March 2015 Ask the Expert: Managing Metastatic Breast Cancer Treatment Side Effects

March 1, 2015

Knowing what to expect from the side effects of your anticancer medicines can make it easier for you to manage them when they appear. As someone living with metastaticinfo-icon breast cancer, you know that keeping side effects in check is a key part of living well from day to day.

This March, Living Beyond Breast Cancer expert Evelyn Robles-Rodriguez, RN, MSN, NPC, AOCN answered your questions about what side effects you may experience, how to handle them, what to do if a side effectinfo-icon becomes too much and what your healthcare team can do to help.

Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare providerinfo-icon because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counselinginfo-icon or medical advice.

Question: The consultant "spooked" me into agreeing to epirubicin (Ellence) and cyclophosphamide (Cytoxan) chemotherapy. It has made me very ill but he thinks this will bring the tumor markers down. Should I continue?

Ms. Rodriguez: Deciding on a treatment for your cancer should be a team effort between yourself and your healthcare team. If you have any doubts or concerns about your treatment, you should not hesitate to discuss this with your oncologistinfo-icon. Make sure that before you leave the office, all of your concerns and questions have been addressed.

Before continuing your treatment, make sure you fully understand your options and that you discuss with the oncologist the side effects you are experiencing and how these could be managed. Additionally, consider obtaining a second opinion from a different provider to assure you have made the right choice.

Question: This chemo makes me so tired that I can barely function. How do I regain my energy? Is there anything beyond exercise that can help fatigue? I feel like there's a pill for most of the other side effects of treatment, but not that one.

Ms. Rodriguez: Approximately 9 out of 10 persons receiving cancer treatment experience fatigueinfo-icon at one time or another. It is important to speak to your healthcare providerinfo-icon about this issue as there are many causes of fatigue. Because there are many causes, there is not one magic pill to treat it.

Exercise has been shown in various studies to be one of the best treatments for this conditioninfo-icon. This does not mean you have to throw yourself into exhaustive exercise. Discuss with your healthcare provider if it is the right time for you start exercising. If it is safe for you to exercise, start small (10 or 15 minutes daily) and increase your time week by week – walk to your mailbox or around your neighborhood; walk in front of your TV; garden using protective clothing; play with your kids; or walk the mall. Build yourself up until you are able to do at least 30 minutes daily, 5 days each week. Making exercise fun and doing things you enjoy can help you stick with it long-term and can also help improve your mood.

There also complementary therapies that have been shown to help reduce fatigue. These include acupunctureinfo-icon, massage, meditation, reiki, tai chiinfo-icon and yogainfo-icon. Some cancer centers have complementary medicineinfo-icon programs that are low cost or free for cancer survivors. Speak to your healthcare team about your options.

Question: Treatments for ER-positive metastatic cancer as well as pelvic radiation can cause vaginal atrophy. What are some treatments that help? Would estrogen cream applied sparingly be OK to use?

Ms. Rodriguez: Vaginal atrophy, thinning and dryness of the vaginal tissues, can be a bothersome side effectinfo-icon of cancer treatment. This can lead to burning or pain in that area and pain with intercourse. Estrogeninfo-icon cream may be an option for some women suffering with vaginal atrophy due to the treatment of their disease if nothing else has helped. However, there are other options to consider and your healthcare providerinfo-icon can help you with these or refer you to someone.

It is helpful for women to use water based vaginal lubricants with sexual activity to help reduce painful intercourse and sexual play. These can be used on either or both partners and can be purchased without a prescriptioninfo-icon. Over-the-counterinfo-icon vaginal moisturizers can also be of help in hydrating the vaginal tissueinfo-icon and helping regain elasticity. These are used irrelevant of sexual intercourse.

Vaginal dilators are vaginal inserts that can be used to help make the vaginal canal longer and wider and help stretch any scarring in that area. They are often paired with a lubricantinfo-icon. There are sexual rehabilitationinfo-icon programs though physical or occupational therapyinfo-icon that can help measure for these. These therapists can also help some women with needed physical therapyinfo-icon for pelvic floor dysfunctioninfo-icon. A sex therapist or behavioral medicineinfo-icon therapist can also help with the emotional issues associated with this side effect.

Finally vaginal hormones, such as an estrogen cream, may be an option. Most of these do have some absorption into the circulation. Moreover, there are no long-term studies on the safety of these products in breast cancer survivors. However, for some women in whom nothing else has helped, they may be approved by your oncologistinfo-icon.

Question: What can be done about persistent low hemoglobin blood counts? My oncologist is reluctant to do blood transfusions because of eventual buildup of antibodies. The oncologist says we are still early in the disease and may want to keep transfusions for later on.

Ms. Rodriguez: Anemiainfo-icon, or low hemoglobin, is a common side effectinfo-icon of some cancer treatments. Hemoglobin is an iron-rich proteininfo-icon in the red blood cells that carry oxygen from the lungs to the rest of the body. Some patients may be eligible for medications such as darbepoetin alfa (Epogen) and epoetin alfa (Procrit) which can help your body make more red blood cells. Some patients may benefit from an iron, folate or B12 supplement to treat their anemia. These options are not for everyone; therefore, speak with your healthcare providerinfo-icon about whether they are right for you. In the meantime, enriching your diet with foods high in iron and B12 may be of small benefit.

