There are over 3.1 million breast cancer survivors in the United States, and this number is projected to increase to more than four million by 2024. Caring for this population is fraught with both clinical and economic challenges including managing side effects of long-term treatment and preventive therapies and their associated costs. According to data presented by Dr. Beverly Moy (Massachusetts General Hospital Cancer Center) in an educational session on strategies to improve survivorship care, the cost of breast cancer survivorship care was $8 billion in 2014, more than all other cancers combined. While breast cancer survivors are living longer, they are living with the long-term effects of curative therapies and a chronic risk of recurrence.
In December 2015, ASCO and the American Cancer Society jointly published the Breast Cancer Survivorship Care Guidelines to help physicians care for patients after therapy. The guidelines were developed by a multidisciplinary team that included BCRF investigators Drs. Arti Hurria and Patricia Ganz and included recommendations for assessment and management of physical and psychosocial long-term and late effects of breast cancer and treatment.
Dr. Moy pointed out that in spite of ongoing survivorship initiatives by many cancer organizations and recommendations for survivorship care plans, little progress has been made on implementing these recommendations consistently across cancer care centers. Several care models have been developed that differ by amount of time, infrastructure and resources required. Implementation is hampered by insufficient staff, funding and resources at many cancer care centers, as well as lack of evidence of their effectiveness on patient outcomes and quality of life.
Endocrine therapies are very effective in both treating cancer, as well as reducing the risk of it returning. Because of the strong data from prevention studies, endocrine therapies (tamoxifen and aromatase inhibitors (AIs)) may be prescribed for five years or more, but their anti-estrogenic effects as well as effects on bone make long-term use intolerable for many women. BCRF investigator Dr. Debra Barton recommended the following steps that oncologists can take to improve patient adherence to endocrine therapies:
Side effects of treatment are a major reason women discontinue their prescribed endocrine therapy. Because they block the effects or production of estrogen, endocrine therapies may cause menopause-like symptoms, which differ somewhat between tamoxifen and aromatase inhibitors (AIs), but include hot flashes, vaginal dryness, joint pain and fatigue.
Studies suggest that for some women, short-term, a low dose anti-depressant in combination with sustained cognitive behavioral therapy may reduce the discomfort of hot flashes, while limited evidence exists to support the use of dietary supplements including soy, vitamin E, black cohosh, magnesium or flaxseed. To treat vaginal dryness, Dr. Barton suggested vaginal moisturizers over lubricants as they have a more lasting effect. Lubricants that contain glycerin, she noted, can cause vaginal yeast infections.
Additionally, she cautioned against the used of low-dose vaginal estrogens. In spite of evidence that the estrogen exposure did not increase cancer risk, long-term prospective studies on safety are lacking, particularly in women taking aromatase inhibitors. Vaginal testosterone has been shown to improve symptoms, albeit with androgen-associated side effects such as hair growth and acne. Dr. Barton’s group has studied the use of DHEA – a natural precursor to estrogen and androgen. Her studies, which will be published soon, showed that nightly use of a DHEA-containing cream over 12 weeks significantly improved vaginal dryness compared to moisturizers.
Studies of interventions for joint pain do not support the use of non-steroidal anti-inflammatories (NSAIDS) or omega 3 fatty acids; however, one small study found that glucosamine with chondroitin improved symptoms in 39/56 patients studied. While there is evidence that low Vitamin D levels are associated with joint pain, randomized controlled clinical trials of vitamin D supplementation have had mixed results. Acupuncture and exercise have been shownin small studies to improve AI-induced joint pain.
Dr. William Gradishar finished the session with a discussion on the role of bone modulating agents for symptom management in breast cancer. Chemotherapy can have direct effects on bone as well as estrogen metabolism and production, which further impacts bone mineral density, increasing the risk of fracture. Radiation therapy and hormonal therapy, particularly aromatase inhibitors, also weaken bones directly and indirectly. In pre-menopausal breast cancer patients, an ovarian suppressing agent may be used in combination with endocrine therapy to reduce estrogen production – also affecting bone health. Bisphosphonates and a targeted therapy called denosumab have been shown to reduce fractures in these patients and have also been used in patients with advanced breast cancer who are at a high risk of fracture and bone metastasis.
The effects of cancer treatment can linger long after treatment ends. Patients should discuss lingering side effects with their oncologists to ensure they recieve appropriate care for symptom management.
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