March 2015 Ask the Expert: Managing Metastatic Breast Cancer Treatment Side Effects
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 metastatic 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 effect 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 provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.
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 oncologist. 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.
Ms. Rodriguez: Approximately 9 out of 10 persons receiving cancer treatment experience fatigue at one time or another. It is important to speak to your healthcare provider 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 condition. 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 acupuncture, massage, meditation, reiki, tai chi and yoga. Some cancer centers have complementary medicine programs that are low cost or free for cancer survivors. Speak to your healthcare team about your options.
Ms. Rodriguez: Vaginal atrophy, thinning and dryness of the vaginal tissues, can be a bothersome side effect of cancer treatment. This can lead to burning or pain in that area and pain with intercourse. Estrogen 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 provider 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 prescription. Over-the-counter vaginal moisturizers can also be of help in hydrating the vaginal tissue 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 lubricant. There are sexual rehabilitation programs though physical or occupational therapy that can help measure for these. These therapists can also help some women with needed physical therapy for pelvic floor dysfunction. A sex therapist or behavioral medicine 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 oncologist.
Ms. Rodriguez: Anemia, or low hemoglobin, is a common side effect of some cancer treatments. Hemoglobin is an iron-rich protein 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 provider 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.
Ms. Rodriguez: Hand-foot syndrome is a skin reaction to medications such as Xeloda 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 tissue 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 effect 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 provider.
Ms. Rodriguez: Weight gain and thinning hair could be a side effect of letrozole or could be a side effect of menopause 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 provider.
Ms. Rodriguez: Afinitor has been known to cause increased liver enzymes or counts in patients. There is also a risk of reactivation of hepatitis infection if you have had hepatitis in the past, which can also affect the liver counts.
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 pump enough blood to meet the needs of the body. Perjeta is given in conjunction with trastuzumab (Herceptin), 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 scan and the medication stopped if there is a clinically significant decrease in the heart function. If the heart function returns to baseline within 3 weeks of stopping Perjeta and Herceptin, these medications can be resumed.
Ms. Rodriguez: Exercise has actually been proven to lower estrogen levels and the levels of fat in your body. The more fat in the body (by being overweight) the higher your levels of estrogen production. Exercise has also been shown to help improve symptoms of fatigue, mood and well-being. Unless there is another contraindication, women are encouraged to exercise throughout their cancer journey.
Ms. Rodriguez: The best way to gain muscle is through exercise and an increased intake of protein. 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 fatigue.
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 dietitian 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.
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 provider know if there is any sign of infection such as redness, pain or pus.
Ms. Rodriguez: Peripheral neuropathy is a side effect of certain chemotherapy 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 provider as soon as possible if you are experiencing this side effect. At times, it may be necessary to lower the dose of the chemotherapy or change to another treatment to avoid this becoming a long term problem.
Nonmedical treatments include physical or occupational therapy to help with strength and pain. Complementary medicine techniques such as massage or acupuncture may be of help for some patients. There are a number of oral medications and topical gels that may help improve nerve pain but these would need to be prescribed by a healthcare provider.