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7

Side effects of breast cancer treatment

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Contents

Objectives

When you have completed this chapter, you should be able to:

Case study 1

A 60 year old woman who has had her first cycle of chemotherapy for breast cancer is seen with a fever and feeling generally unwell. She started her chemotherapy 10 days before but is unsure what drugs she is receiving. On examination, she looks pale, is vomiting and has a temperature of 39.5 °C. She also complains that she has had a sore mouth for the past few days.

  1. What is the possible diagnosis?
  2. What urgent test should be done?
  3. How should she be treated?
  4. Should she be referred to the hospital?
  5. What is the probable cause of her sore mouth?

Case study 2

A 45 year old woman had a mastectomy for breast cancer 3 years ago and is now on tamoxifen. She wants to stop her hormone therapy as she feels tired on the treatment. She has heard that it causes thinning of the bones and cancer of the uterus.

  1. For how long should she stay on tamoxifen?
  2. What effect does tamoxifen have on the bones?
  3. How can cancer of the uterus be screened for?
  4. What other side effects can you get from tamoxifen?
  5. Why are there such a wide range of side effects of tamoxifen?

Case study 3

A 38 year old woman comes to the clinic 1 year after a right-sided mastectomy for breast cancer. She has had a swollen right arm for a few months. The swelling became worse a few days back after she had cut her hand.

  1. What is the diagnosis?
  2. What treatment should be started immediately?
  3. What should be looked for on examination?
  4. If the swelling persists, what treatment can be given?

Case study 4

A 60 year old woman is receiving adjuvant radiotherapy after breast surgery. She has an area of redness and sensitivity in the area being radiated and is worried that she will lose all her hair. She sleeps most of the day as she feels very tired.

  1. What local skin changes can be expected with radiotherapy?
  2. How should the acute skin changes be managed?
  3. Will she lose her hair?
  4. Is it common to feel tired during radiotherapy?

Side effects of chemotherapy

7-1 What are the common drugs used for chemotherapy?

The commonest regimes to be used in South Africa for breast cancer are:

These regimes can be used alone or in combination with taxanes such as paclitaxel and docetaxel.

Note
Adriamycin is a trade name for doxorubicin.

7-2 What are the side effects of chemotherapy?

There are many side effects of chemotherapy. They depend on the regime being given and the individual’s response to treatment. The commonest side effects are:

7-3 Which drugs lead to hair loss?

The commonest drugs that are used to treat breast cancer cause hair loss:

7-4 When does hair loss occur and does it regrow?

It usually starts falling out within days after the first dose. Hair loss on the head and elsewhere on the body may be complete or partial. It is very rare for hair not to grow back but it often is not as thick and may be grey or curly.

Hair usually grows back after chemotherapy.

7-5 How are the nails affected and what can be done about the side effects?

Nails become ridged and discoloured. Although nail changes cannot be prevented, it is better if standard nail care is increased. It is important that all patients regularly:

In addition, it is important to prevent damage by:

7-6 What drugs cause nausea and vomiting and when do these side effects occur?

Nausea and vomiting can occur with any chemotherapy drug but the following commonly cause vomiting:

Vomiting can occur:

7-7 Why does vomiting occur with chemotherapy?

7-8 What drugs can be used to prevent vomiting and how should they be given?

Anti-emetics (anti-nausea drugs) are used to treat vomiting:

Anti-emetics can be given orally, rectally or intravenously.

To try and prevent vomiting, both anti-emetics and steroids are given together with the chemotherapy. For the first few days after chemotherapy, valoid suppositories and stemetil tablets should be given even if there is no nausea.

7-9 What non-drug treatment can be used for prevention and treatment of nausea and vomiting?

7-10 What is mucositis and what drugs cause it?

Mucositis is inflammation of the mucous membranes. Generally, it affects the gums and the intestinal lining.

It is commonly seen when cyclophosphamide, methotrexate or 5-fluorouracil are given. These drugs are in the CMF regime.

7-11 What symptoms are caused by mucositis?

Pain in the mouth which may lead to dehydration. As a result of the inflammation, there may be secondary infections, particularly Candida.

