Keep in mind that survivors should continue to have screening for other cancers per the American Cancer Society guidelines and routine health maintenance as recommended by the USPTF.
This patient received the following treatment for Breast Cancer
- lymph nodes taken from above the waist
- cyclophosphamide (cytoxan®, neosar®)
- doxorubicin (adriamycin®, rubex®)
- x-ray based radiation / conformal radiotherapy
- radiation treatment for breast cancer after mastectomy
Concerns caused by medical therapies
A Lack of Knowledge
- Many cancer treatments today have not been available long enough to determine what effects they may cause in years after treatment.
- Evaluate for any new or worsening symptoms that may be unexplained by other factors.
Risk of Developing Cataracts
- Increased risk for cataracts due to certain chemotherapy agents. Assess for symptoms at annual physical exam.
- Survivors should have eye exam by an ophthalmologist every 1-2 years
Risk for Cardiac (Heart) Problems Related to Anthracycline Chemotherapies
- Annual physical exam that includes a complete cardiac exam.
- Consider cardiac studies (echocardiogram or MUGA).
- Monitor and manage blood pressure and cholesterol levels.
- Encourage a heart healthy lifestyle- smoking cessation, proper diet and regular exercise, etc.
Risk of Developing Osteoporosis
- Long term use of corticosteroids, receiving chemotherapy medications or radiation to weight bearing bones all increase the risk of developing osteoporosis.
- Calcium intake of 1200-1500mg per day plus Vitamin D 400-800iu or 800-1000iu per day (either in dietary intake or supplements).
- Encourage smoking cessation and minimal or no alcohol intake.
- Promote healthy lifestyle with good diet and regular exercise including weight-bearing exercise 2-3 times per week.
- Consider screening with DEXA scan.
Risk of Liver Toxicity
- Strongly encourage to limit alcohol intake.
- Monitor LFTS (liver panel), a complete blood count with platelets, and a prothrombin time test annually while on therapy.
- Encourage good hygiene and skin care.
- Evaluate for any signs of infection or non-healing skin wounds.
- “Chemo-brain” can include difficulty with short term memory, multi-tasking, new learning, reading comprehension, working with numbers and a decrease in concentration ability.
- Evaluate for cognitive changes and confirm that any cognitive changes are not due to a treatable cause such as hypothyroidism, depression, or anxiety.
Fertility Concerns for Female Survivors
- Due to cancer treatments, survivors may have sexuality fertility issues after treatment.
- Refer to reproductive specialist, experienced in working with cancer survivors, if needed.
- Pregnant survivors should consider being followed by a high-risk obstetrician.
- Survivors should be aware of the possibility of getting pregnant even after menstruation has stopped (due to treatments). All patients who were actively menstruating before beginning cancer treatment should use birth control during cancer treatment and for months afterwards, even if periods have stopped.
Side Effects While taking Tamoxifen
- Adjunct tamoxifen therapy can last for 5 or more years after primary therapy.
- These may cause hot flashes and other symptoms of menopause.
- There is an increased risk of endometrial cancer and blood clots while taking this medication.
- Encourage a discussion with the oncology team to manage any symptoms that may lead the survivor to discontinue the medication.
Sexuality Concerns for Female Survivors
- Chemotherapy agents are associated with vaginal dryness, painful intercourse, reduced sexual desire and ability to achieve orgasm. Many of these issues are caused by the sudden onset of menopause, as a result of cancer therapy.
- OncoLink’s article on Vaginal Dryness and Painful Intercourse provides product suggestions and tips.
- Encourage open communication with patient to help them address any sexuality issues. May also consider referring to a therapist experienced in working with cancer survivors.
Risk of Developing a Blood Cancer
- Certain chemotherapy agents or radiation can lead to the development of leukemia, MDS, or lymphoma. This typically occurs 4-10 years after therapy, but could occur as soon as 1-3 years after therapy (early onset is most common with etoposide or teniposide).
- Annual complete blood count with differential. Evaluate for concerning sign/symptoms.
Risk of Bladder or Urinary Tract Toxicities
- Risks include hemorrhagic cystitis and decreased bladder capacity. Evaluate for concerning urinary symptoms and provide appropriate follow-up with urinalysis and urology consult.
- Encourage to avoid alcohol and smoking cessation.
Risk of Developing Bladder Cancer
- Encourage smoking and alcohol cessation
- Patients who also received radiation to abdomen at increased risk.
- Assess for urinary symptoms.
