenopathy, weight loss, persistent cough, cardiopulmonary symptoms, and musculoskeletal pain.2
Routine lab work, chest x-rays and bone scans rarely identify metastatic disease in asymptomatic patients (15-25% of all cases of metastatic disease). Women with a history of breast cancer are at risk for second primary cancers in the contralateral breast. This is estimated at 0.5 to 1% per year and is greater in women with hereditary breast cancer.3
General: All patients with breast cancer should have regular follow-up surveillance. The responsibility for follow-up should be formally allocated to a single physician. The frequency of visits should be adjusted according to individual patients' needs. All visits should include a medical history. For women who are taking tamoxifen, it is important to ask about vaginal bleeding. Physical examination should include breasts, regional lymph nodes, chest wall, lungs and abdomen. The arms should be examined for lymphedema. Annual visits should include mammographic examination. Routine laboratory and radiographic investigations should not be carried out for the purpose of detecting distant metastases.
Patients should be encouraged to report new, persistent symptoms promptly, without waiting for the next scheduled appointment. If a woman wishes to carry out breast self-examination, it is reasonable to teach her the proper procedure. Psychosocial support should be encouraged and facilitated.
Cognitive Functioning: Chemotherapy may affect cognitive functioning and this may be sustained. However, there is no correlation between subjective complaints of cognitive impairment and objective measures. Fatigue may affect approximately one-quarter to one-third of breast cancer survivors. Patients should be asked about symptoms of fatigue. Physiologic causes of fatigue should be investigated and ruled out. Depression and pain are potentially treatable underlying factors.
Weight management should be discussed with all breast cancer survivors. Overweight patients should be encouraged to participate in evidence-based weight management programs.
Bone Health: Patients who are postmenopausal, or are premenopausal with risk factors for osteoporosis, or are taking aromatase inhibitors, should undergo a screening bone mineral density test. Patients should be counselled on exercise and on adequate intake of calcium and vitamin D. Osteoporosis treatment should include a bisphosphonate.
Sexual Functioning: Sexual functioning should be discussed with women at follow-up visits.
Pregnancy: Women considering pregnancy following a diagnosis of breast cancer should be informed of the limited data on the effect of pregnancy on outcomes such as breast cancer recurrence and survival. Most of the studies have been retrospective case series or case-control studies with small numbers of patients. Nevertheless, there is currently no evidence that subsequent pregnancy adversely affects survival. The literature suggests that pregnancy after a carcinoma of the breast is not hazardous. It is however recommended that patients be advised to delay pregnancy. The length of the delay depends upon two factors, the initial stage of the disease and thus the probability of the development of metastatic disease; and the age of the patient at the time of diagnosis. The greatest incidence of both locoregional recurrence and distant metastases occurs within the first two years following diagnosis and treatment. It would appear that for women in their 30s desirous of a subsequent pregnancy a delay of two years should be recommended. For very young women with breast cancer a delay of five years may be more appropriate since the chance of developing metastatic disease is much reduced after such an interval and child bearing potential is probably not significantly adversely affected. This, however, is always a personal decision.3
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5. Role of hormone replacement therapy in women with a previous diagnosis of breast cancer
- Routine use of HRT (either estrogen alone or estrogen plus progesterone) is not recommended for women who have had breast cancer. Randomized controlled trials are required to guide recommendations for this group of women. Women who have had breast cancer are at risk of recurrence and contralateral breast cancer. The potential effect of HRT on these outcomes in women with breast cancer has not been determined in methodologically sound studies. However, in animal and in vitro studies, the development and growth of breast cancer is known to be estrogen dependent. Given the demonstrated increased risk of breast cancer associated with HRT in women without a diagnosis of breast cancer, it is possible that the risk of recurrence and contralateral breast cancer associated with HRT in women with breast cancer could be of a similar magnitude
- Post-menopausal women with a previous diagnosis of breast cancer who request HRT should be encouraged to consider alternatives to HRT. If menopausal symptoms are particularly troublesome and do not respond to alternative approaches, a well-informed woman may choose to use HRT to control these symptoms after discussing the risks with her physician. In these circumstances, both the dose and the duration of treatment should be minimized
- The role of HRT in women with a known genetic mutation in BRCA1 or BRCA2 causing an increased risk of breast or ovarian cancer is also unknown. There is evidence that oral contraceptives may be of value in decreasing the incidence of ovarian cancer. It is not clear if either oral contraceptives or HRT affects the incidence of breast cancer in carriers of BRCA1 or BRCA2 mutations. There is one study suggesting that early and multiple pregnancies are not protective in these women, so more research is needed.4
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6. Guidelines for contraception following a diagnosis of breast cancer
If permanent contraception is desired by the patient and her partner, then tubal ligation should be considered. For patients who are not yet ready to contemplate sterilization, a non-hormonal procedure such as barrier techniques or an IUD should be recommended.5
7. Guidelines for prevention of osteoporosis
Postmenopausal women have an increased risk of osteoporosis. As well, this risk can be increased further by factors such as family history, smoking, diet (excess caffeine and salt), early menopause, chemotherapy, long term corticosteroids and some hormonal therapies that lower estrogen.
