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Physical Long term side effects

Late Effects of Cancer Treatment

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Some patients will continue to experience side effects from the initial treatment. This section reviews long-term physical effects after primary therapy in cancer survivors.

Lymphedema

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Lymphedema is a condition characterized by the buildup of lymph fluid in the interstitial tissue, leading to swelling in areas such as the limbs, neck, trunk, or genitals, and is associated with solid tumours caused by melanoma, breast, genitourinary, gynaecological, and head and neck cancer​

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Why does lymphedema happen? 

It is a common side effect of cancer treatment, and can occur due to blockage or damage to the lymphatic system can occur due to tumor pressure on the lymph nodes or vessels, the spread of cancer cells into the lymphatic channels (known as lymphangitic carcinomatosis), removal or surgery on lymph nodes, or as a result of radiation therapy or chemotherapy.

 

At first, the affected area can become slightly swollen, uncomfortable, and “tingly,” and then may get more swollen over time. If the lymphedema progresses, the limb (or other areas) can become even more swollen, uncomfortable, heavy, or numb. Early treatment of lymphedema is important, so you should tell your doctor if you experience any of these symptoms. Your doctor may also rule out other causes like recurrent breast cancer, infection or thrombosis. The good news is that today there are more options than ever, for treating lymphedema, and most have demonstrated effectiveness in research studies.

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Stages of lymphedema:​​

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1. Stage 0:

  • No swelling but there may be subtle symptoms, such as:

    • A heavy feeling in a limb

    • Feeling of fatigue in a limb

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​2. Stage 1:​

  • Swelling can be seen on the side of body that was treated

  • Swelling in a limb is reduced with elevation

  • An indent in the skin may occur when pressure is applied (called pitting)

  • Area with lymphedema is larger, heavier, or stiffer

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3. Stage 2:

  • The swollen area has a spongy texture

  • Swelling in limb does not decrease with elevation

  • An indent in the skin (pitting) is less visible as swelling increases

  • Scar tissue may form making the swollen area larger and feel hard

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​4. Stage 3:

  • Swelling has further increased making the area larger

  • Skin of swollen area is severely dry, scaly, or thickened

  • In the limbs, fluid leakage and blisters are common

  • Moving limbs or turning your neck may be limited

  • Skin of swollen area may have fungal infections or benign tumors

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​Lymphedema risk factors:

  • Survivors who have undergone surgery, radiation, or chemoradiation involving the lymph node system are at increased risk of developing lymphedema

  • Additional factors that can raise this risk include having a sentinel node biopsy, a body mass index (BMI) over 30 kg/m², localized infections, a higher number of lymph nodes removed, and a more extensive initial spread of the disease.

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​Screening for lymphedema:

Effective screening for lymphedema involves using both objective measurements and patient-reported symptoms to detect early signs of swelling. The goal is to identify and treat lymphedema as soon as possible, ideally before it causes significant discomfort or functional issues.

1. Baseline measurements: Before surgery, it is important to measure the size of both arms to establish a baseline. This helps distinguish true swelling from natural differences between arms.

2. Tape measure: Tape is used to measure the circumference of specific points along the arm. These measurements are then used to calculate the total limb volume.

3. Perometry: Uses infrared light to quickly and accurately measure limb volume.

4. Bioimpedance Spectroscopy (BIS): Measures tissue resistance to electrical current, reflecting fluid content in the limb.

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Treatment options:

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Self-care management:

  1.  Apply gentle pressure and keep your hands soft and relaxed​

  2. Use just enough pressure to softly stretch the skin to its natural extent, then ease up and allow the skin to return to its original position. If you can feel the muscles beneath your fingers, you're pressing too hard.

  3. Use the palms of your hands instead of your fingertips to maximize contact with the skin and effectively stimulate the lymphatic vessels.

  4. Perform the massage in the direction of parts of your body that haven't been affected by cancer treatment.

  5. Ensure you're comfortable during the process. You might support the arm on the side that had cancer treatment with a table or pillows, allowing your shoulder and arm to relax. You can do self-massage while sitting, standing, or lying down, whichever position feels best for you.

  6. Incorporate self-massage into your routine (similar to other self-care activities) in a way that suits your lifestyle.