Concerns caused by surgery
Lymph nodes taken from above the waist
- Perform thorough assessment of area at risk for lymphedema, which may include limbs, genitals, abdomen or head/neck area.
- Concerning signs/symptoms of lymphedema may include: full or heavy feeling, skin changes (reddened, warm, cool, dry, hard, stiff), aching/discomfort, tightness, or less movement/flexibility in nearby joints.
- Encourage preventive measures, self-assessment of changes to limbs and prompt reporting of any sign of infection.
- Referral to a Certified Lymphedema Therapist at the first sign of swelling results in the best outcomes.
- Risks of surgery include nerve damage and scarring which can lead to decreased range of motion, pain, difficulty with motor skills and sensation on affected side.
- Consider referral to physical therapy for decreased range of motion in the shoulder.
- Consider physical or occupational therapy for difficulty with motor skills, temperature sensation or balance.
- Treat neuropathic pain with tricyclic antidepressants, carbamazepine, gabapentin or pregabalin.
- Refer to pain specialist if pain does not improve.
Concerns caused by radiation therapy
Radiation can cause damage to any tissues within the field of treatment. The following concerns include all areas generally included it the treatment field for this patient’s type of cancer.
- The Children’s Oncology Group recommends survivors should not scuba dive without medical clearance by a diving medicine specialist.
- Annual influenza vaccine and pneumococcal vaccine every 5 years.
- Counseling for tobacco cessation.
- Chest X-ray for new cough or shortness of breath.
- Immediate evaluation of hemoptysis.
Heart / Cardiovascular
- Survivors are at risk for early CAD, hypertension, valve abnormalities, fibrosis of cardiac tissue, heart failure and MI. The risk varies greatly depending on dose, number of fractions, shielding and combination with chemotherapy.
- Annual H&P, including blood pressure, cholesterol levels and blood sugar.
- Counseling on healthy lifestyle including exercise, tobacco cessation and healthy diet.
- High-risk survivors may benefit from an annual EKG and screening echocardiogram.
- Radiation can increase the risk of bone fractures. Joints in the treatment field can develop permanent stiffness, pain and arthritis.
- Rapid evaluation for fracture after trauma.
- Physical or occupational therapy and NSAIDs for arthritis.
- Skin is more sun sensitive after radiation. Counsel to use sunscreen diligently.
- Evaluation by a wound care specialist for any non-healing ulcers.
- Skin can develop chronic swelling, wounds, changes in texture and color.
- Radiation increases the risk of lymphedema over surgery alone. A Certified Lymphedema Therapist should be consulted at the first sign of swelling for best outcomes.
- Survivors should be educated about self care and to notify the healthcare team with any signs of infection. Instructions for survivors on risk reduction from the NLN: http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf
- Radiation and/or surgery can damage nerves, which can be further aggravated by scar formation and result in neuropathic pain. Survivors with this pain may benefit from seeing a pain specialist.
Radiation to Chest wall for breast cancer (after mastectomy)
- Survivors of breast cancers, particularly left-sided breast cancers, may be at increased risk of cardiac complications. Please see the description of heart/ cardiovascular late effects for more information.
- Yearly mammograms for those who had single mastectomy.
- Annual examination of breast tissue and/or chest wall by breast cancer specialist.
- Caution when surgery is considered after radiation to the chest wall or reconstructed breast.
- Consideration of physical/ occupational therapy for arm pain, weakness, or swelling.
- Rapid evaluation for new arm swelling, redness, or pain, especially with fever.
Follow Up Care
The National Comprehensive Cancer Network Clinical Practice Guidelines recommended follow up care for this patient's breast cancer includes:
- Mammogram annually for those who had single mastectomy (first one six months after therapy for survivors who had lumpectomy and radiation therapy).
- Perform monthly self-breast exams and / or examination of the chest wall and scar line. Report any changes, lumps, swelling or skin rashes to your physician.
- Seen by oncologist every 4-6 months for 5 years, then annually.
- Women with an intact uterus on tamoxifen should see a gynecologist annually and notify their physician of any vaginal bleeding.
- Women taking aromatase inhibitors should have a Dexa scan at baseline, then periodically.
- Consider referral to genetic counseling if family or personal history includes early age at diagnosis (<50), triple negative disease, multiple primary cancers, or a strong family history of breast or ovarian cancer.
- Evidence has shown that leading an active lifestyle and maintaining a healthy weight (body mass index of 20-25), may lead to improved breast cancer outcomes.
© 2013 Trustees of the University of Pennsylvania