7-12 How can mucositis be managed?

It can be managed by good oral care:

7-13 What drugs cause diarrhoea and when does it occur?

Methotrexate and 5-fluorouracil (in CMF) are the most likely drugs to cause diarrhoea. It can occur at any stage of the treatment cycle.

7-14 How should diarrhoea be treated?

It must be treated as an emergency and drugs to control the diarrhoea must be given immediately. Imodium and codeine phosphate can both be used but if there is no response, the patient must be referred urgently to the oncology team.

Refer any patient with severe diarrhoea early.

7-15 How should constipation be managed?

Constipation may be due to the chemotherapy drugs, analgesics (such as morphine) or anti-emetic drugs.

It is important to identify the cause of the constipation. If it is due to morphine, see the chapter on palliative care. If it is due to one of the other drugs, try changing the drug used.

7-16 Which side effects from chemotherapy need urgent medical attention?

7-17 What is neutropenic sepsis?

Chemotherapy drugs damage any cells that are rapidly dividing, not only cancer cells. This includes cells in the bone marrow, especially white blood cells which are needed to attack bacteria that can cause infections. Chemotherapy stops white cell production so any minor infection can become a major problem.

Note
More correctly a low white cell count is called leukopenia but in practice it is usually referred to a neutropenia.

7-18 How do you know if a woman has neutropenic sepsis?

If a patient is on chemotherapy and feels unwell, the diagnosis of neutropenic sepsis must be suspected. The patient will usually feel terrible and have a high temperature (above 38 °C) but may not have any other signs of an infection.

Ask for a full blood count (FBC) to look for a low white blood count, differential count and other signs of bone marrow suppression. The bone marrow also produces red blood cells and platelets. Therefore there may not be enough red blood cells being produced and the patient will become anaemic. A deficiency in platelets results in bruising.

Neutropenic sepsis is commonest 10 days after the first cycle of chemotherapy and is more likely to occur in older people.

Treat suspected neutropenic sepsis immediately with intravenous broad-spectrum antibiotics.

A full blood count must be done urgently, a doctor called immediately and antibiotics started if neutropenic sepsis is suspected.

7-19 How should the other side effects be managed?

There are many non-specific side effects of chemotherapy such as tiredness, a feeling of not being able to think clearly (‘chemo brain’), aching of joints and neuropathy (pins and needles in hands and feet). These should be dealt with practically and sympathetically. They can be managed by the oncology team.

Infertility after chemotherapy is a common problem particularly in women over 35 years and should be dealt with by the oncology team. Infertility is not predictable and contraception must still be used as younger women may still be able to fall pregnant after chemotherapy.

Women receiving cancer treatment should avoid falling pregnant without discussing the risks with their oncologist.

Patients on chemotherapy often need help for psychosocial problems.

Side effects of hormone treatment

Unlike the side effects from chemotherapy, the side effects from hormone (endocrine) treatment do not make women severely ill, so can generally be managed by the oncology team.

7-20 What are the common side effects of tamoxifen?

Tamoxifen was first used 40 years ago and many side effects have been listed. Most of the side effects do not occur acutely but some time after treatment has been started. The side effects of tamoxifen are due to both the estrogen blocking and estrogen-like actions of the drug. The important ones are:

Tamoxifen is taken for at least 5 years. Recently it has been advised that it be taken for 10 years.

Tamoxifen increases the risk of deep venous thrombosis.

7-21 How should the side effects from tamoxifen be managed?

In general, side effects from tamoxifen should be managed by the oncological team. It is important to remember the risk of deep vein thrombosis and avoid using tamoxifen in women with a history of deep vein thrombosis or pulmonary embolism. If a patient is going for surgery subcutaneous heparin should be considered.

Encourage patients to decrease their calorie intake and increase their exercise to help prevent weight gain.

Women should discuss their side effects from tamoxifen with their oncologist.

7-22 What are the side effects from aromatase inhibitors?

The side effects of aromatase inhibitors are due to a lack of estrogen.

7-23 How should the side effects of aromatase inhibitors be managed?

The side effects should be managed by the oncology team:

Estrogen vaginal creams should not be given with aromatase inhibitors.