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Skin care (infection control):

  1. ​Thorough skin and nail care is important to help prevent infections and entry points for bacteria

  2. If you notice any abrasions or small tears, such as paper cuts, treat them immediately with a topical antibiotic to reduce the risk of infection

  3. Use a mirror to carefully examine areas that are hard to see, especially if you have neuropathy, to spot any issues early

  4. Wash the affected limb daily with a pH-neutral soap, and dry it thoroughly, paying special attention to areas between fingers and toes to prevent moisture buildup and skin problems

 

​Compression

There are several types of compression:

  1. Compression bandaging: Multi-layered “short-stretch” bandages are used to reduce swelling

  2. Compression garment: A compression sleeve may be used to prevent lymphedema, as it can delay or prevent lymphatic fluid buildup and swelling

  3. Manual lymphatic draining: Manual lymphatic draining focuses on opening the lymphatic pathway, softening the scar tissues, and to promote and stimulate lymphatic drainage

  4. Pneumatic compression pump: Pneumatic devices are medical devices that use a series of inflatable sleeves placed around the affected limb. These sleeves automatically and gently inflate and deflate in a controlled sequence, applying pressure to help move excess lymphatic fluid out of the limb

  5. Electrically stimulated lymphatic drainage: A less commonly used intervention that involves applying electrical currents to tissues, which can influence cellular and molecular processes

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​Progressive resistance training (exercise):

  1. This training involves gradually increasing the intensity (weight) or volume (sets and repetitions) in very small increments over time, with careful monitoring​

  2. This approach is ideally supervised by a lymphedema specialist to ensure safety and effectiveness, especially for individuals at risk of or managing lymphedema

  3. These exercises are found to be effective: 

  • Arm lifts (front and side)

  • Chest expansion exercises

  • Forearm flexion and extension

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Surgery, eligibility criteria:

  1. ​Lymphedema surgery is not yet a standard treatment in Canada and is typically reserved for severe cases that do not improve with conservative therapies like lymphatic drainage or compression.

  2. For patients diagnosed early, the usual approach is conservative management, which includes daily use of a compression garment guided by a lymphedema therapist for 3 to 6 months. In some cases, this may be sufficient to resolve swelling, especially in upper-extremity lymphedema.

  3. If swelling persists after this period, and the patient is medically fit, surgical options may be considered. In more advanced cases with significant swelling, pitting, and recurrent cellulitis (skin infection), patients often benefit from complete decongestive therapy until swelling is well-controlled before exploring surgery.

  4. Patients experiencing recurrent cellulitis may also benefit from preventive antibiotics to reduce infection risk. 

  5. Patients with uncontrolled primary cancer or recurrence near the original tumor site (such as lymph nodes or nearby tissues) are generally not candidates for surgery, as their treatment focus is on cancer management.

  6. Additionally, individuals with very high body weight (high BMI) are more prone to developing lymphedema naturally. Weight-loss efforts are encouraged, as reducing weight can lead to significant improvements and may reduce the need for surgical intervention.

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Medical therapies

Some oral medications, such as benzopyrones, have been tested in clinical trials to evaluate their potential to help reduce swelling, however there is no strong evidence​

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​Here are some other things that you can do at home to reduce the risk of recurrence or worsening of lymphedema. 

  • protect your arm, hand, chest, or other body parts from cuts, injury, overuse, extreme temperatures, and other situations that can increase the production of lymph

  • learn the signs and symptoms of infection including redness, warmth and increased swelling

  • Replace your compression garments when necessary 

  • set an exercise and weight control plan and stick to it!

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Pain ​

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Pain can be caused by all treatments for cancer and by the cancer itself. Pain varies depending on the individual and type of treatment. For example, some patients have relatively little discomfort with lumpectomy and require mild analgesics medication. Others may have moderate to severe pain after mastectomy and reconstruction that require stronger medication. Speak to your doctor as the plan for post-operative pain is best individualized between clinicians and patients with regular monitoring for pain relief. Good communication is essential to getting continuous relief for any pain you may experience due to breast cancer or its treatment. The nature of your pain can change over time, and this may require a change in your treatment.

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​Type of chronic pain syndromes per system:

1. Neurologic system

  • Chemotherapy-induced peripheral neuropathy

  • Postoperative pain syndromes

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2. Rheumatic system

  • Other sources of pain in cancer survivors include migratory, non-inflammatory muscle and joint pain (myalgias and arthralgias), which can result from treatments such as tamoxifen, aromatase inhibitors, radiation therapy, steroid use or tapering, and from physical deconditioning. d

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3. Integumentary system

  • Pain in cancer survivors can also result from graft-versus-host disease (GVHD), affecting the skin, mucous membranes, and musculoskeletal system

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4. Lymphatic system

  • Pain or discomfort may also occur from lymphedema, which can develop after breast surgery, axillary or inguinal lymph node removal, or radiation therapy

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5. Skeletal system

  • Osteoporosis

  • Osteonecrosis (bone tissue death) affecting the femoral head, knee, or humeral head

  • Osteonecrosis of the jaw from bisphosphonates, denosumab, or radiation to the head and neck

