‘Lost in Transition’ After Breast Cancer

The time after cancer treatment for survivors can sometimes be considered “lost in transition” since patients can sometimes feel they are not finished or even cured from cancer despite being told that they are healthy, according to a presentation at CURE®’s Educated Patient® Breast Cancer Summit.

During the presentation, Dr. Jeffery Peppercorn, director of supportive cancer and survivorship and associate professor of medicine at Massachusetts General Hospital Cancer Center, mentioned that although cancer survivors may feel lost, there are ways to navigate life after surviving breast cancerwith approaches including exercise and seeking care with a primary care physician.

“So we’ve moved hopefully from a period where people are feeling lost in transition to a feeling (that) you’re in a safe harbor and we have lots of resources available,” said Peppercorn during the presentation.

There are a little more than 4 million breast cancer survivors in the U.S., and that number is rapidly growing because of incidence increase and early diagnosis and treatment.

He explained that ideal care will vary per patient, and that not every survivor has the same concern. Also, care may differ over time. Some issues a breast cancer survivor might experience are physical such as symptoms and side effects; emotional such as anxiety and fear of recurrence; and practical which include financial toxicity and employment issues.

One side effect discussed during the presentation was fatigue, which can coincide with hot flashes, pain, depression and anxiety. Peppercorn offered an acronym for helpful tips on a better night’s sleep for survivors using the word “SLEEP”:

• Schedule: waking up and falling asleep on a consistent schedule
• Light: expose yourself to bright light during the day and keep your bedroom dark at night with no light from a cell phone or television
• Environment: keeping the bedroom cool, comfortable, dark and relaxing
• Exposures: avoid alcohol, nicotine, caffeine and large meals close to bedtime
• Physical Activity: exercise during the day but never right before bed

Hot flashes are also something survivors may experience.Peppercorn recommended acupuncture and yoga — specifically hot yoga — as natural remedies, and Effexor XR (venlafaxine) or Horizant (gabapentin) as drugs. Although, he said, “I don’t love to give a drug and then add another drug to treat its side effects, and many of my patients feel the same way.

In a survey of 200 women on an aromatase inhibitor, a drug commonly used to treat breast cancer in postmenopausal women, 45% reported joint pain or stiffness, 30% said it improved over time and 20% said it required a change of therapy. Some remedies Peppercorn suggested included breaks from the treatment and switching from the aromatase inhibitor to include vitamin D, exercise and acupuncture.

Survivors might also experience sexual health side effects such as dryness, loss of libido, body changes or pain. Peppercorn recommended nonhormonal moisturizer, counseling, yoga, acupuncture and exercise.

Bone density reduction can often occur after chemotherapy. Recommended treatments include exercise; the National Comprehensive Cancer Network recommends daily exercise such as “walking, tai chi, physical therapy and dancing,” in addition to vitamin D (at least 800 units/daily), Reclast (zoledronic acid) and Prolia (denosumab).

“Chemo brain,” occurs in approximately 60% of survivors, although approximately 30% of patients talk to their doctor about it. Peppercorn recommended reducing stress, fatigue, pain and increasing exercise to improve these symptoms.

Fear of cancer recurrence is something that is also seen a lot in survivors. Peppercorn notes the MGH Survivors Needs Assessment, which reported that 88% of survivors had a fear of recurrence and 53% categorized it as a major fear. The fear of occurrence is often associated with stress and anxiety and can lead to negative lifestyle changes such as decreased exercise and increased alcohol intake.

Peppercorn recommends patients to receive validation from their doctors, especially focused on the fact that fear of cancer recurrence normal and information on the risk for and patterns of reoccurrence because it can vary by patient. Other remedies should also be suggested such as mind-body programs, meditation, counseling, exercise and spirituality.

Lastly, Peppercorn does not want survivors to forget about their primary care physician. “There have been a lot of studies of this looking at mammograms, cholesterol testing, bone density, colonoscopy, flu shots, etc., and consistently, people get the best care if they’re seeing both their oncology team and their primary care in years out,” he said.

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