Side effects from radiotherapy

7-24 When may side effects from radiotherapy occur?

Like the side effects from hormone therapy, those from radiotherapy do not generally present acutely so can be managed by the treating team.

Side effects can occur:

In most cases, patients having radiotherapy have daily doses so can be advised by the oncology department.

7-25 What side effects occur during radiotherapy treatment?

7-26 What skin changes occur in the area being irradiated?

After about 10 days of treatment, the skin becomes darker and redder. It looks like sunburn but may also be flaky. The skin may become thickened and even look similar to peau d’orange skin change seen with breast cancer.

There will be hair loss in the areas irradiated (e.g. under the armpit).

Skin changes due to radiotherapy may look similar to changes due to cancer.

7-27 How should the skin be treated during radiotherapy?

The advice varies in different departments. Most will recommend that only simple products are used on the skin. Deodorants, perfumed soaps and talcum powder should be avoided.

If the skin is red and sore, Maizena (cornstarch) may be applied.

The skin should not be exposed to the sun.

7-28 What general changes occur during radiotherapy?

Many women feel tired during their radiotherapy. This tends to improve when the course of radiotherapy is completed. If the radiotherapy is to the collarbone area as well, she may develop a sore throat.

Patients receiving radiotherapy often feel very tired.

7-29 What side effects occur after radiotherapy?

These are far less common than they used to be:

Side effects due to surgery

7-30 When may side affects occur after surgery?

These may occur:

They may be due to the surgery or to the anaesthetic. Only surgery-related problems will be discussed here. All complications are commoner in smokers, diabetics, older patients and those who have had previous radiotherapy. The simpler the surgery, the less likely the complications.

7-31 What side effects occur immediately after surgery?

The commonest problem is bleeding. This usually occurs within 1-2 days after surgery and the women may need to return to theatre. Bleeding should be looked after by the surgical team.

7-32 What wound complications occur within weeks of surgery?

Complications after a reconstruction may be difficult to deal with and must be treated by the reconstructive surgeons.

7-33 What shoulder complications may occur within weeks after surgery?

It is very common to have some stiffening of the shoulder even if axillary surgery has not been done. The stiffness may be very mild and will get better by itself or may be very severe.

Shoulder exercises should be done by all patients who have had axillary surgery. If the arm cannot be lifted above 90°, the women should be referred for physiotherapy. If there are no physiotherapy facilities, she must be encouraged to do regular arm exercises.

7-34 What long-term surgical complications can occur?

Lymphoedema

7-35 What is lymphoedema?

Lymphoedema is swelling of a limb caused by obstruction of the lymphatic system. As a result of obstruction to lymph drainage, lymph leaks out of the lymphatics into the surrounding tissue and causes swelling. Lymphoedema of the arm is common in patients with breast cancer. Check for cancer recurrence or new cancer in any patient presenting with lymphoedema.

7-36 What causes breast cancer patient to get lymphoedema?

It is caused by damage to the axillary system of lymph nodes. This may be damaged by:

Breast cancer involving the axillary nodes may block the lymphatics. The more lymph nodes that are removed at the time of surgery, the more likely it is that lymphoedema will be a problem. Lymphoedema is also more common in patients who are treated with both surgery and radiotherapy.

Lymphoedema is more common in patients who have had both surgery and radiotherapy.

7-37 How can lymphoedema be prevented?

The best way to prevent lymphoedema is to diagnose cancers at an earlier stage when less surgery and radiotherapy will be needed.

Any woman who has had lymph node surgery should protect that arm. For example, she should wear gloves when gardening and not allow the arm to be used for an intravenous drip.

Sentinel lymph node surgery reduces the chance of lymphoedema as the need for axillary clearance is often reduced.

7-38 How can lymphoedema be managed?

An infection should be ruled out. If the arm is red and swollen, the patient should be put on antibiotics and followed up to ensure it gets better.

The simplest way to improve lymphoedema is with elevation, exercise and compression bandaging. Exercises should be done. A website listing exercises may be found at the end of the book under ‘Useful websites’.

Elevation involves keeping the arm up for as much of the day as possible.

