Posted By SHL Librarian
Moderator: Frederick M. Dirbas, MD
Physician Leader, Stanford Cancer Center’s Breast Disease Management Group
Thursday, October 7, 2010
Each year more than 190,000 American women are diagnosed with breast cancer, the second-most common type of cancer in the United States (skin cancer is first). As research and innovations in technology and treatments enable earlier detection and better care, more people are surviving cancer and living longer after a diagnosis. The National Cancer Institute estimates that 3 million people were living with cancer in the United States in 1971; today that number is close to 12 million.
There are more than 2 million breast cancer survivors today, which is creating a new niche of care because survivorship can lead to new health needs and concerns. Survivors can have heightened risks for long-term side effects from treatments or the disease, and they must deal with psychological issues, sexual concerns, pain, fatigue, and quality of life issues.
Stanford Supportive Care, a program that addresses these concerns by bridging medical care with non-medical healing, and the Stanford Health Library brought together several Stanford specialists to talk about the unique issues of breast cancer survivorship.
“After we treat the disease, we want to help patients live a full and healthy life,” said Frederick M. Dirbas, MD, Physician Leader of the Stanford Cancer Center’s Breast Disease Management Group, who moderated the panel of experts. “It’s important to bring our expertise together for patients, their families, investigators, and clinicians.”
Survivorship: Dealing With Feelings
David Spiegel, MD
Medical Director, Stanford Center for Integrative Medicine
Sadness and grief are normal reactions to a diagnosis of cancer, and for most people these feelings will come and go throughout treatment and afterwards. But as many as 25 percent of cancer patients suffer from depression and go undiagnosed.
“The worst time is when you are told you have cancer,” said Spiegel. “The second worst time is when the treatment is over. You lose your contacts and your routine, but your body reminds you all the time that you are a cancer survivor. It’s a difficult transition at many levels.”
It’s important to develop strategies to adjust to this transition, from health maintenance to social activities and family roles. And an important part of taking care of yourself is to manage your moods. Depression can have a direct effect on quality of life, and can also influence recovery time, pain thresholds, and even life expectancy.
“Cancer has an effect on the brain both in terms of emotion and cognition,” said Spiegel. “There is a relationship between psychological stress and cancer: Emotional well-being can have a profound effect on health outcomes.”
Studies of cancer survivors have shown that that depression affects 25 percent of cancer survivors, compared to 3 percent of the general population. Depression, fatigue, poor sleeping patterns, and medications also affect memory, concentration, and mental agility-a condition referred to as “chemo brain.” Exercise and sleep can help, as can medication to help restore perspective.
Many cancer survivors benefit from group or individual psychotherapy. “Therapy can create an opportunity for emotional release, to learn new coping skills, and to develop new goals,” Spiegel said. “Dealing with your feelings-even negative ones-can help you covert from feeling damaged to being in a position of coping and even transcendence.”
Advances in Breast Cancer Surgery
Irene Wapnir, MD
Chief, Breast Surgery
How breast cancer is treated depends on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast. There are gradients in each of those factors, however, that can complicate what surgery is most appropriate as well as outcomes.
For example, improved screening from mammograms and breast imaging has led to a 500 percent increase in finding invasive lesions, growths that can vary from normal cells to cancer. The surgical treatment of breast cancer has changed drastically over the years, from mastectomy to lumpectomy to axillary lymph node dissection (ALND).
Twenty years of data has shown outcomes to be almost equal for these surgical modalities, said Wapnir, but which one to use is based on the tumor size or whether the cancer is localized. “A lumpectomy preserves much of the breast but still increases chance of recurrence,” she said. “You have to be aware of how much risk you’re willing to accept.”
Improvements to lumpectomy techniques also make the option available to older and pregnant women as well as women with multiple cancers. Advances in reconstruction are also leading to better cosmetic outcomes.
“We are now in a better place in terms of choices, making the aftermath of surgery less frightening to women,” she said. “We have new procedures to avoid side effects like lymphedema and the ability to modify treatment regimens so we can get insight on what the tumor is like and select the best treatment more quickly and effectively.”
Sexuality and Breast Cancer Survivorship
Leah Millheiser, MD
Clinical Assistant Professor, Obstetrics and Gynecology
Director, Female Sexual Medicine
Though there is not much data available on female sexuality problems after cancer treatment, it appears to be a significant issue. One large-scale study found that while 80 percent of responders reported a good or satisfying sex life before treatment, 70 percent reported sexual problems after treatment.
