Patients diagnosed at any stage of cancer seek to maintain their quality of life both during and after treatment. The American Cancer Society (ACS) and ASCO developed and released breast cancer survivorship care guidelines to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer (J Clin Oncol 2016;34:611-35). Quality of life is a significant concern for patients living with metastatic cancers who are on continual treatment, often for years, until the end of life.
In the U.S., it is estimated that 3.5 million women are living with a history of invasive breast cancer. An additional 246,600 women and 2,600 men will be newly diagnosed with invasive breast cancer this year. The ACS/ASCO Breast Cancer Survivorship Care Guidelines summarized current literature and evidence for the assessment and management of physical and psychosocial long-term and late effects of breast cancer and treatment.
All breast cancer treatments—surgery, radiation, chemotherapy, hormonal therapy, and targeted therapy—can have long-term and late effects that impact physical and psychosocial well-being of women. A long-term effect is something that starts during treatment and does not subside. A late effect is something that develops much later. Some of the physical effects of treatment are summarized in the Table.
According to the ACS/ASCO report, long-term and late psychosocial effects after breast cancer treatment include depression, distress, worry or anxiety, fear of recurrence, fear of pain, end-of-life concerns, loss of sexual function, and/or desire, challenges with body image and self-image, relationship, and other social role difficulties and concerns with finances and return-to-work.
Body Image Concerns
Between one- and two-thirds of breast cancer survivors express concerns over body image and appearance changes. This is a particular concern to young women who have undergone breast cancer treatment. Loss of a breast, scarring or disfiguration due to surgery or treatment, lymphedema, hair loss, sexual dysfunction (due to loss of libido, vaginal dryness or pain with intercourse), and chemotherapy-induced early menopause can all affect how a woman feels about her body and subsequently, her intimate relationships.
The ACS/ASCO Breast Cancer Survivorship Care Guidelines recommend active surveillance by primary care physicians to assess body image concerns so appropriate interventions can be initiated. Options include oral pentoxifylline and vitamin E in patients with radiation-associated breast/soft-tissue scarring, breast-reconstructive surgery to improve breast symmetry, breast forms, prostheses or special lingerie to help a woman recover her pre-cancer self-image. The report further recommends women with body image concerns be referred for psychosocial care.
The reported rates of sexual health problems after breast cancer treatment range widely and include sexual desire disorder/decreased libido (range of 23-64% of patients), issues with arousal or lubrication (20-48% of patients), orgasmic concerns (16-36% of patients), and difficult or painful sexual intercourse (35-38% of patients). Patients treated with chemotherapy tend to report more of these sexual concerns than those treated only with surgery and/or radiation. Changes in body image due to breast cancer treatment or loss of skin sensitivity after radiation can also affect sexual health.
Menopausal symptoms can be induced in young women treated with chemotherapy that affects ovarian function or that targets estrogen production or function. Younger women typically experience more vasomotor symptoms (hot flashes or night sweats) because of the abrupt changes in hormones and more than half of women taking tamoxifen report hot flashes.
The Breast Cancer Survivorship Care Guidelines recommend the clinical care team counsel patients about the possibility of sexual dysfunction and premature menopause due to breast cancer therapy and discuss treatment options to manage side effects. Non-hormonal, water-based lubricants and moisturizers remain the primary recommendation for vaginal dryness. Selective serotonin reuptake inhibitors, gabapentin, or lifestyle modifications may mitigate symptoms of premature menopause.
The clinical care team should evaluate any reported concerns about sexuality and sexual health following breast cancer treatment. Patients experiencing sexual health issues after cancer care should be referred to psychosocial interventions such as brief psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy.
Unique Challenges for Young Women
Young women with a high risk of breast cancer recurrence face unique challenges in achieving intimacy and quality of life after breast cancer treatment. In particular, for young women diagnosed with BRCA-breast cancer, mastectomy and prophylactic removal of the ovaries are recommended to decrease the chance of breast cancer recurrence or future ovarian cancer. The loss of one's breasts will affect a woman at any age but for young women still dating, it can create new layers of complexity in intimate relationships and family planning. Likewise, young women facing the prospect of removal of the ovaries may have a heightened sense of urgency to start a family.
Many women who have undergone breast cancer treatment are relieved that the cancer was treated and are eager to resume their lives. However, the post-treatment experience will be unique to each woman and all women undergoing breast cancer treatment, or who have completed treatment, should feel empowered to talk about all health issues, including sexual health, body image, and other psychosocial issues, with their clinical providers—their oncologist, primary care doctor or gynecologist. Medical practitioners should assess these issues in their patients and the ACS/ASCO Breast Cancer Survivorship Guidelines provide a framework to better understand the issues and recommendations for care based on the current medical evidence.
MARGARET FLOWERS, PHD, is Associate Director of Grants & Scientific Communication at the Breast Cancer Research Foundation, New York, N.Y. MARC HURLBERT, PHD, is Chief Mission Officer at the Breast Cancer Research Foundation.
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