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6. Myofascial system 

  • Musculoskeletal pain in cancer survivors can include rotator cuff tendonitis, adhesive capsulitis (frozen shoulder), and neck or back pain

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7. GI/urinary/pelvic system

  • Chronic pain in cancer survivors may include chronic pelvic pain. Urinary or fecal urgency and incontinence are common, and radiation-related adhesions can also contribute to discomfort

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8. Genital system

  • Pain during sexual activity (dyspareunia) in cancer survivors can result from menopause, reduced vaginal lubrication due to radiation, or vaginal strictures/fibrosis caused by radiation dyspareunia​

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Cancer treatment-related pain syndromes:

The following are the types of pain that can be caused by the different cancer treatments.

1. Surgery 

  • Surgery can lead to persistent post-surgical pain syndromes, such as postmastectomy pain and phantom limb pain.​

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2. Radiation Therapy

  • Surgery can lead to persistent post-surgical pain syndromes, such as postmastectomy pain and phantom limb pain.​

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3. Chemotherapy-Induced Peripheral Neuropathy

  • The most common pain syndrome caused by chemotherapy is chemotherapy-induced peripheral neuropathy (CIPN).​

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4. Hematopoietic Cell Transplantation

  • In addition to chronic pain from chemotherapy or radiation therapy, chronic graft-versus-host disease (GVHD) is another source of persistent pain in recipients of hematopoietic cell transplantation.​

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5. Hormonal Therapy

  • Aromatase inhibitors, often prescribed for several years after breast cancer treatment to prevent recurrence, can cause arthralgias, which are characterized by joint pain and stiffness.

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Treatment options:

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Pharmacologic approaches:

1. Co-analgesics

  • Medications commonly used to manage pain in cancer survivors include antidepressants, anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other therapies.​

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2. Opioids

  • Opioids may be considered for cancer survivors experiencing moderate to severe pain that has not improved with non-opioid medications or non-drug approaches.

  • Clinicians prescribing opioids to cancer survivors should be aware of the risk factors for opioid misuse or abuse.​

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Non-pharmacologic approaches:

1. Cognitive behavioral therapy

  • Pain that does not improve with medical treatment alone, or that occurs alongside other symptoms such as fatigue and emotional distress, should be referred for cognitive-behavioral therapy.​

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2. Exercise

  • Strength training and aerobic exercises are effective in improving pain ​

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3. Physical medicine and rehabilitation

  • Physical therapy

  • Transcutaneous electrical nerve stimulation

  • Scrambler therapy​

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4. Integrative medicine approaches

  • Physical therapy

  • Transcutaneous electrical nerve stimulation

  • Scrambler therapy​

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5. Interventional approaches

  • Local injections

  • Interventional neurostimulation therapies

  • Neuraxial analgesia
     

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Fatigue

 

Cancer related fatigue (CRF) is a common yet under-reported side effect of most cancer treatments. However, many people with cancer also face other health or emotional issues that can contribute to or worsen their fatigue. Experts describe cancer-related fatigue as a feeling of physical, emotional, and/or mental exhaustion linked to cancer and its treatment. Unlike normal tiredness after a busy day, cancer-related fatigue is a persistent lack of energy that is distressing, does not improve with rest or sleep, and interferes with daily activities. Many cancer survivors continue to experience this type of fatigue for months or even years after their treatment has finished. 


Unlike typical fatigue, CRF tends to be more intense, lasts longer, and is not relieved by rest or sleep.  Known risk factors for CRF include medication side effects, unmanaged pain, anemia, emotional stress, sleep problems, poor nutrition, decreased physical fitness, and an increase in the number and severity of other health conditions. CRF can occur at any point during the cancer continuum.

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Common signs include:

  • Persistent feelings of tiredness

  • Lack of energy

  • Physical weakness

  • Cognitive impairments/delays

  • Sleep disturbances

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​Conditions that cause or worsen CRF include:

  • Anemia

  • Pain

  • Sleep-related problems

  • Depression

  • Anxiety

  • Diet or nutrition-related problems

  • Infection

  • Changes in thyroid functions

  • Rheumatologic or autoimmune disorders

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Treatment Options:


Non-pharmacological intervention:

1. Physical activity

  • Physical activity is recommended during and after cancer treatment. Evidence shows that those who exercise 3-5 hours per week may experience better health outcomes and fewer side effects, including fatigue. You can divide this time into shorter sessions of 10-15 minutes at different times of the day, depending on your energy levels. Most exercise programs have two main components: 

    • ​Cardiovascular endurance (cardio): Activities like walking, jogging, and swimming help get your heart pumping and blood flowing, improving heart and blood vessel health. Walking for 2-3 times per week for around 30-60 minutes can help with CRI. 

