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7.2 Other Post-treatment Issues

7.2.1 Second Cancers

In addition to the recognized increase in risk of developing a carcinoma of the contralateral breast, patients who have had breast cancer have a statistical increase in their risk of developing sarcoma of the breast/chest wall if treated with radiotherapy, carcinoma of the colon, carcinoma of the endometrium, and carcinoma of the ovary. The family physician should be aware of these possibilities in the follow-up of patients with breast cancer and should ask about corresponding signs or symptoms during the annual history.

7.2.2 Contraception

Ideally, patients who have been treated for breast cancer should avoid contraception that includes a hormonal maneuver. If a patient with a history of breast cancer requires contraception, then tubal ligation could be considered. Other options include non-hormonal contraception, such as a barrier techniques or an IUD.

7.2.3 Hormone Replacement Therapy After a Diagnosis of Breast Cancer

The Breast Tumour Group of BC Cancer has had a number of discussions regarding the use of hormone replacement therapy (HRT) after a diagnosis of breast cancer. The traditional dogma has been that any use of hormones in patients with a personal history is contraindicated. This is based on the epidemiology of primary breast cancer, which reports an increased incidence of breast cancer in postmenopausal women exposed to long-term estrogen replacement therapy.1 As well, a recent study has confirmed that HRT using a combination of progesterone and estrogen is also associated with an increased risk of developing breast cancer.2

There is no direct evidence that estrogen causes recurrence in women with a previous history of cancer, but there is evidence of a decreased recurrence rate when women with a history of breast cancer are treated with Tamoxifen or after oophorectomy. Concerns about doing harm and contributing to incurable breast cancer recurrences have limited the use of estrogen replacement in these women. However, we are seeing an increased number of young women with early breast cancer and a relatively good prognosis, who are experiencing early menopause after adjuvant chemotherapy. As well, through screening mammography, we are identifying large numbers of older women with highly curable breast cancer.

At this time, there is no good information on the risks of giving hormone replacement therapy to women after a diagnosis of breast cancer. There are a number of series reported in the literature, which are not helpful because the studies are too small and have very short follow-up.3,4,5,6 Although there are plans for large randomized studies of women with a history of breast cancer to assess the risks and benefits of hormone replacement therapy, this data will not be available for many years.

Without evidence of safety our general policy has been to do no harm and therefore to not risk prescribing HRT to women with a previous history of any breast malignancy if there are other therapeutic options that can result in similar outcomes. Although there is evidence that HRT can improve bone health and conflicting evidence for cardiac health, there are often other therapies and lifestyle changes that can also be of benefit and should be considered as the first options in women with a history of breast cancer. 

Non-hormonal Therapies

  1. Hot Flushes: Hot flushes may be particularly noticeable in the first few months after cessation of chemotherapy or the start of hormonal therapy.  These hot flushes may decrease over time, and patients may consider avoiding other therapy, at least initially. Avoidance of triggers for hot flushes may be helpful, including avoidance of caffeine (coffee or tea), chocolate, alcohol, colas, stress, hot weather. Medications that have been shown to be effective for some women include venlafaxine (Effexor) (lowest effective dose of 37.5 mg/day), clonidine (Dixarit) (0.05 mg bid), and gabapentin (Neurontin) (900 mg/day). 
  2. Vaginal Irritation/Dyspareunia: Non-hormonal, water-soluble moisturizers or lubricants applied directly to the vagina (e.g. Replens vaginal suppositories, or introitus, and/or penis, e.g. KY Jelly, may improve daily irritation or dyspareunia). 
  3. Heart disease: There is controversy over the role of hormone replacement and the prevention of heart disease. Maintenance of appropriate weight through diet and exercise, avoidance of smoking and management of hypertension and cholesterol may be of major benefit.
In situations where there is a greater health risk from the non-breast cancer disease and there are no other options, the woman should be informed of the situation clearly and an individual decision to use HRT may be appropriate. Similarly, if there are symptoms that interfere significantly with a woman's quality of life (i.e. troublesome hot flashes, vaginal dryness, vaginal atrophy, dyspareunia, sleep disturbances, depression) and there are no other therapeutic options, HRT can be considered. For vaginal complaints, topical estrogens using as low a dose as possible, may be considered. In all situations the woman must be fully informed about the risks, benefits, and areas where we are lacking in clear information, and the use of HRT monitored and for a limited duration.

