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Long term side effects

Late Effects of Cancer Treatment

Some patients will continue to experience side effects from the initial treatment. 

 

These side effects include: 

-Physical side effects

-Psychological side effects 

 

 

Physical Side effects:

This section reviews long-term physical adverse after primary therapy in breast cancer survivors.

 

Lymphedema

Lymphedema is abnormal swelling that can develop in the arm, hand, breast, or trunk, as a side effect of breast cancer surgery or radiation therapy. Lymphedema can appear in some people during the months or even years after treatment ends. 

 

Why does lymphedema happen? 

Surgery and radiation therapy for breast cancer can remove or damage the important pathways of the lymphatic system. The lymph system is part of the immune system, that collects and carries clear lymph fluid through the tissues to the blood. Lymph builds up gradually and the lymphatic system gets overwhelmed. 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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Treatments include arm elevation, compression sleeves and bandages, manual lymphatic drainage, and pneumatic pumps that help lymph flow out of the arm, hand, trunk, or other body parts which may be affected.  Exercise and losing weight are also effective. 

 

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

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

 

Pain management and comfort measures:

Pain can be caused by all treatments for breast 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 medication1. Others may have moderate to severe pain after mastectomy and reconstruction that require stronger medication1. 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.

Chronic pain can also be caused by mastectomy and radiation to tissues causing permanent tightness and shrinkage2. Treatment includes pain medication, physiotherapy, and massage therapy. Further, a doctor or pain specialist can help you manage your symptoms so you can continue your cancer treatments. Further, women may experience post-operative muscle tightness, difficulties in lifting the arm, and soreness around the shoulders. Gentle stretching exercises can usually begin soon after surgery (usually within 24hr hours), to maintain an adequate range of motion. Your oncology team may refer you to physiotherapy.

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Fatigue:

 

One of the most prominent symptoms reported by breast cancer survivors is fatigue. It is a potential side-effect of surgery, radiation and chemotherapy, as well as the cancer itself. Poor nutrition, changes in sleep patterns, and other medical conditions like anemia and thyroid problems may also cause or worsen fatigue.  

 

Fatigue can persist in survivors for years after the end of treatment. Cancer-related fatigue can be distressing, and if persistent, it can significantly impact personal, social life, or work and can have a negative impact on the overall quality of life. Depression can often be confused as fatigue because the symptoms are similar, so speak to your doctor about your feelings of depression.

 

There are so many ways you can improve your energy, and your feelings of well-being. Let's start with exercise. It’s important to start small, even if you were physically active before your cancer. Walking is enough to help you both mentally and physically. even on days where all you can manage is to walk to the end of your driveway. Once your energy improves, gradually increase the amount of exercise you’re doing.  Find an exercise partner to help motivate you on the days when you really don’t want to get out of bed.

 

The second is nutrition. There are many energy-boosting foods that can help relieve your symptoms of fatigue. From protein-rich foods like fish, chicken and eggs to fiber-rich foods like whole grains, beans and lentils. A healthy diet can significantly improve your energy level. What about ways to eat healthy on those days when your energy is low?  You will be able to intake food without much preparation or effort by eating small, frequent meals or snacks such as fiber-rich

cereals, or nuts.

 

Here are some other tips that can help you increase your energy and improve your quality of life:

  • Avoid drinking caffeine before bed.

  • Take short naps during the day, and try to sleep for a full 7 to 8 hours at night.

  • Drink lots of water.

  • Do your exercises at home.

  • Notice the times of the day when you have the most energy, and schedule activities during those times.

  • Check with your doctor to make sure you don’t have any other problems such as infection, or thyroid problems.

  • If possible, have your cancer treatments at the end of the day so you can go home to bed immediately afterward.

 
Neuropathy

It can be a side effect of chemotherapy, radiation or surgery. Neuropathy may present with loss of sensation, numbness, tingling, burning, decreased feeling of hot and cold, discomfort when touched, muscle weakness and cramping. This can involve your upper and/or lower limb3.