    • Weight training (resistance or strength training): This involves exercises that use resistance, such as bands, free weights, or your own body weight, to help build muscle strength. Regular resistance training is most effective when done consistently.​

2. Yoga

  • Yoga combines physical activity, meditation to focus the mind, and breathing and emotional control. These practices are believed to help balance the body and mind. Studies have shown that yoga can reduce fatigue, improve sleep quality, and decrease anxiety and depression in people with cancer.

  • There are many styles of yoga, ranging from gentle to more vigorous practices. It is important to practice under the guidance of a well-trained instructor to ensure safety and effectiveness. 

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3. Cognitive behavioral therapy (CBT)

  • Cognitive Behavioral Therapy (CBT) is an approach that helps individuals identify and change negative thoughts to promote positive behavioral changes. It is provided by mental health professionals such as behavioral therapists. 

  • One form of CBT, called cognitive restructuring, involves recognizing stress-inducing or negative thoughts as they happen. Once these thoughts are identified, you can work to modify or reframe them to improve your emotional well-being.

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4. Acupuncture

  • In acupuncture, a licensed or certified practitioner inserts very thin needles into specific points on your body.

  • You might experience mild discomfort or tingling when the needles are inserted, but other needles may not be felt at all.

  • Acupuncture can help reduce pain and lessen fatigue.

  •  Although generally safe, acupuncture may not be suitable for everyone, especially if you have certain health conditions such as a high risk of bleeding or infection.

  • It is important to ask your care team whether acupuncture is safe for you.

 

5. Massage therapy

  • Massage therapy is a treatment in which the soft tissues of the body are kneaded, rubbed, and stroked.

  • It can help reduce stress, alleviate pain, and decrease cancer-related fatigue

  • Additional health benefits may include lower blood pressure and improved circulation.

  • Before scheduling a massage, verify that the therapist is experienced in cancer-specific massage techniques, as there are health risks associated with receiving treatment from a provider who is not trained in these areas.  

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6. Bright white light therapy

  • Bright white light therapy (BWLT) involves exposure to very bright fluorescent light from a device or box designed for home use.

  • The light stimulates the part of the brain that controls circadian rhythms.

  •  1250–10,000 lux in the morning for 30–40 minutes.

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7. Nutrition check-up

  • Cancer treatment frequently leads to side effects such as nausea, vomiting, diarrhea, mouth sores, changes in taste, and loss of appetite.

  •  As a result, many individuals may find themselves eating and drinking less overall.

  • Consulting with a nutritionist or registered dietitian can be beneficial, as these professionals can provide personalized guidance on eating and drinking habits tailored to your health status and specific needs.

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Pharmacologic medications:

1. Melatonin

  • Not recommended for long term use due to insufficient evidence.​​

2. Ginseng

  • Some evidence for American ginseng; not routinely recommended​​

3. Omega polyunsaturated fatty acids

  • Studied at various doses, however there is insufficient evidence for routine use​​​

4. Wakefulness agents

  • Armodafinil, modafinil - not routinely recommended​​

5. Psychostimulants

  • Not routinely recommended​​

6. Steroids

  • Short-term corticosteroids (e.g., prednisone, dexamethasone) for advanced cancer

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Remember to treat yourself kindly! If you are too fatigued to complete a task that you had planned, it is completely fine if you cannot wait. Ensure that you are your own first priority to avoid other potential adverse effects. Additionally, remember there are many people that are here to support you if you are in need of help.

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Chemotherapy-Induced Peripheral Neuropathy 

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Chemotherapy-induced peripheral neuropathy (CIPN) is a common and significant side effect experienced by some cancer patients. It is caused by certain chemotherapy drugs, including taxanes, platinum compounds, vinca alkaloids, and others. This condition results in nerve damage, leading to symptoms such as numbness, tingling, pain, and weakness, primarily in the hands and feet.

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Common signs include:

  • Numbness

  • Tingling

  • Pain, particularly in hand and feet

  • Cold sensitivity

  • Discomfort swallowing cold liquids

  • Muscle cramps

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Neuropathy often affects the upper and/or lower limbs, impacting daily activities and quality of life.

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When does it happen:

Symptoms of CIPN usually appear within the first two months of treatment, and can occur due to chemotherapy type, dose, and duration. Risk factors may include predisposing factors such as demographics, genetics, comorbidities, depression, and lack of physical activity.