Compression with bandaging can be very effective but must be done by a trained person.

7-39 Who should treat lymphoedema patients?

The best combination is a trained physiotherapist or nurse working together with the patient and her family.

7-40 Does lymphoedema management always work?

No. If the lymphoedema has been there for a long time, there are changes to the soft tissues in the arm which may not be reversible. As a result the arm may be permanently swollen. Only the lymphoedema fluid but not the other changes will respond to management.

It is important to start management for lymphoedema early to try and prevent a chronic problem.

Case study 1

A 60 year old woman who has had her first cycle of chemotherapy for breast cancer is seen with a fever and feeling generally unwell. She started her chemotherapy 10 days before but is unsure what drugs she is receiving. On examination, she looks pale, is vomiting and has a temperature of 39.5 °C. She also complains that she has had a sore mouth for the past few days.

1. What is the possible diagnosis?

Neutropaenic sepsis (septicaemia).

2. What urgent test should be done?

A full blood count. If her white blood count is below 2 × 10°/µL, it is diagnostic of neutropenic sepsis. Her pallor suggests she may also be anaemic.

3. How should she be treated?

4. Should she be referred to the hospital?

Yes, as an emergency. She needs to be admitted to hospital urgently as neutropaenic sepsis is a very serious condition.

5. What is the probable cause of her sore mouth?

Mucositis. This is a common side effect if cyclophosphamide, methotrexate and 5-fluorouracil are given in the CMF regime.

Case study 2

A 45 year old woman who had a mastectomy for breast cancer 3 years ago is now on tamoxifen. She wants to stop her hormone therapy as she feels tired on the treatment. She has heard that it causes thinning of the bones and cancer of the uterus.

1. For how long should she stay on tamoxifen?

Hormone therapy should be given for at least 5 years. Many women are advised to take it for 10 years.

2. What effect does tamoxifen have on the bones?

Tamoxifen thickens the bone. In contrast, aromatase inhibitors make the bones thinner.

3. How can cancer of the uterus be screened for?

The lining of the uterus will get thicker before cancer develops. Therefore the uterus should be screened with an ultrasound scan every year.

4. What other side effects can you get from tamoxifen?

Increased risk of blood clots particularly deep venous thrombosis (DVT), hot flushes, vaginal discharge, weight gain and decreased libido (sex drive).

5. Why are there such a wide range of side effects of tamoxifen?

Because tamoxifen both blocks estrogen (causing hot flushes, weight gain and decreased libido) as well as having estrogen-like effects (causing increased blood clotting, vaginal discharge and bone thickening).

Case study 3

A 38 year old woman comes to the clinic 1 year after a right-sided mastectomy for breast cancer. She has had a swollen right arm for a few months. The swelling became worse a few days back after she had cut her hand.

1. What is the diagnosis?

Lymphoedema although she may have an infection making it worse.

2. What treatment should be started immediately?

Antibiotics.

3. What should be looked for on examination?

She must be examined to determine whether her cancer has not recurred.

4. If the swelling persists, what treatment can be given?

Exercises, elevation and compression bandaging for the lymphoedema.

Case study 4

A 60 year old woman is receiving adjuvant radiotherapy after breast surgery. She has an area of redness and sensitivity in the area being radiated and is worried that she will lose all her hair. She sleeps most of the day as she feels very tired.

1. What local skin changes can be expected with radiotherapy?

After about 10 days of treatment, the skin becomes darker and redder and looks like sunburn. Less commonly the skin may become thickened and even look similar to peau d’orange skin change seen with breast cancer.

2. How should the acute skin changes be managed?

She should only use simple products on the skin. Deodorants, perfumed soaps and talcum powder should be avoided. If the skin is red and sore, cornstarch (Maizena) may be applied. The skin should not be exposed to the sun.

3. Will she lose her hair?

This is very unlikely as loss of hair on the head is associated with chemotherapy rather than radiotherapy. She may lose some hair in her axilla. Epirubicin, doxorubicin and the taxanes (paclitaxel and docetaxel) are the drugs usually associated with hair loss.

4. Is it common to feel tired during radiotherapy?

Yes. This is a very common complaint.