Health Care Issues for Breast Cancer Survivors

October 01, 2006

by Debra Ravasia, MD

Northwest Woman

More than two million women in the United States live with a history of breast cancer. Early detection programs have led to improved prognosis, and screening programs increase the number of women in whom breast cancer is diagnosed. Even though the lifetime risk of breast cancer is 12.6%, the risk of death from breast cancer is only 3.6%. Most women in whom breast cancer is diagnosed do not die of their disease. Eighty percent of women in whom breast cancer is diagnosed can expect to live at least 5 years. Every year in the United States 180,000 women are diagnosed with breast cancer and another 25,000 women receive a diagnosis of in-situ-carcinoma of the breast (severe pre-cancer). Breast cancer survivors face unique health issues, says Dr. Debra Ravasia. It is important to have follow-ups to detect recurrences early. The long-lasting side effects of treatment such as, premature menopause, cognitive effects and lymphedema can occur. Many women have questions regarding childbearing, use of hormone replacement therapy, other medications for menopausal symptoms and psychological and social aspects of survival.

Medical Evaluations

For the rest of their lives, women with a history of breast cancer are at risk for recurrence. The risk of cancer in the other breast is 0.5 to 1% per year and is slightly higher in women who have received radiation therapy before the age of 45. Most recurrences are detected within five years, but some can occur many years later. Follow-up visits with a physician, either oncologist or primary care, are recommended every 3-6 months for 3 years and then every 6-12 months for 2 years. Yearly mammograms in both breasts, even if it is a reconstructed breast, continue to be very important. Recent data show that more than half of the breast cancer survivors are not having their regular yearly mammograms as recommended. The reason for the lack of follow-ups is unclear, but likely represents a misunderstanding on the part of women and their physicians about the ongoing need for these. Most recurrences are detected by women or their physicians by breast exams or mammograms. More elaborate tests have resulted in slightly earlier detection of recurrences but do not improve survival, therefore are currently not recommended.

A small proportion of women with breast cancer carry the breast cancer gene (BRCA-1 or BRCA-2). Women who carry this gene may have life expectancy gains from removal of the other breast and removal of the ovaries, since they are also at risk for ovarian cancer. Women who may wish to consider testing for this gene are those with a strong family history of breast cancer before the age of 50, with a personal or family history of ovarian cancer, or a family history of male breast cancer or Ashkenazi Jewish ancestry. Family members of women with the BRCA gene who test positive themselves may benefit from intensive surveillance or prophylactic surgery.

Local Complications of Breast Cancer Treatment

Common side effects are usually mild, but can cause some degree of interference with day to day activities and quality of life. They include pain and numbness in breast, chest wall or axilla (15-75%), arm swelling (10-25%) or restricted arm movement (25%). Women with arm swelling (lymphedema) after surgery may benefit from elevation, compression sleeves and physical therapy. Newer techniques for lymph-node biopsy have reduced the likelihood of this complication.

Breast reconstruction is an option for most women after mastectomy, either right away or later and does not seem to affect long-term survival or delay detection of recurrences. It can be done with a woman’s own tissue (often one of the abdominal muscles) or with implants. Many factors go into this decision.

Long-Term Chemotherapy Risks

These include small risks of leukemias, lymphomas and heart failure which occur in less than 1% of women who have received chemotherapy. The risk depends on the type of chemotherapy that was required. Some women who have received chemotherapy report some degree of decrease in cognition and ability to stay focused on tasks, that usually lasts less than a year, but can last longer.

Chemotherapy can temporarily or permanently cause the menses to stop. Women over the age of 40 are much more likely to experience complete menopause as a result of chemotherapy than women under the age of 40. When this occurs, the onset of the menopause tends to be fast, within weeks rather than years, so menopausal symptoms can be severe. Even women who continue to menstruate for a few years after chemotherapy tend to go through menopause prematurely, at younger ages than the general population.

Tamoxifen Effects

Tamoxifen is a medication that has an anti-estrogenic effect on the breasts. Other anti-estrogens are currently being used in some women, as well as, treatment for estrogen responsive breast cancers. About half of the women taking Tamoxifen report hot flashes, night sweats, vaginitis, vaginal itching, dryness and pain with intercourse, as well as diminished sexual interest and satisfaction. Some of these side effects can be overcome with non-hormonal treatments for hot flashes such as soy supplements and black cohosh. Medications such as Effexor and Paxil, or Clonidine, have been used with some success. When vaginal symptoms are severe, local estrogens, in tablet or ring form, are sometimes used, as their absorption into the blood stream is very low. However their safety and effect on breast cancer survival is unknown at this time. High quality vaginal lubricants such as Replens and Astroglide tend to help with vaginal dryness to a larger degree than KY jellies. Tamoxifen may slightly increase risk of uterine cancer, so any patient who experiences uterine bleeding while on Tamoxifen needs prompt and thorough investigation to rule this out.

Pregnancy after Breast Cancer

Pregnancy after breast cancer does not seem to increase risk for recurrence. Traditionally women have been advised to wait for the first two years before pursuing pregnancy because of the higher risk of recurrence. Decisions about childbearing after breast cancer can be difficult and intensely personal. Women make decisions about long-term health prospects vs. importance of having a child because they tend to have reduced fertility. They sometimes need assisted reproductive technologies such as in-vitro fertilization, which involve exposure to high doses of estrogen. The effect of in-vitro techniques on risk of recurrence in breast cancer survivors is not known at this time. Most women experience some difficulty with lactation in the breast that has received breast cancer treatment.

Hormone Replacement Therapy

Pharmaceutical or compounded, is generally not recommended for women who have survived breast cancer. Alternative means of coping with hot flashes such as dressing in layers, sleep aids, room temperature control and avoidance of caffeine are recommended. Medications such as Effexor, Paxil and Clonidine may be of some benefit, and are non-hormonal. Soy and black cohosh may provide some relief.

Women who undergo menopause prematurely as a result of breast cancer treatment are at increased risk for osteoporosis and need regular bone density screens for this. To help prevent this complication, women living with a history of breast cancer should usually take 1200 to 1500 mg of calcium a day, vitamin D 400 to 800 IU per day, and do plenty of weight bearing exercises. When diminished bone densities are detected, non-hormonal medications may be recommended for treatment.

Psychological and Social Issues

Breast cancer diagnoses and treatments are life-altering events. Impacts the women, and their relation with spouse, family and friends can be profound. Having a serious illness of any kind often contributes to psychosocial difficulties. Prevalent issues among breast cancer survivors include mood disorders, fatigue, anxiety, impaired cognition and sexual dysfunction. These are usually most severe and intense during the first year after diagnosis. Breast cancer survivors, their physicians and caregivers can take heart from a few observations: (1) Most impairments resolve with time. (2) Long term quality of life among breast cancer survivors is quite high, similar to age matched controls.

Survivors of breast cancer usually identify many positive aspects of life after the diagnosis of cancer. They often adapt an optimistic outlook on life, a renewed sense of confidence, purpose and vitality. They often have a heightened awareness of health issues and are interested in lifestyle modifications and medical evaluations that can make them feel better and live longer.