Question: Is it unusual to still have hand-foot syndrome side effects even after being off capecitabine (Xeloda) for 4 months?​

Ms. Rodriguez: Hand-foot syndrome is a skin reaction to medications such as Xelodainfo-icon which is caused by small amounts of the medication leaking out of the small blood vessels on the palms of the soles and feet. This can lead to tissueinfo-icon damage in that area which can cause symptoms including pain, numbness, tingling, burning, itching, redness, swelling and a rash. As the symptoms worsen, there can be cracking, flaking or peeling of the skin, blisters or sores, and severe pain which can make using your hands and walking difficult. This side effectinfo-icon generally resolves shortly after stopping Xeloda (weeks to a few months), especially in less severe cases. Since stopping treatment has not helped improve this problem, I would discuss this with your healthcare providerinfo-icon.

Question: I'm taking letrozole (Femara) for breast cancer treatment, but have gained weight and have thin hair. Do these go away after I stop letrozole, or should I continue it for another 5 years?

Ms. Rodriguez: Weight gain and thinning hair could be a side effectinfo-icon of letrozoleinfo-icon or could be a side effect of menopauseinfo-icon or other medical issues such as thyroid disease. If it is due to letrozole, the thinning hair should improve after stopping letrozole. However, the weight gain will need to be worked on with a healthy diet and exercise. Before deciding to stop letrozole due to these side effects, consider the benefits of the medication versus the risks of stopping and make an informed decision in collaboration with your healthcare providerinfo-icon.

Question: I have been taking everolimus (Afinitor) for almost a year. My liver count is high so my doctor had a PET scan and an MRI done. Both came back negative. Can this drug cause my count to rise? Have other patients had this problem?

Ms. Rodriguez: Afinitor has been known to cause increased liver enzymes or counts in patients. There is also a risk of reactivation of hepatitis infectioninfo-icon if you have had hepatitis in the past, which can also affect the liver counts.

Question: I read up on pertuzumab (Perjeta) and I kept reading about the left ventricle. Does it somehow affect my heart? I have been on it since November 2013.

Ms. Rodriguez: Perjeta has a box warning of cardiomyopathy, which is the inability of the heart muscle to contract. Cardiomyopathy can lead to heart failure, the inability of the heart to pumpinfo-icon enough blood to meet the needs of the body. Perjeta is given in conjunction with trastuzumabinfo-icon (Herceptininfo-icon), which can increase the risk of developing heart failure. For that reason, the left ventricular ejection fraction needs to be checked every 3 months while on Perjeta and/or Herceptin through an echocardiogram or a MUGA scaninfo-icon and the medication stopped if there is a clinically significant decrease in the heart function. If the heart function returns to baselineinfo-icon within 3 weeks of stopping Perjeta and Herceptin, these medications can be resumed.

Question: Fitness magazines tell you that exercise helps women produce estrogen and then women with breast cancer are told to exercise. For those with estrogen receptor-positive breast cancer, is exercise good or bad?

Ms. Rodriguez: Exercise has actually been proven to lower estrogeninfo-icon levels and the levels of fat in your body. The more fat in the body (by being overweightinfo-icon) the higher your levels of estrogen production. Exercise has also been shown to help improve symptoms of fatigueinfo-icon, mood and well-being. Unless there is another contraindicationinfo-icon, women are encouraged to exercise throughout their cancer journey.

Question: I need to know what to do to get fat under my skin and gain some muscle? I just keep losing weight.

Ms. Rodriguez: The best way to gain muscle is through exercise and an increased intake of proteininfo-icon. Try protein products including eggs, beef, fish, pork, poultry, tofu, cheese, beans, Greek yogurt and nuts and seeds. There are also protein powder products such as whey, which can be used to make drinks or shakes. Becoming physically active can help prevent muscle waste and can help decrease symptoms of fatigueinfo-icon.

To gain weight and fat, a diet high in calories can be of help. Using a supplement, such as Carnation Instant Breakfast or Ensure, can help increase calories. Use these supplements as a snack in between meals and not as a meal substitute.

Talk to a dietitianinfo-icon to better understand how many calories you should be eating to gain weight and tips on how to sneak calories and protein into your diet.

Question: How do I manage yellowing nails with colored streaks due to paclitaxel (Taxol)? Any tips on how to maintain nails so they will not fall off or become infected? I am already using glutamine.

Ms. Rodriguez: The changes in nail color do clear when treatment is completed. To protect your nails, keep them trimmed and clean and wear gloves when doing household chores, gardening or cleaning. You can polish your nails but avoid cutting or removing your cuticles or using artificial nails. Use a good moisturizer around your cuticles and let your healthcare providerinfo-icon know if there is any sign of infectioninfo-icon such as redness, pain or pus.

Question: What will help pain caused by chemo?

Ms. Rodriguez: It depends on what kind of pain you are having. Talk to your healthcare providerinfo-icon so that they can help assess what type of pain you are having and prescribe the appropriate treatment.

Question: What medical and nonmedical treatment options are recommended for peripheral neuropathy?

Ms. Rodriguez: Peripheral neuropathyinfo-icon is a side effectinfo-icon of certain chemotherapyinfo-icon due to irritation or damage to the nerves. This can cause patients to experience symptoms including pain, numbness, tingling, or weakness in the hands or feet. It can affect sensation to heat, cold and sense of touch. It can also affect walking, balance, coordination, and lead to clumsiness. It can lead to trouble using your hands to pick up objects or fasten your clothes.

First, it is extremely important to speak to your healthcare providerinfo-icon as soon as possible if you are experiencing this side effect. At times, it may be necessary to lower the doseinfo-icon of the chemotherapy or change to another treatment to avoid this becoming a long term problem.

Nonmedical treatments include physical or occupational therapyinfo-icon to help with strength and pain. Complementary medicineinfo-icon techniques such as massage or acupunctureinfo-icon may be of help for some patients. There are a number of oralinfo-icon medications and topicalinfo-icon gels that may help improve nerveinfo-icon pain but these would need to be prescribed by a healthcare provider.