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Treatment options:

Pharmacological:

  • NSAIDs

  • Acetaminophen (paracetamol)

  • Adjuvant analgesics

    • ​selected antidepressants (e.g., venlafaxine)

    • selected anticonvulsants (e.g., gabapentin and pregabalin)​

Non-pharmacological:

  • Acupuncture

  • Exercise

    • Sensorimotor training​

  • Compression therapy using surgical gloves

  • Cryotherapy

    • Frozen gloves and socks​

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​It is important to take safety precautions as the decreased feeling in your hands and feet may increase the risk of injury. 

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Acute Radiation Dermatitis 

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Acute radiation dermatitis (ARD) frequently occurs in cancer patients receiving radiotherapy and is typically characterized by redness (erythema), skin peeling (desquamation), and pain. The development of radiation dermatitis is a complex process involving damage to the skin layers caused by radiation, which affects the cells responsible for skin regeneration. This damage can impair the skin’s protective barrier and lead to increased inflammation, resulting in symptoms such as redness, pain, and various skin changes.​

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​Common signs include:

  • Changes in skin pigmentation

  • Pain

  • Burning

  • Tenderness

  • Pruritus (persistent intense itching)

  • Edema (swelling caused by excessive fluid)

  • Desquamation (skin shedding/peeling) either dry and/or moist, with ulceration in severe cases

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Risk factors:

​1. Treatment-related factors

  • Radiation dose

  • Irradiated volume

  • Bolus

  • Concurrent chemotherapy

  • Treatment positioning​

2. Intrinsic factors

  • BMI

  • Irradiation site

  • Smoking status

  • Skin pigmentation

 

Treatment options:

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1. Topical non-steroidal agents and corticosteroids

  • Non-steroidal and steroidal agents have been studied for managing radiation dermatitis, with some research showing conflicting results

  • Biafine has been found to significantly reduce the risk of severe radiation dermatitis

  • Other agents, such as doxepin and sucralfate, have limited supporting evidence or have demonstrated only minimal benefit 

  • In terms of safety, there is some potential concern with few individuals facing side effects ​

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2. Barrier films and dressings

  • Barrier films or dressings were found to be effective in preventing radiation dermatitis

  • There is some insufficient evidence on certain barrier films such as Hydrofilm, Mepilex Film, No-Sting Barrier Film, and SLND ​

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3. Natural, miscellaneous, and alternative therapies

  • Natural products such as aloe vera, oral enzymes, olive oil, calendula, and curcumin have been studied with oral enzymes and olive oil show significant reduction in radiation dermatitis 

  • Other products such as honey-based products, vitamins, chamomile-based creams have shown minimal or no benefit

 

4. Laser therapy

  • Photobiomodulation (low-level laser therapy) has been studied in multiple research efforts, with most findings indicating that it may help prevent or lessen the severity of acute radiation dermatitis 

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5. Systemic and other treatments

  • Some studies have examined systemic agents such as oral enzyme mixtures, which showed potential in preventing acute radiation dermatitis 

  • However, evidence supporting the use of other systemic medications and multi-component therapies remains limited 

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Consult your healthcare provider before applying any products to the treated area, including makeup, hair removal tools, ointments, and creams.

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You may feel embarrassed or may not like the visual outcome of this side effect however use it as a battle scar to encourage you and remember your own strength. You are fighting this disease with so much bravery and strength. Be proud of yourself!

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Bone health (osteoporosis)​

Cancer and its treatments can cause bone loss which can increase the risk of fractures and osteoporosis. Osteoporosis is a complex condition influenced by genetic factors, but currently, there are no specific genetic markers used routinely to predict low bone strength or rapid bone loss. Low bone mineral density (BMD) can increase skeletal fragility and could induce the onset of osteopenia and osteoporosis.

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Common signs include:

  • Fractures 

  • Stooped posture or kyphosis (hunched back)

  • Loss of height over time

  • Bone tenderness or pain

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Treatment Options:

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Non-pharmacologic Options:

1. Exercise

  • Exercise has shown to be a potential to improve bone health among survivors, especially for those with bone metastases 

  • Aerobic exercises (e.g., walking, jogging, swimming) may help with preserving BMD

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2. Avoid smoking 

  • Smoking cessation is important to bone health as it has been found that smoking can reduce BMD

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3. Limit alcohol

  • Excessive alcohol consumption can cause impaired bone formations and mineralization

  • Alcohol sensitivity also plays a role as those with high alcohol sensitivity tend to experience earlier and more frequent bone metastasis compared to those with lower sensitivity

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4. Get enough vitamin D

  • It has been found that higher vitamin D levels in survivors are associated with better bone mineralization which can help prevent or slow down bone loss 

  • How much vitamin D is needed: 

    • For those between 1 and 70 years of age, including women who are pregnant or lactating, the recommended dietary allowance (RDA) is 15 micrograms (μg) per day. Because 1 μg is equivalent  to 40 International Units (IU), this RDA can also be expressed as 600 IU per day.

