Breast cancer survivorship: key issues and priorities of care

MENOPAUSAL SYMPTOMS

Many breast cancer treatments can induce menopausal symptoms that may be more severe than those of the physiological menopause, and significantly affect quality of life. A variety of approaches can be attempted including acupuncture, cognitive behavioural therapy, antidepressants, and gabapentin. Hormonal replacement therapy should be avoided in women with a history of early breast cancer because this may precipitate recurrence. Urogenital symptoms including atrophic vaginitis can be a particular problem with aromatase inhibitor therapy. Lifestyle modifications may help, such as stopping smoking and avoiding scented hygiene products. Vaginal non-hormonal preparations may also be helpful, but topical oestrogen preparations are best avoided if possible owing to the potential for systemic absorption. Occasionally, menopausal symptoms are so troublesome that women wish to stop their endocrine therapy; in these cases, discussion with the patient’s oncologist as to the risk–benefit trade-off is usually indicated.

BONE HEALTH

Women treated for early breast cancer, particularly those on adjuvant hormone therapies, are at significant risk of osteoporosis and its associated complications. In patients who are pre-menopausal, tamoxifen appears to accelerate annual bone loss by 1–2% only, and therefore these patients do not routinely require bone monitoring or protection. By contrast, aromatase inhibitors (such as letrozole, anastrazole, and exemestane) significantly increase the risk of osteoporosis and associated fracture.^4,5 Patients receiving these agents should have a calcium-rich diet, take 1000–2000 IU vitamin D daily and undertake regular weight-bearing exercise. For those with a baseline T score of <2, assessment of bone mineral density should be undertaken every 1–2 years. In the event of >10% loss annually, or 4–5% if the patient was osteopenic at baseline, an oral or intravenous bisphosphonate should be initiated.⁶

PSYCHOLOGICAL

There is no standard psychological reaction to a diagnosis of breast cancer, and patients vary in their ability and methods of coping. They may struggle with uncertainty, particularly in relation to future recurrence, family and relationship stress, disordered mood including anxiety and depression, and issues around body image. Effective patient-centred communication and a continued focus on supportive self-management are key to detecting and preventing potential psychological problems. In difficult cases, referral for counselling or cognitive behavioural therapy may be helpful.

Some patients report cognitive problems during the time of chemotherapy, including difficulties with word-finding, multitasking, short-term memory, and attention span, and in some cases these persist beyond treatment completion. There is evidence that non-pharmacological intervention, such as cognitive training, exercise, yoga, and mindfulness-based activities, may be helpful in some patients.

FATIGUE

Cancer-related fatigue is poorly understood, but has been reported in 30–50% of breast cancer survivors in the first 5 years after treatment.⁷ Significant risk factors include chemotherapy and coexistent depression, anxiety, or catastrophising personality, and identifying these at-risk patients early may be helpful. Management may include promotion of physical activity and exercise, acupuncture, cognitive-behavioural interventions, and mind–body interventions such as yoga and massage. Guarana and ginseng may be helpful, but this has not been confirmed in randomised clinical trials.

LOCAL AND REGIONAL CHANGES

Changes in the breast tissue are common in patients who have undergone surgery and adjuvant radiotherapy; these can include breast shrinkage, telangiectasia, pigmentation, and breast swelling. Patients are counselled regarding these changes prior to therapy, but they can nonetheless cause concern, and if there is uncertainty as to the significance of clinical findings, patients should be reassessed at their breast unit.

Breast-cancer-associated lymphoedema is three times more common in patients who have undergone axillary dissection compared with those who had sentinel lymph node biopsy only. Those who have had more nodes removed, mastectomy, or who are overweight are also at higher risk.⁸ Post-surgery, patients are given advice on how to prevent and treat symptoms, which includes manual lymphatic drainage, compression therapy (sleeves or bandages), and good skin care. All patients should be advised to avoid trauma and venepuncture to the affected arm, to obtain antibiotics promptly if infection develops, and to maintain a healthy body weight.