If a bone density scan at the start of treatment indicates that the patient is at increased risk of osteoporosis the use of medications such as bisphosphanates (eg. alendronate (Fosamax)) may be recommended along with the guidelines below.
Protein, calcium and vitamin D are essential for strong bones. A daily dose is the sum of what you consume from food sources and from supplements. For postmenopausal women the recommended daily dose is 1500 mg of calcium and 800 IU of vitamin D. For premenopausal women the recommended daily dose is 1000 mg calcium and 400 IU vitamin D. Calcium intake from all sources should not exceed 2500 mg per day.6
Patient Guidelines for the Prevention of Osteoporosis in Women are available here.
Vitamin and Mineral Supplements:
Patients who cannot meet the recommended amounts of calcium with food alone may consider a supplement. Calcium carbonate is the least expensive calcium supplement and is well tolerated by most people when taken with food. The absorption of calcium from supplements is most efficient at doses of 500 mg or less. Some calcium supplements also include vitamin D (patients should check the label for the exact amount). A standard multivitamin and mineral supplement provides approximately 175 mg of calcium and 400 IU of vitamin D and other nutrients.6
Physical Activity:
Physical activity maintains optimal bone health and decreases the risk of a bone fracture by improving bone mass and increasing muscular strength, coordination and balance and thereby reducing falls. Physical activity that is weight bearing is best; examples include walking, dancing, aerobics, skating and weight lifting. 6
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8. Role for exercise following a breast cancer diagnosis
Although the scientific evidence for advice on nutrition and physical activity after cancer is much less certain than for cancer prevention, it is likely that following the American Cancer Society guidelines on diet, nutrition, and cancer prevention may be helpful in reducing the risk for recurrence of a second cancer. Furthermore, obesity has been shown to adversely affect prognosis of breast cancer survivors, so a healthy body weight should be encouraged. Avoiding or reversing weight gain after breast cancer treatment is especially responsive to exercise interventions and, in particular, resistance training.7
The American Cancer Society's guidelines for physical activity for cancer prevention are:
"Engage in at least moderate activity for 30 minutes or more on 5 days or more days of the week (10 minutes of exercise three times per day has the same benefit as 30 minutes once a day); 45 minutes or more of moderate to vigorous activity on 5 days or more per week may further enhance reductions in the risk of breast and colon cancer."7 Moderate activity is anything that makes you breath hard but can still carry on a conversation. Vigorous activity is anything that results in an increased heart rate, breathing rate and sweating.6
Some patients will have particular issues where exercise precautions need to be followed. Patients who are anemic should delay exercise until the condition has improved; patients with compromised immune function should avoid public gyms and other public places until their white blood cell count improves; survivors with severe fatigue should limit exercise to 10 minutes of stretching per day; patients undergoing radiation should avoid chlorine exposure to radiated skin; and those with peripheral neuropathies may have a reduced ability to perform exercises that use the affected limb because of weakness or loss of balance.7
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9. Nutrition guidelines following a breast cancer diagnosis
Most women find that making big changes in their lifestyle (diet, exercise) is very difficult at the time of diagnosis and during treatment. Saving major changes until after your treatment can be helpful. During treatment, it is helpful to keep the changes small and focus on keeping up strength.