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.7 It is not clear if either oral contraceptives or HRT affects the incidence of breast cancer in carriers of BRCA1 or BRCA2 mutations. Women with BRCA1 or BRCA2 mutations should be assessed by the Hereditary Cancer Program to discuss these issues.

In summary, the role of HRT in women with a history of breast cancer is unknown. If there are options for other therapies they should be used. Research may give us new insights in the next few years. If there are patients that need further assessment, please consult their oncologist. If HRT is used, it is advisable to prescribe the lowest dose of estrogen to relieve symptoms, to monitor the patient carefully and to consider short-term use until long-term data is available.

References

  1. Collaborative Group on Hormonal Factors in Breast Cancer. Breast Cancer and hormone replacement therapy: collaborative re-analysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet 1997; 350: 1047-1058.
  2. Schairer C, Lubin J, Troisi R, et al. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA 2000; 283: 485-491.
  3. Powles TJ, Hickish T, Casey S; Hormone replacement after breast cancer. Lancet: 1993; 342: 60-61.
  4. Stoll BA. Hormone replacement therapy in women treated for breast cancer. Eur J Cancer 1995; 25: 1909-1913.
  5. Disaia PJ. Estrogen replacement therapy for the breast cancer survivor; A reappraisal. J Surg Oncol 1997: 64; 175-80.
  6. Eden JA. A case controlled study of combined continuous estrogen-progestin replacement therapy among women with a personal history of breast cancer. Menopause 1995; 2: 67-72.
  7. Narod SA, Risch H, Moslehi R et al Oral contraceptives and the risk of hereditary ovarian cancer. NEJM 1998; 339: 424-427.

7.2.4 Patient Guidelines for the Prevention of Osteoporosis in Women

Revised 9 March 2011

Postmenopausal women have an increased risk of osteoporosis. As well, this risk can be increased further by factors such as family history, smoking, diet, early menopause, chemotherapy, long term corticosteroids and some hormonal therapies that lower estrogen.

The following guidelines are provided to patients to reduce the risk of bone loss during and after treatment. If a patient’s bone density scan at the start of treatment indicates that she or he are at increased risk of osteoporosis, medications such as bisphosphonates (eg. alendronate (Fosamax®) should be considered.  In addition, the following guidelines regarding management/prevention of osteoporosis, including information about optimal consumption of Calcium and Vitamin D, encouragement of weight-bearing exercise, avoidance of excessive caffeine and salt, and smoking cessation should be given to the patient. 

Calcium & Vitamin D

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. The recommended daily intake for calcium is 1200 mg. A daily supplement of 1000 IU of vitamin D is recommended for bone health and the prevention of cancer, in all women.

Food Sources of Calcium

Food SourcePortion Size
Calcium (mg)
Cheese (Swiss)
50 g (2 oz)
440
Cheese (Cheddar/Mozzarella)
50 g (2 oz)
390
Milk (skim, 1 or 2% MF or whole)
250 mg (1 cup)
300
Buttermilk, or Chocolate milk
250 ml (1 cup)
300
Yogurt, plain
175 ml (3/4 cup)
300
Milk powder, dry
45 ml (3 Tbsp)
280
Fortified Beverages (soy, rice, orange juice)
250 ml (1 cup)
300
Blackstrap Molasses
15 ml (1 Tbsp)
180
Parmesan Cheese
15 ml (1 Tbsp)
90
Sardines, with edible bones
24 mg
90
Cottage cheese, 2% MF
125 ml (1/2 cup)
80
Figs, dried, uncooked
3
80
Orange, raw
1 medium
50
Broccoli, frozen, boiled, drained
250 ml (1 cup)
50

Adapted from the Manual of Clinical Dietetics, 6th Edition (p.746-747), by American Dietetic Association et al, 2000.