 

Treatments for neuropathy include medications, massage, and transcutaneous electrical nerve stimulation (TENS)4.  Strategies that you can try for managing neuropathy include, regular exercise, avoiding tight fitting shoes or socks, and extreme hot and cold temperatures4,5. During the chemotherapy administration, keeping your hands in an ice bath, or frozen gloves may help you. Speak to your oncology team as they may consider changing the dose of treatment. Further, it is important to also take safety precautions as the decreased feeling in your hands and feet may increase the risk for injury 

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Skin changes

Radiation-induced skin effects range from slight peeling, dryness, itchiness skin darkening, breast fullness and heaviness6.  To manage skin changes, wear loose-fitting clothes; wash with mild soap and lukewarm water; moisturize your skin twice a day with a thick cream that contains no alcohol, perfume or dye; use gentle laundry detergents that are free of perfumes or dyes; and protect your skin from the sun. Your doctor may prescribe corticosteroid cream if needed. For breast fullness and heaviness, you can use a firm, athletic bra.

Bone health

Women who are treated with aromatase inhibitors (AI)s can experience joint and muscles pain as a side effect7. Additionally, AIs can increase the risk of osteoporosis and subsequently the risk of fracture7.  Therefore, if a bone density scan shows signs of bone loss, your doctor may prescribe a bone-modifying agent. To promote good bone health, get enough calcium and vitamin D, and maintain a healthy weight. Perform weight-bearing exercises, such as walking, dancing and climbing stairs, which stimulate the production of bone-forming cells. Also, help prevent falls by wearing shoes that fit well and by avoiding clutter and small rugs in your home.
 

Cognitive dysfunction (brain fog)

Data suggest that cognitive dysfunction related to chemotherapy may be an issue for breast cancer survivors8. Cancer-related brain fog is the feeling you get when your mind is hazy or cloudy. You can’t quite concentrate like you used to, multi-tasking has become more challenging impaired verbal and visuospatial abilities or you have difficulty remembering things that occurred recently9. While it’s most commonly known as a side effect of chemotherapy, many patients who don’t get chemo complain of similar symptoms10. It might be related to other drugs you’re taking, the cancer itself, fatigue, low blood count, stress or hormone changes.

 

It’s important to give yourself time to heal. Over time, most patients find that their cognitive abilities improve9,10. These symptoms improve with time and can be stabilized after six months from the therapy completion9. But for some, symptoms can continue long after treatment ends. Strategies you can use to cope with brain fog include, using a calendar to keep all your important information in one place; exercising your brain with crossword puzzles and games; get proper sleep, physical activity and nutrition; and keep a record of your cognitive difficulties to share with your doctor, who may have other solutions. Also, sign up for mindfulness meditation classes. Meditation can help you focus your thoughts and improve your attention.

 
Menopausal symptoms

 

Endocrine and/or chemotherapy may induce temporary or permanent ovarian failure.  Symptoms include, hot flashes, dry vagina night sweats, sleep problems, mood changes, weight gain and slowed metabolism, thinning hair and dry skin11. Hormone therapy (HT) has been studied in breast cancer survivors, but safety has been questioned11. Ask your doctor for safer alternative medication to treat menopausal symptoms.

 

There are many strategies that you can do to improve your symptoms. For example, physical exercise, particularly aerobic exercise (walking, running, bike riding, swimming), can help reduce hot flashes, sleep disturbances and mood swings11. Other strategies to manage hot flashes include wearing cotton, keeping ice water nearby to drink, taking a cool shower before going to bed, and limiting alcohol and caffeinated beverages.

Melancholy

Psychological Side effects 

You are not alone: Overcoming psychological issues 

If you’re a breast cancer patient who’s experiencing significant depression or anxiety, you’re not alone. Roughly one-quarter of breast cancer survivors experience psychological issues after completion of therapy

Fear of recurrence

 

Fear of recurrence (FOR) is a highly prevalent symptom in cancer survivors. Patients may experience intrusive thoughts, and anxiety which commonly occurs in the days and weeks prior to surveillance visits. These symptoms usually subside after receiving negative results but can occur before the next visit. Of course, some degree of anxiety is a normal reaction in breast cancer survivors, however, sometimes symptoms can interfere with your quality of life or clinical care.  For example, survivors may avoid surveillance visits or request more imaging or outpatient visits. Therefore, if you are experiencing these symptoms, it is important to get help by speaking to your oncology team, or family doctor. They may also refer you to a trained professional or therapist.