    • For those 71 years or older, the RDA is 20 μg per day (800 IU per day).

  • Food  sources of vitamin D:

    • Fish: herring, mackerel, salmon, tune, swordfish, snapper

    • Milk

    • Kefir

    • Fortified plant based beverages

    • Margarine, fortified

    • Egg

    • Orange juice, fortified

    • Mushrooms, white

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5. Include a serving of high protein food at each meal

  • Protein is an important macronutrient that influences collagen and hormone synthesis which helps with building bone mass 

  • The protein requirement is >1 gram  per kilogram of body weight each day 

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6. Get enough calcium

  • Calcium is important for maintaining bone health, and individuals should take the adequate intake to maintain normal ionized calcium levels 

  • Adults aged 19-50 years should take 1000mg of calcium each day. Adults over 51 years, should take 1200mg 

  • Food sources of calcium:

    • Cheese: swiss, cheddar, mozzarella, cottage cheese, ricotta cheese, paneer cheese

    • Milk (skim, 1% or 2% MF or whole)

    • Buttermilk or Chocolate milk

    • Yogurt, plain

 

Pharmacologic Options

1. Bone-modifying agents

  • Antiresorptive agents (bisphosphonates and denosumab) are currently the most used to reduce to risk of both cancer-induced and cancer-therapy induced bone loss 

  • Bisphosphonates are alendronate, risedronate, and zoledronate

  • Denosumab are RANK ligand inhibitors 

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Why does it happen:

  • Oophorectomy (removal of ovaries)

  • Gonadotropin-releasing hormone (GnRH) agonists

  • Chemotherapy-induced ovarian failure or aromatase inhibitors (AIs) and antiandrogens

  • Hypogonadism (reduced hormone production)

  • Early menopause

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Risk factors:

  • Age

  • Female sex

  • Ethnicity (Asian or Caucasian)

  • Low levels of physical activity

  • Smoking

  • Alcohol consumption (>3 units per day)

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Menopausal & Vasomotor Symptoms

 

Menopause is defined as 12 months of amenorrhea and is caused by the cessation of ovarian reproduction function (absence of menstruation). Many survivors may experience menopausal symptoms regardless of ovarian function. In those with previous chemotherapy, pelvic radiation, or on tamoxifen, regular estradiol level testing can help confirm their current menopausal status.​

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Vasomotor symptoms (VMS) refer to the side effects caused by cancer treatments such as endocrine therapies, ovarian function suppression, and chemotherapy which suppress an individual’s estrogen levels.

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Common signs include:

  • Vasomotor symptoms (ie. hot flashes/night sweats)

  • Vaginal dryness

  • Urogenital symptoms (e.g., urogenital atrophy and urinary incontinence)  

  • Sexual dysfunction

  • Sleep disturbances

  • Mood disturbances + depression

  • Cognitive dysfunction

  • Arthralgias (joint pain)

  • Myalgias (muscle pain)

  • Fatigue

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Why does it happen:

  • Ovarian suppression caused by adjuvant endocrine treatment such as aromatase inhibitor or tamoxifen can lead to menopausal symptoms

  • This substantial decrease in estrogen can lead to symptoms similar to menopause, including hot flashes, vaginal dryness, and discomfort during sex 

  • These symptoms occur because estrogen is important for regulating body temperature and maintaining vaginal tissue health 

  • One of the main causes of hot flashes is the effect of low estrogen on the hypothalamus, a brain region that controls body temperature 

  • When estrogen levels are low, the hypothalamus becomes more sensitive to minor temperature changes, causing the body to react as if it is overheated, resulting in hot flashes 

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Treatment options:

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Non-hormonal pharmacological:

1. Anticonvulsants

  • Gabapentin and pregabalin are anticonvulsants that can reduce hot flashes but may cause sedation if not carefully titrated 

  • It has been found that taking a dose of 900 mg per day of gabapentin can reduce hot flashes by 44% 

  • Using gabapentin at bedtime only can help reduce night sweats and improve sleep quality 

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2. Selective serotonin reuptake inhibitors (SSRIs)/ Serotonin norepinephrine reuptake inhibitors (SNRIs)

  • Both SSRIs, such as paroxetine and fluoxetine, and SNRIs, such as venlafaxine, have been associated with reductions in hot flashes exceeding 50% 

  • SSRIs are effective in reducing the frequency and intensity of hot flashes by increasing serotonin levels which helps with regulating body temperature and reducing symptoms

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3. Clonidine

  • A blood pressure medication that reduces hot flashes by around 40%, but side effects like dry mouth and dizziness limit its use 

