The following article features in Issue One of the ST BREAST magazine.
“Many women need help navigating all that a breast cancer diagnosis brings,” she said. “It’s not only physical support, it’s psychological, spiritual, emotional and financial.”
One thing she is particularly passionate about is the importance of exercise. “I cannot say strongly enough that exercise in cancer care saves lives. We know it can reverse treatment related side effects, improve muscle mass, stamina, self-esteem and quality of life. Importantly, it can slow disease progression and improve the chances of survival.” Diana also says it’s a common misconception that suffering during therapy is a sign the drugs are doing their job.
“Some women believe they have to feel horrendous, but if they are experiencing a problem, we need to make them feel better. We have come a long way in the past 15 years and there are things we can do now to help women tolerate treatment better and to move forward beyond treatment.”
These are some of her insights.
Many women report sleep disturbances and feeling profoundly tired during and after treatment. Fatigue typically starts to lessen around three months post-completion of therapy. By 12 months, most women will return to previous energy levels. Undiagnosed depression, an underactive thyroid or diabetes can worsen this fatigue and need to be treated. About 10% still experience profound fatigue and we need to understand more through research and support these patients better.
The shock of a diagnosis is enough to set you into a bad sleep pattern. Depression can cause some women to wake very early. Also, we use steroids during chemotherapy and that can interrupt sleep cycles. But getting enough sleep is really important for patients, because we process things at night as well as during the day. It is important that women discuss their sleep patterns with their doctors. We should be saying not, ‘How did you sleep?’ but ‘What was the quality of your sleep?’ There is a lot of work being done on sleep at the moment and I think it is intertwined with cognition. If you are fatigued, you might feel unable to exercise, although exercise can actually improve fatigue and improve sleep.
Women report that they are ‘kind of resting but not really resting enough’, or ‘sleeping but not sleeping enough’ – it’s a vicious cycle. We know exercise can help and we know that yoga can help. The sooner you intervene with a sleep pattern, the better.
Many women report that simple things they once found easy to remember are now difficult. They report vague or ‘fuzzy’ thought patterns. Writing lists can help.
Challenging your brain with tasks that are different to what you are used to can help restore some of the brain’s neuroplasticity. These symptoms often start improving at the 6 to 12 month mark post-therapy. It is important that undiagnosed depression is not worsening any cognitive changes and is treated. Exercise can also help to improve cognitive function.
Some patients report a metallic taste in their mouths as a result of therapy; others can suffer quite serious mouth ulcers, which can impact their appetite. There are management strategies we can employ to help women through these symptoms, but generally speaking, I would say that taste and appetite generally return within about three months of completing therapy.
Even in this age of sentinel node biopsies or removal, about one in five patients will still experience lymphoedema, which is a swelling of the arm that can occur after treatment for breast cancer.
It is a consequence of removing lymph nodes from under the arm, so the body’s lymph system is not draining effectively. There is no cure for lymphoedema, but there are management strategies to alleviate symptoms and to minimise the chance of swelling. It first needs to be identified by an occupational or lympoedema therapist. We have moved away from advising not to use the arm and actually encourage exercising the arm actively.
Many women gain weight as a result of their treatment and this can impact their general body image. Weight gain can occur for a variety of reasons, including medication-induced menopause, or reduced activity levels because of fatigue and not feeling well. Again, exercise is really important and referral to a dietitian where possible.
Often a woman’s hair is linked to her identity and her femininity and as we all know, chemotherapy can result in hair loss – and not just from your head, but on all parts of your body, including eyelashes, eyebrows, nasal hair and pubic hair. Some centres – including ours – use ‘cooling caps’ which keep your scalp at a very low temperature during a chemotherapy infusion. Research has shown that these caps can prevent hair loss altogether for some people. For women who do lose their hair, it can take three to four months following the completion of treatment before they see any meaningful new growth. It tends to grow back curlier or different in texture than before and maybe coarser, even when it has previously been straight. In many cases hair does not stay curly, but it may still have a wave.
Many patients who are free from breast cancer report a persistent sensation of pins and needles or a loss of feeling in their fingers and toes. This is known as neuropathy and it results from the nerve damage linked to some chemotherapy agents. Neuropathy can be debilitating and sometimes it is never resolved – impacting quality of life for the rest of a patient’s life. Neuropathy usually resolves with time, usually by one year post chemotherapy. For some, it can impact quality of life long term. Exercise can help maintain core body strength to reduce risk of falls.
Hot flushes are a commonly reported menopausal symptom associated with breast cancer treatment. Up to 80 per cent of women with breast cancer, particularly younger women, experience hot flushes. They can be more severe for breast cancer patients than they are for naturally menopausal women without breast cancer, and may persist for many years beyond treatment. Some women notice that caffeine (including tea) , stress, red wine and chocolate can worsen flushes. Avoiding these triggers can improve
symptoms. There are many medications available to reduce flushes and best discussed with your doctor.
Some hormone therapies may cause joint pain as a side effect. This most commonly occurs in the morning upon waking. Gentle exercise can help. A small number of women need to trial different hormonal therapies with their doctor.
Women who have had breast surgery often notice they have a decreased range of movement in their shoulders, so are less able to do stretching exercises. Seeing an accredited exercise physiologist or physiotherapist increases confidence and ability to regain or even improve upper body function.
Brittle bones, or osteoporosis, can be a result of some therapies. It is something we worry about for our patients, but some survivors don’t seem to think as much about this. Keeping a healthy vitamin D level and performing weight bearing exercises, such as walking or running, can protect against osteoporosis happening in the first place. There are also medications to treat osteoporosis.
Some women experience depression during or after treatment and it is completely understandable - it is a reaction to an abnormal situation. Women are often dealing with partners – some are supportive and some unfortunately, are not. Dealing with children, depending on their age, can also be exceptionally difficult. Women might also be dealing with employers and negotiating reduced hours or fewer days.
Breast cancer may have affected a woman’s fertility, either permanently or for a period of time. It depends on the type of breast cancer and the type of treatment. Many women wonder how they will explain to a new partner that they have had treatment when they were younger, or that they can’t have children. There are so many issues and there are breast cancer counsellors who can help women navigate these kinds of conversations.
Dr Diana Adams