 

There are medications your doctor can prescribe designed to help mood disturbances caused by chemical imbalances in the brain. But there are many things you can do on your own to help alleviate your sadness, fear and anxiety, such as, relaxation exercises, which can help improve your mood and reduce your feelings of anxiety and stress. Additionally, you can try yoga, meditation, massage, music or art therapy and get support from your family, friends or fellow breast cancer patients and survivors. Participating in support groups can help you find hope and new ways of coping with your feelings.

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Anxiety

 

Approximately 18 to 25 percent of long-term cancer survivors report anxiety.1 Reasons for heightened distress after a breast cancer diagnosis includes, fear of recurrence, concerns about family, changes in self-perception and body image, and increased awareness of vulnerabilities.2 Several factors have been identified as a risk for anxiety for survivors including, advanced disease, presence of long-term physical symptoms that are related to treatment, lack of social support, and a previous history of mental conditions.2

Physical and psychological symptoms of anxiety include insomnia, hyper-vigilance to symptoms or events, shortness of breath, jitteriness, distractibility, worrying thoughts, apprehensive, low concentration, emotional numbness and fatigue.1 If these symptoms interfere with your quality of life and the ability to carry out daily activities, further evaluation and treatment may be required. Speak to your doctor if you are experiencing these symptoms. Treatments include, talk therapies, either individually or in a group, and anti-depressants. You may try relaxation exercises that can help improve your mood, such as, yoga, meditation, or massage2.

Depression

 

In breast cancer survivors, depression is less common compared to anxiety1. However, it’s associated with a twofold increase for all-cause of mortality2. Symptoms of clinical depression include, at least two weeks of unusual sadness or decreased pleasure in daily activities, a decline in functioning, as well as five of the following; a significant change in weight or appetite, change in sleep (this can include either lack of sleep or excessive sleepiness), fatigue or loss of energy, guilt or worthlessness, low concentration or more indecisive, or suicidality. It may be something you notice yourself or observed by your friends and family.3

While some sadness or anxiety is normal when you have breast cancer, mood disturbances require treatment if they are severe, persistent, or accompanied by thoughts of death and dying. If this is the case for you, ask your oncology team or your family doctor. Treatments include talk therapies, and anti-depressants or anti-anxiety agents designed to lift mood disturbances. You may try relaxation exercises that can help improve your mood, such as, yoga, meditation, and massage.

It is important to get help immediately if you are experiencing thoughts of suicide.
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Survivor guilt

 

It’s a complex psychological condition that is described as a sense of blame for the diagnosis, loss and grief. Additionally, feeling that you have done something wrong that can be never corrected as a result of having survived cancer3. This can lead to a mood disturbance. However, survivors may use this guilt to give back by participating in advocacy activities or positive health changes in health (diet, exercise and smoking cessation).

Social issues:

 

Cancer and its treatment can have a broad reach into the lives of cancer survivors, their caregivers and their social network (eg, friends, community, church). Specific issues that have been evaluated are discussed below.

  • Caregivers

Breast cancer exerts its effects on the spouse or significant other particularly during active treatment. Caring for a cancer patient can take a toll on the caregiver’s health. Available data has suggested that caregivers experience distress, anxiety and depression. Sharing thoughts and feelings about the cancer experience of both the patient and caregivers is found to decrease distress and/or depression.

  • Children

Mothers with breast cancer report various concerns about their children, ranging from their daily disruptions to questions about dying and leaving their children behind. It can also be a difficult conversation to talk to your children about breast cancer. Children of parents who are breast cancer survivors may face psychosocial issues. These include feelings of uncertainty, anxiety and isolation. A child's age, cognitive capacities, strengths and gender may influence children responses to their mother’s breast cancer. Recent studies have shown that adolescent5. females were found to be the most negatively impacted5. One study demonstrated that among adolescent daughters of breast cancer survivors, those exhibiting greater anxiety had mothers who demonstrated greater anxiety in their relationship.

