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November Ask the Expert: Managing Side Effects

During the month of November, Living Beyond Breast Cancer expert Evelyn Robles-Rodriguez, RN, MSN, NPC, AOCN, answered your questions about how to manage the side effects of breast cancer treatment.

You may also be interested in September 2010 Ask the Expert: Neuropathy.

Managing bone pain with paclitaxel (Taxol)?

How to manage joint pain associated with tamoxifen?

Should a compression garment be worn to manage lymphedema all the time or just when issues arise?

How to manage hair loss? Will hair eventually come back?

How to manage fatigue?

Managing a loss of libido and lack of interest in sex; is it a common problem in senior couples?

Long-term side effects of radiation and risk of secondary radiation-related malignancies?

How to manage hot flashes?

How long does it take to adjust to tamoxifen?

How often to see a physical therapist to manage limited range of motion in arm after surgery?

How to manage cold flashes?

How to manage acid reflux?

Managing discomfort after reconstructive surgery?

Question: My patient, who is triple-negative and has undergone double mastectomy, chemo, radiation and now chemo again, is experiencing extreme bone pain with paclitaxel (Taxol). Any recommendations for relieving this pain? She is not able to sleep, and only Tylenol or Tylenol PM has been recommended by her medical oncologist.

Ms. Robles-Rodriguez: Approximately 60 percent of women suffer from bone and muscle ache with paclitaxel, and about 8 percent have severe symptoms. The symptoms usually start 24-72 hours after receiving the medicine and last anywhere from 2 to 7 days.

There are medicines that have been studied to treat and prevent these symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently documented pharmacologic agents used to treat this symptom, but not every woman responds to these or is able to tolerate the side effects. Corticosteroids have also been used, but they should only be used for a limited amount of time. Narcotics have been shown to help women with severe symptoms that have not responded to other treatments. Gabapentin (Neurontin), glutamine and antihistamines such as fexofenadine (Allegra) have been studied to treat and prevent these symptoms, but the study results are conflicting.

Because these symptoms can affect the woman’s quality of life and treatment, she should explain to her medical oncology team the impact that this side effect is having on her life and discuss other treatment options to relieve her pain. Ruling out other causes for the severity of the pain (such as rheumatoid arthritis) and consulting with a palliative care and/or pain management specialist may also be of help.

Question: How can I manage joint pain associated with tamoxifen?

Ms. Robles-Rodriguez: Joint pain is more commonly seen with the use of aromatase inhibitors and is an uncommon side effect of tamoxifen. However, many women report joint pain and stiffness with the use of tamoxifen. Using Tylenol may help. If this does not help and you can tolerate medicines such as ibuprofen, that would be a good second choice. Finally, some women report improvement with the use of glucosamine. Please speak with your medical oncology team to find out which therapy may be most appropriate for you.

Question: I had a modified radical mastectomy 10 years ago; I have lymphedema in the arm but not all the time. It comes and goes. Should I wear the compression garment all the time or just when I have issues. It is my right arm and I am right handed.

Ms. Robles-Rodriguez: Lymphedema is a chronic problem that requires ongoing treatment. To prevent the problem from getting worse, I recommend that you wear your compression garment every day. Meet with a Certified Lymphedema Therapist as newer research recommends progressive weight-bearing exercise to help improve this condition.

Question: My hair has grown back to a degree, but it’s so much thinner and a bit sparse. I still have to wear my wig as I am too embarrassed to be without it. I am on anastrozole (Arimidex). Will my hair eventually fill in?

Ms. Robles-Rodriguez: Hair can change after chemotherapy treatment. For example, it can become curlier or a different color, but usually women get most of their hair back.

The time it takes for hair to fully return varies from woman to woman. Some women’s hair does not come back as thick as before treatment, and a few women can get hair thinning with anastrozole. If it has been more than six months since you completed your chemotherapy treatment and your hair is still sparse, speak with your medical oncologist. Using minoxidil (Rogaine) can help some women.

Question: I have had ongoing fatigue since I began chemotherapy. It has been almost a year since my last treatment, and I'm still not where I used to be. Is this going to last for the remainder of my lifetime? How can I manage this?

Ms. Robles-Rodriguez: Fatigue is one of the most commonly reported symptoms related to cancer treatment and can last years after the treatment was completed. Report the fatigue to your healthcare provider so he or she can rule out any other cause for this problem.

Although it may sound contradictory, many studies have shown that exercise can improve fatigue. If you are not already exercising, speak with your healthcare provider about starting an exercise program. Exercise can help not only physically, but also psychologically.

Make sure you are eating a balanced diet and drink plenty of fluids. Finally, be good to yourself. Understand that this is a common problem, get rest when you need it and save your energy for the important things in your daily life.

Question: I am taking letrozole (Femara), and I have had few side effects that I am aware of. The one that is most bothersome is a loss of libido. I am not very interested in the physical side of sex. Sex is painful, and my husband is having trouble maintaining an erection. He is afraid of hurting me. It has been 12 months since we have been successful. We tried lubricants, etc. and they are not very satisfactory. I should add that I am 71 and my husband is 77. I have been on letrozole for 2 1/2 years. We were fine before I started the medication. I just wondered if this is a common problem in senior couples (married 50 years)? I feel a bit guilty that I am just not very interested anymore. My husband still is. Suggestions?