  • It has been shown to be an effective alternative to hormonal therapy as it reduces hot flashes 

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4. Oxybutynin

  • Used primarily for overactive bladder; has shown to significantly decrease hot flashes and improve quality of life, with manageable side effects 

  • Individuals who received oxybutynin reported seeing improvement in VMS symptoms, sleep and overall quality of life at 4 weeks of taking it

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5. Fezolinetant

  • A non-hormonal oral medication approved in 2023 for menopausal VMS, currently under study for breast cancer survivors 

  • It was found to show improvement among individuals within moderate to severe VMS, with mild and not dose dependent symptoms such as nausea, headache, diarrhea 

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6. Elinzanetant

  • A medication targeting brain receptors involved in temperature regulation, showing promise in reducing hot flashes in clinical trials 

  • A novel drug that has appeared to be well tolerated in current trials 

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Non-pharmacological: 

1. Physical Activity

  • Engaging in 150 mins of moderate-intensity or 75 mins of vigor intensity activity can be spread out over the course of a week — if considered feasible and safe

  • There is mixed results as to whether exercise effectively helps VMS, however moderate activity and strength training is suggested to be better than vigorous exercise

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2. Acupuncture

  • Acupuncture is used as a treatment option for hot flashes in the general population but for cancer survivors, the evidence is quite limited 

  • It has been shown to reduce VMS symptoms in some but not all postmenopausal women 

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3. Lifestyle

  • Limiting alcohol intake, engaging in physical activity, maintaining a healthy diet high in vegetables, fruits, beans/legumes, and whole grains could help with the menopausal symptoms 

  • Reducing alcohol and tobacco may reduce VMS however the evidence is quite limited 

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Infertility​​

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People treated for cancer may face a higher risk of infertility, meaning they might not be able to have children. This is often caused by cancer treatments such as chemotherapy and radiation, which can damage reproductive organs. Some chemotherapy drugs can harm the ovaries in women and testicles in men, sometimes causing  complete loss of egg or sperm production, leading to sterility. 

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Radiation therapy can also affect reproductive organs, especially when directed at the pelvis. High doses of radiation to the ovaries and uterus increase the risk of ovarian failure, miscarriage, early delivery, and slower fetal growth. The side effects depend on the radiation dose and the person’s age.

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Why does it happen:

  • Cancer treatments such as chemotherapy and radiation can be gonadotoxic, meaning they may cause temporary or permanent damage to the ovaries and impair fertility. 

  • However, as long-term survival rates are increasing there are now more effective fertility preservation options available, and these techniques are widely accessible.

  • Additionally, careful radiation planning can help spare or reduce the dose to reproductive organs, minimizing the impact on fertility. Importantly, the number of survivors of reproductive age is increasing, providing hope for many individuals wishing to have children after cancer treatment. 

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Future fertility after cancer:

1. Fertility preservation

  • If you wish to preserve your fertility before cancer treatment, two important tests are recommended to assess your reproductive health:

    • ​Anti-Mullerian Hormone (AMH) blood test: This measures the level of AMH in your blood, which indicates your ovarian reserve or remaining egg supply. 

    • Antral Follicle Count (AFC) ultrasound: This imaging test counts the number of small follicles in your ovaries, providing an estimate of your remaining eggs.

  • These tests help evaluate your fertility potential both before and after treatment, guiding fertility preservation options.

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2. Egg freezing

  • During two weeks of fertility hormone injections, your ovaries are stimulated to produce multiple eggs. Once the eggs have matured, a doctor will remove them using an ultrasound-guided procedure. You will be sedated with medication to help you relax and stay comfortable during the process.

  • It's important to note that eggs that are frozen are not fertilized with sperm at this stage; they are preserved for future use. When you decide to try to conceive, the eggs can be thawed and fertilized with sperm through in vitro fertilization (IVF) 

  • The process follows these steps: ovarian stimulation, egg retrieval, cryopreservation, vitrification techniques, storage in liquid nitrogen 

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3. Embryo freezing

  • Embryo freezing involves fertilizing eggs with sperm and then freezing the resulting embryos for future use. Your chances of a successful pregnancy later on depend on the number and quality of embryos that are frozen 

  • Having more high-quality embryos increases the likelihood of achieving pregnancy when you decide to use them.

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4. GnRH agonist

  • For people undergoing chemotherapy for breast cancer, a medication called a GnRH agonist may be used to help protect the ovaries and reduce the risk of ovarian failure

  • This treatment can help preserve fertility by temporarily suppressing ovarian function during chemotherapy 

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5. Pregnancy after cancer

  • Pregnancy does not seem to increase the risk of your cancer returning 

  • If you are considering pregnancy, consult your cancer care team 

  • The majority of cancer recurrences occur within the first two years, so it is recommended to avoid pregnancy during this period 

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ASK YOUR HEALTHCARE TEAM: 

  • How will my treatment plan affect my fertility? 