Calcium intake from all sources should not exceed 2000 mg per day.

Food Sources of Vitamin D

Food SourcePortion Size
Vitamin D (IU)
Fish, herring
100 gm (3 oz)
900
Fish, mackerel or salmon
100 gm (3 oz)
650
Fish, sardines or tuna
100 gm (3 oz)
250
Milk or Soy Beverage, fortified
250 ml (1 cup)
90
Margarine, fortified
5 ml (1 tsp)
55
Egg
1 large
25

Adapted from the Manual of Clinical Dietetics, 6th Edition (p.746-747), by American Dietetic Association et al, 2000.

Vitamin D intake from all sources should not exceed 4000 IU per day.

Vitamin and Mineral Supplements

If you can't meet the recommended amounts with food alone, 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 (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.

Protein

Adequate protein is required to maintain bone health. Include one of the following protein rich foods at each meal: meat, fish, poultry, beans, lentils, nuts, eggs, milk, yogurt and cheese.

Caffeine and Salt

Excess caffeine and salt can have a negative effect on bone. Caffeine is found in coffee and also tea, chocolate (cocoa) and some soft drinks. For optimal bone health, limit coffee to less than 4 cups per day.

Foods high in salt generally include processed foods such as canned soups, snack foods, crackers, pastas and sauces. Check the nutrition label on processed foods and limit salt to less than 2100 mg per day.

Physical Activity

Being physically active 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.

Smoking

Smoking is related to poor bone and general health. If you smoke, ask your doctor for assistance to stop smoking.

Developed by BC Cancer Breast Tumour Group, 14 Oct. 2004; Revised March 2011

7.2.5 Pregnancy Following Breast Cancer

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 thirties 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. As well, pregnancy while on Tamoxifen is contraindicated.  Survivor preferences and medical indications must be balanced for individualized decisions regarding the optimal time to become pregnant after treatment of breast cancer. 

7.2.6 Lymphedema

Updated 5 March 2007

These guidelines are based on a review of published data and expert opinion from the Cancerlit and Medline databases (1966-2000) and from recent breast cancer textbooks.  The guidelines largely reflect evidence at Levels III-V and sometimes rely on consensus and common sense, due to limited clinical research in this area. 

Limitation of shoulder mobility may occur in as little as two weeks following immobilization. Post-operative physiotherapy is useful for most patients.

This guideline applies to the provision of upper extremity rehabilitation, as well as hand and arm care, to prevent/manage symptoms of the upper extremity including decreased range of motion, pain and lymphedema in people who have received axillary surgery as part of the management of breast cancer. Because breast cancer occurs predominantly in women, the remainder of the text addresses women with breast cancer, but recommendations are largely applicable to men as well.

Recommendations

Upper Extremity Rehabilitation

  • Pre-operative, bilateral upper extremity function, e.g. active range of motion (ROM), strength, sensation, and limb circumference, should be assessed by the surgeon, family physician, or a physical therapist to provide a baseline prior to treatments.1,2,3
  • Post-operative physical therapy should begin the first day following surgery. Gentle ROM exercises should be encouraged in the first week after surgery.1,2,4
  • Active stretching exercises can begin 1 week after surgery, or when the drain is removed, and should be continued for 6-8 weeks or until full ROM is achieved in the affected upper extremity. Women should be instructed in scar tissue massage.1,2,3,5
  • Post-operative assessments following surgery to include ROM, strength, sensation, limb circumference, and scar and chest wall tissue mobility.1,3,6
  • Progressive resistive exercises, i.e. strengthening, can begin with light weights (1-2 lbs.) within 4-6 weeks after surgery. A compression sleeve should be worn during any resistive exercises or strenuous upper body athletic activity.2,3,4,5,6,7
Hand and Arm Care