Ms. Robles-Rodriguez: Sex is an important part of a healthy relationship for many couples, no matter how old you are. Physical and emotional aspects can play a role in sexual response. Since you had a healthy sexual relationship prior to starting letrozole, the problems you are experiencing are not likely due to you being a “senior couple.”

The first step would be to treat the physical aspects. Make sure you see a gynecologist to ensure there are no easily treated problems leading to painful intercourse, such as a yeast infection. Vaginal dryness can occur with letrozole, and this makes intercourse very painful which further decreases libido. If water-based lubricants such as Astroglide or Moist Again have not helped, ask your oncologist if you would be a candidate for local estrogen treatment such as Vagifem or Estring.

To treat the emotional barriers, open communication with your partner is extremely important. If you can’t begin this communication process on your own, consider seeing a sex therapist. Although many couples are hesitant about this form of therapy, women affected by breast cancer and their partners can benefit from counseling. Trained therapists can help you and your partner open up about what is bothering you and help get your intimacy back on track.

Question: What is the current information regarding long-term side effects of radiation for breast cancers? Please include comment on risk of secondary radiation-related malignancies?

Ms. Robles-Rodriguez: The long-term side effects of radiation therapy for breast cancers depends on the type of radiation given, the amount of radiation given, whether it was administered after lumpectomy or mastectomy and the side of the body treated (if left-sided, there could be heart-related side effects).

Risk of secondary malignancies after having received radiation therapy is low. These cancers usually appear 5 or more years after having received radiation and are rare. Speak with your radiation oncologist regarding your risk for particular long-term side effects rbased on the therapy that you received.

Question: I am a one-year survivor of triple-negative breast cancer. I got a lumpectomy, AC-T dose dense chemotherapy and radiation. Before all of this started, I was 62 and almost done with hot flashes (ovaries removed at 40). Post treatment, they are back with a vengeance. Suggestions?

Ms. Robles-Rodriguez: Hot flashes can be a very bothersome side effect of breast cancer treatment and can affect women who have already been in menopause for many years. The hot flashes can be severe enough to affect quality of life.

My first recommendation would be to identify things that trigger your hot flashes so that you can control or avoid them (such as stress, alcohol, smoking, caffeine, a high carbohydrate diet, hot or spicy foods, warm environments and clothes that don’t breathe well such as polyester, wool and silk). Dress in layers and keep cool fluids at hand. Exercise, relaxation techniques and acupuncture have all been found to help women lessen the hot flashes.

If all else fails, speak with your medical oncologist as there are several prescription medications that can decrease hot flashes including blood pressure-lowering agents and antidepressants.

Question: I got through surgery and treatment fine, but I have been on tamoxifen for about 8 weeks and am just not feeling myself. How long should I expect the adjustment period to last?

Ms. Robles-Rodriguez: Most women adjust to tamoxifen within a month of starting it but can have lingering side effects which may require follow-up. Discuss the specific adjustment problems you are having with your physician so can be addressed . Many side effects caused by tamoxifen are manageable, including hot flashes, mood changes and vaginal symptoms.

Question: I have had two reconstructive surgeries following my breast cancer diagnosis. After each surgery I have ended up with an odd side effect: limited use of my left arm. How often should I be seeing the physical therapist? They only have me going once a week, and my arm movement is very limited.

Ms. Robles-Rodriguez: Limited range of motion of the arm on the treated side can occur after breast surgery. This can require physical therapy as well as performing exercises at home. Every woman is different and has varied physical therapy needs. Speak with your physical therapy and surgical team to find out how often you should be receiving physical therapy.

Question: Since treatment, I am cold ALL the time, except when having a hot flash. Should I expect this to change over time, or can this be a permanent thing? I finished everything (mastectomy, chemotherapy, radiation) except tamoxifen about 1 1/2 years ago.

Ms. Robles-Rodriguez: Although you often hear about hot flashes in the media, cold flashes can also be a common occurrence in women who are going through hormonal changes. Other conditions such as anemia and thyroid disease can also cause women to feel cold. Talk with your healthcare team as they can evaluate you for other causes of the coldness.

Question: I am a one-year survivor of triple-negative breast cancer. I received lumpectomy, AC-T dose-dense chemotherapy and radiation. I am doing well, but I still suffer from acid reflux which started with paclitaxel (Taxol). I take pantoprazole magnesium twice daily. Will this problem continue forever? Is there anything else I should do?

Ms. Robles-Rodriguez: Reflux can be a side effect of some chemotherapy but can also have other causes. If you have not met with a gastroenterologist, make an appointment with one and consider an upper endoscopy to evaluate the severity of the reflux and if there are other complications.

Sometimes you need to change the medication you are using for the reflux as it can lose its efficacy after prolonged use. Evaluate your diet and lifestyle for immediate relief. There are certain foods that can be avoided (e.g. caffeine, spicy foods, alcohol) and lifestyle modifications that can be made (e.g. eating smaller meals, not lying down for a couple of hours after eating) to help improve this common problem.

Question: I'm a month past my initial reconstructive surgery, and my doctor has inflated my bilateral expanders four times. I have problems getting comfortable and sleeping, and I'm uncomfortable during most of the day and night. What can I do?

Ms. Robles-Rodriguez: Reconstructive surgery is a process, and for some women it can be a very uncomfortable one. Let your reconstructive team know how you are feeling as they can decrease the amount they are injecting into the expander or increase the time intervals between injections. You can also try Tylenol or ibuprofen for pain if needed.

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