“The most common concerns are body image issues and hot flashes,” said Millheiser. “Since early-onset menopause is a result of cancer treatment, there are real physical problems, such as vaginal dryness, pain during intercourse, and vaginal shrinkage. And for younger women, especially, there is the increased emotional distress of dealing with infertility.”
Because estrogen is closely related to cancer, many women are leery of using vaginal estrogen to address dryness and sexual discomfort. But vaginal estrogen is minimally absorbed, unlike systemic estrogen, so many women can use it, Millheiser said. For those who cannot use vaginal estrogen, she advises using a moisturizer or vaginal dilator as soon as there is pain: Waiting will not help the problem and can lead to a cycle of miscommunication with your partner.
She recommends silicone-, water-, or oil-based personal lubricants during intercourse, such as Replens or K-Y Liquibeads, but warns that petroleum-based lubricants can harbor bacteria in the vagina and cause damage to latex condoms. Though there are no FDA-approved treatments to enhance female libido, a neutraceutical called ArginMax and a nonhormonal arousal oil called Zestra appear to increase desire. Studies also show that a Mediterranean diet, one high in fruits, vegetables, fish, and whole grains, may improve sexual function.
“After cancer therapy, women need to become comfortable with their body,” Millheiser said. “They need to use whatever methods work for them-self-exploration, pain medications, sexual lubricants-and they need to go slowly and chose the right timing to learn to relax with their sexuality.”
Breast Cancer and Cardiac Complications
Randall Vagelos, MD
Medical Director, Cardiac Care Unit
The heart can be affected by cancer therapy, especially in conjunction with other lifetime risk factors, such as smoking, high blood pressure, enlarged heart muscle, or other conditions. And many common side effects of treatment, like tightness in the chest, shortness of breath, or fatigue, can also be symptoms of a heart problem.
“It’s important to know the state of the heart before starting any cancer treatment,” said Vagelos. “Many cancer therapies can exacerbate cardiac conditions.”
Radiation can be a risk to heart heath and tends to amplify the effects of other therapies. Common anticancer drugs like anthracycline affect cell turnover and replication, which can cause cardiac damage over time. The long-term use of anthracyclines can lead to cardiomyopathy and congestive heart failure even years after exposure. Tyrosine kinase inhibitors, which can “turn off” certain cell functions, can weaken heart muscle, although its effects reverse as soon as the drug is stopped.
The condition of the heart can be carefully scanned and monitored with noninvasive imaging techniques and other technologies to make sure patients receive optimal benefits from their treatment. Minimizing cardiac toxicity requires knowing pre-existing conditions and risk factors; using medications like ACE inhibitors and B blockers to override risk; and monitoring the heart using imaging, biomarkers, cardiac biopsies, or echocardiograms.
“All medical interventions have some risk, but our challenge is to maintain the balance between risk and benefit,” he said.
Osteoporosis and Bone Health
David Feldman, MD
Because estrogen is so intertwined with breast cancer, and the hormone is so crucial in protecting the bones, osteoporosis (loss of bone density) has become a common concern for cancer survivors, said Feldman.
All women dealing with lower estrogen levels-whether from cancer treatment or age-related menopause- should take a bone density scan (DXA) to measure and track osteoporosis. The test results compare your measurements with others your age (Z score) and with a normal young person (T score). FRAX, an online fracture assessment tool, can also allow you to measure your risk for osteoporosis.
To prevent osteoporosis, you need to take 1200-1500 milligrams a day of calcium supplements, maintain a regimen of weight-bearing and strengthening exercises, and be aware of strategies to prevent falls.
Most people do not get enough sun exposure to produce the necessary levels of vitamin D, which helps the body absorb calcium, so take at least 400 International Units per day. Feldman said he expects new guidelines will more than double the recommended dosage of this essential vitamin but suggests getting a blood test to know your starting point so you can track its benefits.
“Everybody should be on calcium and vitamin D,” said Feldman. “Vitamin D supplements are not just for your bones. They also stop cancer cells from dividing, modulate the immune system, and reduce hypertension, and they appear to have potential for other applications. The proof in humans is not quite there yet, but there’s undeniable benefit.”
He also recommends bisphosphonates like Fosamax, Boniva, or Actonel, which are safe and convenient, although bone loss tends to accelerate as soon as you stop taking the drug.
For More Information:
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Stanford Cancer Center
Stanford Health Library
Women’s Health @ Stanford
Stanford Center on Stress and Health
Stanford Hospital Heart Center