  • Based on my situation, which fertility preservation options would you recommend to best suit my needs and goals? 

  • What are the costs associated with fertility preservation options, and are there any financial resources or assistance programs available to help with these expenses?

 

For a lot of people, infertility can be frustrating as it can change future plans to start a family. Know that there are many different resources that can be used to fulfill this dream. Try to stay hopeful!

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​Cardiovascular Disease 

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Cardiovascular disease (CVD) refers to conditions that affect the heart and blood vessels, often leading to reduced blood flow and a higher risk of heart attack or stroke. CVD is the leading cause of death among cancer survivors. The risk of CVD-related death can change over time but may increase significantly more than five years after diagnosis and completion of curative treatment. 

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Risk factors include:

  • Cancer treatments, such as immunotherapy, cytotoxic therapy, hematopoietic cell transplantation (HCT), targeted systemic therapies, and radiation therapy 

  • Pre-existing conditions, including cardiomyopathy, hypertension, high cholesterol (hyperlipidemia), cardiac arrhythmia, previous heart attack (myocardial infarction), carotid artery narrowing (carotid stenosis), and stroke (cerebrovascular accidents) 

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ABCDEs to promote cardiovascular wellness in cancer survivors:

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A

  • Awareness of the risks and signs of heart disease

  • Assessment of cardiovascular disease and overall heart risk, which may include using a CVD risk assessment tool

  • Aspirin use, when appropriate—recommended for secondary prevention, and for primary prevention only after a careful discussion between the clinician and survivor to weigh benefits and risks

B

  • Monitoring and managing blood pressure, including discussing with your clinician the use of hypertension treatments and setting appropriate blood pressure goals.

C

  • Assessment and management of cholesterol, including discussing with your clinician the use of statin therapy for primary prevention and setting target lipid levels.

D

  • Diet and weight management

  • Consideration of cumulative doses of anthracyclines and/or radiation to the heart

  • Prevention and management of diabetes mellitus

E

  • Exercise

  • Echocardiogram (ECHO) and/or electrocardiogram (ECG) based on individual risk

 

Common signs include:

  • Dyspnea (shortness of breath)

  • Tachycardia (rapid heartbeat)

  • Peripheral edema (swelling in legs, ankles, or feet)

  • Weight gain

  • Symptoms of heart failure

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Why does it happen:

Certain cancer treatments, such as anthracyclines, HER2-targeted therapies, radiation therapy, and VEGF inhibitors, can sometimes affect the heart and blood vessels. These effects can occur through several mechanisms, including:

  • Direct damage to the heart muscle

  • Increased oxidative stress, which can harm cells

  • Inflammation in the heart and blood vessels

  • Damage to the lining of blood vessels (endothelium)

  • Scarring (fibrosis) that affects heart function

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Radiation therapy to the chest can damage:

  • Heart muscle (myocardium)

  • Heart valves

  • Blood vessels, potentially leading to cardiomyopathy, valvular disease, or coronary artery disease

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Targeted therapies such as tyrosine kinase inhibitors (TKIs) and VEGF inhibitors may cause: 

  • High blood pressure (hypertension)

  • Irregular heart rhythms (arrhythmias)

  • Heart failure due to effects on blood vessels and the heart muscle

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Ways to cope:

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Monitoring and Prevention

Key strategies to reduce heart complications in cancer survivors include:

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  • Baseline cardiovascular risk assessment and early collaboration between cardiologists and oncologistsMonitoring with cardiac biomarkers (such as troponin and BNP) and imaging tests (echocardiography, MRI) to detect early signs of heart damage

  • Preventive use of cardiovascular medications in high-risk patients to lower the risk of heart injury

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Cardio-protective medication

  • There is a lack of evidence in using beta-blockers, angiotensin II receptor blockers (ARB), or angiotensin-converting enzyme inhibitors (ACEi) to mitigate cardiovascular issues, with some studies showing that MRAs, ACEIs, and beta-blockers can reduce effects

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Lifestyle

interventions

  • Nutrition counseling, physical activity, avoiding risky substances (tobacco, alcohol), stress management, sleep, social connections, and treating co-morbidities are effective in mitigating CVD 

ASK YOUR HEALTHCARE TEAM

  • Are there any medications or therapies I should avoid if I have pericardial effusion or pericarditis?

  • How can we distinguish between my current symptoms and those indicating pericardial issues?

  • Will addressing the pericardial issues affect my ongoing breast cancer treatment?

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