To date, the evidence for dietary fat in affecting the risk of recurrence and survival is not strongly or consistently supportive.8 However, there are currently two major randomized clinical trials (the WINS and the WHEL studies) that will provide more definitive data on whether changes in diet, including reduced fat, can influence the risk of recurrence and survival after a diagnosis of early-stage breast cancer. Results of these studies should be available in 2006.7 The American Cancer Society's guidelines for nutrition for cancer prevention are:
- Eat a variety of healthful foods, with an emphasis on plant sources
- Eat five or six servings of a variety of vegetables and fruits each day
- Chose whole grains in preference to processed (refined) grains and sugars
- Limit consumption of red meats, especially those high in fat and processed
- Choose foods that help to maintain a healthful weight
The Canadian Cancer Society booklet, “Nutrition and cancer: What you need to know”, provides practical nutrition information for treatment and following treatment. It is available at the BC Cancer Agency Nutrition Department, online and by calling the Cancer Information Service at 1.888.939.3333.
10. Foods to avoid - about flax, soy, and alcohol
Although there is much interest in the role of soy foods in breast cancer prevention, scientific support is inconsistent. Current knowledge suggests neither specific benefits nor harmful effects when soy is consumed by as many as three servings per day of soy foods such as tofu and soy milk. Because higher doses of soy have estrogenic effects, it is prudent for breast cancer survivors to avoid high doses of soy and soy isoflavones that are provided by more concentrated sources such as soy powders and isoflavone supplements.7
More research is needed before any recommendations regarding the inclusion of flaxseed in the cancer survivor's diet can be made. If survivors choose to consume flaxseed, using the whole seed provides the potential benefits of both omega-3 fatty acids and fiber, but the seed coat must be broken (either by grinding or soaking) to liberate the omega-3 fatty acids. If flaxseed oil is used, it must be refrigerated shortly after the seed coat is broken.7
Although alcohol intake has been linked with a modest increase in the risk for primary breast cancer, there is limited evidence from studies of breast cancer survivors of a relationship with the risk of recurrence and survival. In the general population, consistent evidence links modest alcohol intake of one to two drinks per day (one drink is defined as 5 oz. of wine, 12 oz. of beer, or 1.5 oz. of hard liquor) with a lower risk of cardiovascular disease. Because some cancer survivors are at risk for cardiovascular disease as well as for cancer recurrence and new primary cancers, the potential benefits and risks of alcohol must be weighed carefully on an individual basis.7
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11. Vitamins or other supplements that should be avoided
Health experts use the term ‘antioxidant’ to refer to certain substances that protect the cells in our bodies. Examples are carotenoids, vitamin C and vitamin E and selenium. There is concern that very large amounts of antioxidants may interfere with cancer treatments, so research is being done to study their effects. At present, supplemental antioxidants are not recommended during treatment. Patients wishing to take antioxidants after treatment should wait for one or two weeks after treatment is finished.7
12. Resources for after treatment
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References:
1. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial peeds of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg.28-29.
2.Burstein HJ, Winer, EP. Primary care of survivors of breast cancer. New England Journal of Medicine. 2000, Oct 12; 343(15): 1086-1093.
3. Clinical practice guidelines for the care and treatment of breast cancer. Guideline 9: Follow-up after treatment for breast cancer (Rev. May 10, 2005), CMA Media, Inc. 2006.
4. Clinical practice guidelines for the care and treatment of breast cancer.Guideline 14: The role of hormone replacement therapy in women with a previous diagnosis of breast cancer (Apr. 16, 2002), CMA Media, Inc. 2006.
5. BC Cancer Agency (http://www.bccancer.bc.ca). Vancouver (B.C.): 2006. (cited Sep 22, 2006). Available from: http://search.phsa.ca/cgi-bin/MsmGo.exe?grab_id=0&page_id=2523&query=contraception&hiword=CONTRACEPTIVE%20CONTRACEPTIVES%20contraception%20
6. BC Cancer Agency (http://www.bccancer.bc.ca). Vancouver (B.C.): 2006. (cited Sep 22, 2006). Available from: BC Cancer Agency's Cancer Management Guidelines -> Breast -> Follow-up
7. Brown JK et.al., Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA Cancer Journal for Clinicians, 2003; 53:268-291, American Cancer Society, © 2003.
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