Q: What are some of the most common side effects of breast cancer treatments?
A: Different treatments have different side effects. There is potential overlap between them and the chance of these occurring varies considerably from common to rare. The following is a summary, but is by no means exhaustive and is not in any particular order:
- Surgical to breast and underarm: Pain, wound issues (infection, healing), numbness, reduction in arm movement, lymphoedema.
- Chemotherapy: There is a very long list of possible side effects, including hair loss, fatigue, ‘chemo fog’, infection, mouth ulcers, nausea, diarrhoea, constipation, skin rash, nail damage, numbness, second cancers, heart damage, anaemia, bleeding, pain.
- Radiotherapy: Skin burn/blistering, heart/lung damage, fatigue.
- Hormone blocking: hot flushes, sleep disturbance, fatigue, dry skin, vaginal dryness, low libido, joint and muscle pain, stiffness, hair thinning, memory/concentration disturbance, mood changes (depression, anxiety, irritability).
- Overall, these treatments can have a significant effect on day-to-day life, with impacts on physical/mental health, relationships, family, and work.
Q: Do the side effects increase/decrease depending on age?
A: Younger patients tend to have a greater impact from the menopausal/hormone blocking type side effects. Those who had few natural menopausal symptoms or are further from natural menopause tend to tolerate these hormone blocking treatments better. Older patients, especially those with other health conditions, can experience more side effects from chemotherapy.
Q: I have heard that chemotherapy and radiation can affect the heart and lungs and some people will suffer heart attacks following treatment. Can you tell us about that?
A: This is thankfully quite rare, and getting more rare as our treatments improve. Certain types of chemotherapy and targeted therapies can affect the heart, such as doxorubicin and trastuzumab, in different ways. Radiotherapy can affect the heart, however with modern radiotherapy plans and breath hold techniques (where patients take a deep breath during treatment, and hold this breath while the radiation is delivered. By taking a deep breath in, your lungs fill with air and your heart will move away from your chest), it does a good job of avoiding radiotherapy to the heart. We do need to be aware of heart-related risk factors, and manage those, because heart disease and breast cancer often coexist.
Q: Do breast cancer treatments affect your bone density?
A: Yes. Firstly, if chemotherapy causes premature menopause, it can result in loss of bone density. Secondly, the aromatase inhibitor class of hormone blocking medication, along with goserelin (used for some premenopausal patients) can cause osteoporosis and fractures. This should be checked at baseline and then monitored over time.
Unfortunately there is limited access to medicare-funded bone density scanning due to restrictions around eligibility. Zoledronic acid is a treatment that is being used for some postmenopausal women as a breast cancer treatment strategy and this helps to improve bone density. There are a variety of other options for managing bone density such as exercise, calcium, vitamin D, not smoking and avoiding falls.
Q: How long do most of the side effects last?
A: The majority of surgical and radiation side effects are typically short lived. Breast pain and numbness can last for years for some people, however, and lymphoedema can occur months to years later and may not resolve.
Chemotherapy side effects are also generally short-lived. Tiredness, nerve damage and chemo-fog can last for a couple of years, and in some cases does not get completely better. Heart damage can arise years down the track.
The hormone blocking side effects peak in the first year or two, and then may get gradually better over time, but many people do not experience resolution of the side effects until they complete their course of treatment. Some stop early due to side effects, but we try to manage these as best we can to prevent premature discontinuation.
Some effects that people experience are due to underlying conditions or aging, so it can be helpful to have a short break in hormone blocking treatment to try to work out what is treatment-related vs natural aging.
Q: What are some of the things that people can do to reduce the side effects as they are going through treatment?
A: Talk to your health practitioners about what you are experiencing – doctors, nurses, psychologists. If you don’t let people know and ask about what can be done, then it is much harder to help.
Keep mentally and physically active. Maintain good mental health practices. Get some sleep and try to eat as good a diet as possible. Seek support with physical activity via an exercise physiologist or physiotherapist. There are many specific options for managing side effects depending on the situation.
We at Breast Cancer Trials are very interested in supporting quality of life. Most trials include a quality of life component and we aim to answer more questions related to improving wellbeing and side effects with future trials.
Q: Are there any natural remedies that can help whilst going through treatment?
A: There are many non-pharmacological options for treatment side effects. This includes natural or herbal treatments, physical therapies and mental health techniques. The main principles are that those treatments should be discussed openly with the treating team to ensure that they are safe and unlikely to interact with the other treatments. Some herbs have hormonal effects that can be detrimental in hormone receptor positive breast cancer. Others can stop treatments from working. Always consult a reputable practitioner and take information from sources that are evidence-based, such as the Memorial Sloan Kettering Cancer Center herbs database.
Q: Can you tell us a bit about the de-escalation trials that Breast Cancer Trials have conducted? And which breast cancers are suitable for a patient to consider de-escalating treatment?
A: We are moving towards ‘treatment optimisation’, because some patients will do well with less treatment, whereas some patients need more treatment to give them the best chance of a good outcome following a breast cancer diagnosis.
The ‘de-escalation’ trials are about finding which patients have a cancer that requires less treatment for the same outcomes. If we can safely avoid giving a treatment, or giving a shorter duration, the side effects of that treatment can be minimised. This is currently being looked at in the EXPERT trial, which uses a special test of the tumour (PAM50), and aims to identify patients who do not need radiotherapy after a lumpectomy for early stage breast cancer. This trial is recruiting worldwide at present.
Cancers that are suitable for de-escalation are typically those with a good prognosis – smaller, lower grade, lymph node negative, hormone receptor positive. However, there are some cancer types that are particularly sensitive to certain treatments. This has been examined with immunotherapy in the Neo-N trial, reducing the amount of chemotherapy, and in the Decrescendo trial, giving additional targeted therapy and giving response-adapted chemotherapy.
Source: Breast Cancer Trials
BCT is hosting a free, virtual Q&A on Thursday 23rd February from 5-6.30pm AEDT about breast cancer treatments and their side effects, featuring breast cancer experts and patients, hosted by Annabel Crabb.
This panel includes Professor Bruce Mann, Professor of Surgery at the University of Melbourne and Director of Research at Breast Cancer Trials, Dr Nicholas Zdenkowski, Medical Oncologist, Ms Jenny Gilchrist, Nurse Practitioner in Breast Oncology at Macquarie University and breast cancer survivor, Ms Naveena Nekkalapudis.
Anyone keen to tune in simply needs to register here where they can submit either a written question or a video question that could be asked or played during the broadcast.