  • Adjustment to work:

Work issues can be a major hurdle in adjustment after breast cancer. Returning to work can be difficult for many survivors as they are recovering from the physical and psychosocial issues related to cancer and its treatment. Worrying about health insurance and benefits poses a high priority concern. Other challenges include fatigue, physical limitations (difficulties with range of motion), psychological issues including anxiety and depression, and also menopausal symptoms. Self-employed survivors also have a more difficult time returning to work. 

References: 

  1. Poleshuck, E. L., Katz, J., Andrus, C. H., Hogan, L. A., Jung, B. F., Kulick, D. I., & Dworkin, R. H. (2006). Risk factors for chronic pain following breast cancer surgery: a prospective study.The Journal of Pain, 7(9), 626-634.

  2. Andersen, K. G., & Kehlet, H. (2011). Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention.The Journal of Pain, 12(7), 725-746.

  3. Speck, R. M., DeMichele, A., Farrar, J. T., Hennessy, S., Mao, J. J., Stineman, M. G., & Barg, F. K. (2012). Scope of symptoms and self-management strategies for chemotherapy-induced peripheral neuropathy in breast cancer patients.Supportive Care in Cancer, 20(10), 2433-2439.

  4. Bandos, H., Melnikow, J., Rivera, D. R., Swain, S. M., Sturtz, K., Fehrenbacher, L., & Ganz, P. A. (2018). Long-term peripheral neuropathy in breast cancer patients treated with adjuvant chemotherapy: NRG Oncology/NSABP B-30.JNCI: Journal of the National Cancer Institute, 110(2), djx162.

  5. Hadji, P. (2009). Aromatase inhibitor-associated bone loss in breast cancer patients is distinct from postmenopausal osteoporosis. Critical reviews in oncology/hematology, 69(1), 73-82.

  6. Tesselaar, E., Flejmer, A. M., Farnebo, S., & Dasu, A. (2017). Changes in skin microcirculation during radiation therapy for breast cancer.Acta Oncologica, 56(8), 1072-1080.

  7. Hermelink, K., Bühner, M., Sckopke, P., Neufeld, F., Kaste, J., Voigt, V., … & Harbeck, N. (2017). Chemotherapy and post-traumatic stress in the causation of cognitive dysfunction in breast cancer patients.JNCI: Journal of the National Cancer Institute, 109(10).

  8. Biglia, N., Bounous, V. E., Malabaila, A., Palmisano, D., Torta, D. M. E., d’Alonzo, M., … & Torta, R. (2012). Objective and self‐reported cognitive dysfunction in breast cancer women treated with chemotherapy: a prospective study.European journal of cancer care, 21(4), 485-492.

  9. Lange, M., & Joly, F. (2017). How to identify and manage cognitive dysfunction after breast cancer treatment.Journal of oncology practice, 13(12), 784-790.

  10. Crandall, C., Petersen, L., Ganz, P. A., & Greendale, G. A. (2004). Association of breast cancer and its therapy with menopause-related symptoms.Menopause, 11(5), 519-530.

  11. Rosenberg, S. M., & Partridge, A. H. (2013). Premature menopause in young breast cancer: effects on quality of life and treatment interventions.Journal of thoracic disease, 5(Suppl 1), S55.

  12. Baqutayan, S. M. S. (2012). The effect of anxiety on breast cancer patients. Indian journal of psychological medicine, 34(2), 119-123.

  13. Tsaras, K., Papathanasiou, I. V., Mitsi, D., Veneti, A., Kelesi, M., Zyga, S., & Fradelos, E. C. (2018). Assessment of depression and anxiety in breast cancer patients: prevalence and associated factors. Asian Pacific journal of cancer prevention: APJCP, 19(6), 1661.

  14. Cvetković, J., & Nenadović, M. (2016). Depression in breast cancer patients. Psychiatry Research, 240, 343-347.

  15. Telling your children. (2020). Retrieved March 25, 2021, from https://www.cbcn.ca/en/children_and_breast_cancer

  16. Di Wei, X. Y. L., Chen, Y. Y., Zhou, X., & Hu, H. P. (2016). Effectiveness of physical, psychological, social, and spiritual intervention in breast cancer survivors: An integrative review. Asia-Pacific journal of oncology nursing, 3(3), 226.