  • Careful hand and arm care, e.g. proper hygiene and avoiding trauma to the arm can minimize risks for infection and lymphedema.8,9,10
  • Minimizing the extent of axillary dissection, preventing infection, and avoiding obesity may help prevent the development of lymphedema.9,11,12,13
  • Generally, injections, vaccinations, venipuncture, and intravenous access in the axillary-dissected arms and shoulder have been contra-indicated.14,15,16 There is some evidence (Level V) that these restrictions can be relaxed.17
  • Many suggestions regarding proper hygiene and trauma avoidance for the axillary-dissected upper extremity are sensible but there is little scientific literature to support these restrictions.
Electrotherapy Modalities

Laser treatment, electrical stimulation, microwave, and thermal therapy are not recommended at this time due to insufficient evidence to support their use as well as published precautions and contra-indications for their use in persons with neoplasms.18,19,20

Therapeutic ultrasound is contra-indicated over sites of possible metastasis in women with a history of breast cancer.19,21,22,23

Exercise for Cardiovascular Fitness

Although these guidelines focus on upper extremity rehabilitation, women who have had breast cancer should be encouraged to engage in an ongoing, regular program of moderate, aerobic exercise.24,25 In a study published in 2005, women who exercised 3-5 hours per week (at an aerobic level equivalent to walking a 20-30 minute mile) significantly reduced their risk of recurrence as well as their risk of dying from breast cancer when compared to women who exercised less than 3 hours per week.26

Benefits, Risks, and Costs

Benefits include functional and timely recovery of the upper extremity and avoidance of lymphedema and/or cellulitis. There may be increased wound drainage if exercises are initiated too early post-operatively (Day 1). However a number of recent studies (Evidence Levels I-II) have supported both the safety and effectiveness of early post-operative exercise. Stretching exercises during the early post-operative period may assist in breaking up of sclerosed lymphatic vessels (which appear as fine, cord-like structures along the medial surface of the upper arm and forearm). Exercises should provide slow, prolonged stretches, particularly to the shoulder abductors and flexors, with minimal pain or discomfort.

To locate a physical therapist in your area who has special expertise in working with women facing breast cancer surgery or recovering from surgery, ask your doctors or women who had breast cancer, or check with the Physiotherapy Association of BC. You do not need a doctor's referral to access physical therapy private clinics. The Medical Services Plan of BC no longer covers the cost of private physiotherapy treatments unless you meet low-income criteria. Prior to scheduling your first appointment, discuss the costs for the initial assessment, follow-up appointments and cancellation policy.

Recommendations included in these guidelines, for standard pre- and post-operative assessments and treatments under the direction of a physical therapist would likely require fewer than 12 visits. In cases where complications arise (e.g. post-treatment lymphedema) additional physical therapy visits would be necessary. There may also be costs of compression sleeves, compression pumps, and antibiotic therapy in cases of infection. Many of these costs are covered, at least in part, through extended health plans.

References

  1. Gerber L. Rehabilitation management for women with breast cancer: Maximizing functional outcomes. In Harris JR, Lippman ME, Morrow M, Hellman S (eds):Diseases of the Breast, Lippincott-Raven, Philadelphia, 1996: 939-947.
  2. Wingate L, Croghan I, Natarajan N, Michalek AM, Jordan C. Rehabilitation of themastectomy patient: A randomized, blind, prospective study. Arch Phys Med Rehab 1989; 70: 21-24.
  3. 3Hladiuk M, Huchcroft S, Temple W, Schnurr BE. Arm function after axillary dissection for breast cancer: A pilot study to provide parameter estimates. J Surg Oncol 1992; 50: 57-52.
  4. Konecne SM. Postsurgery breast cancer inpatient program. Clinical Management 1992; 12: 42-49. 
  5. Miller LT. Postsurgery breast cancer outpatient program. Clinical Management 1992; 12: 50-56.
  6. Maunsell E, Brisson J, Deschenes L. Arm problems and psychological distress after surgery for breast cancer. Can J Surg 1993; 36: 315-320.
  7. Stumm D. Recovering from Breast Surgery: Exercises to Strengthen your Body and Relieve Pain, Hunter House, Alameda, CA, 1995.
  8. Spratt JS, Donegan WL. Surgical management. In Donegan WL, Spratt JS (eds.), Cancer of the Breast, ed. 4, W.B. Saunders, Philadelphia, PA, 1995: 443-504.
  9. Petrek J, Lerner R. Lymphedema. In Harris JR, Lippman ME, et al (eds): Diseases of the Breast., Lippincott-Raven, Philadelphia New York, 1996; 896-903.
  10. Brennan MJ, DePompolo RW, Garden FH. Focused review: Post mastectomy lymphedema. Arch Phys Med Rehabil. 1996; 77: S74 - S80.
  11. Segerstrom K, Byerle P, Graffman S, Nystrom A: Factors that influence the incidence of brachial edema after treatment of breast cancer. Scand J Plast Reconstr Hand Surg 1992; 26: 223-227.
  12. Aitken D. Complications associated with mastectomy. Surg Clin N Am 1983; 63(6): 1331 - 1351
  13. Werner RS, McCormick B, Petrek J, et al. Arm edema in conservatively managed breast cancer: Obesity is a major predictive factor. Therapeutic Radiology 1991; 180: 177 - 184.
  14. Centers for Disease Control and Prevention: General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices(ACIP). Morbidity and Mortality Weekly Report 1994; 43 (RR-1): 6.
  15. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, ed 3. National Committee for Clinical Laboratory Standards (NCCLS). Villanova, PA, 1991: H3-A3.
  16. Koepke JA. Phlebotomy after mastectomy (Letter). Medical Laboratory Observer. 1992; 12-14.
  17. Dawson WJ, Elenz DR, Winchester DP, Feldman JL. Elective hand surgery in the breast cancer patient with prior ipsilateral axillary dissection. Ann Surg Oncol 1995; 2(2): 132 - 137.
  18. Lehmann JF, de Lateur BJ. Therapeutic heat. In Lehmann JF (ed.), Therapeutic Heat and Cold, 4th ed., Williams & Wilkins, Baltimore, MD, 1990: 417-581.
  19. The Chartered Society of Physiotherapy. Safety of Electrotherapy Working Group.Guide lines for the safe use of lasers in physiotherapy. Physiotherapy 1991; 77: 169-170.
  20. Snyder-Mackler L, Collender SL. Therapeutic uses of light in rehabilitation. In Michlovitz SL (ed.): Thermal Agents in Rehabilitation, 3rd ed., F.A. Davis, Philadelphia, PA, 1996: 255-277.
  21. Hogan RD, Burke KM, Franklin TD. The effect of ultrasound on microvascular hemodynamics in skeletal muscle: Effects during ischaemia. Microvascular Res 1982; 23: 370-379.22.
  22. Basford JR. Physical agents and biofeedback. In DeLisa JA (ed.), Rehabilitation Medicine: Principles and Practice, Philadelphia, PA, J.B. Lippincott, 1988: 261-263.
  23. Friedenreich CM, Courneya KS. Exercise as rehabilitation for cancer patients. Clin J Sport Med 1996; 6: 237-244.
  24. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exer 1990; 22: 265-274.
  25. Thune I, Brenn T, Lund E, Gaard M. Physical activity and the risk of breast cancer. New Eng J Med 1997; 336: 1269-1275.
  26. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA. 2005;293:2479-2486.
  27. Sackett DL. Rules of evidence and clinical recommendations on the use of anti-thrombotic agents. Chest 1989;95:2S-4S.

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