Dealing with the Side Effects of Treatment Now and Later
Some other side effects of the treatment are some sleeping disorders. Again there might be many other causes for that, but if it’s related to the drugs we do support with drugs which can help our patients sleep. Most of them are also decreased anxiety and also decreased nausea, Ativan for example, is a sleep aid but also decreases nausea and anxiety, so a number of our patients actually like that. And once the chemo is done, the body doesn’t need it any more, so I know that some patients are concerned that these drugs may be addictive, but they are not. Because the body needs it, you give it, and after the treatment is done you don’t need it and then you can taper yourself off. And I never had a patient who continued staying on these drugs.
In terms of long-term side effects, I think the main two issues we discuss with our patients are the heart side effects, cardiac side effects with the Anthracyclines and then the newer drug Herceptin. With the Anthracyclines, there is a maybe 1%, maximum 1.5% risk of developing heart failure within the next 10 to 15 years. With Herceptin it might be a little higher. However we carefully have to discuss the risks and benefits of the treatment. So if your chemotherapy will give you a 10, 15, 20% benefit and the heart disease risk is only 1%, to many patients it’s really worth it because the alternative would be not being able to treat the breast cancer. Plus with all of the supportive cardiac medications as well as our cardiology colleagues and screening up front for heart disease, I think that risk really goes down even below 1%. So we, in patients who need it, we do cardiac scans, muga scans and echos to assess the heart function and then decide whether we should give the drug or not. Sometimes we see that we cannot give it, so we don’t give the Anthracycline, we look at some alternatives.
Another long term side effect, which in all honesty I have not seen yet, is leukemia risk within the next 15, 20 years, which again is not more than 1%. Because we basically give hydrotropic drugs and they might cause some problems in the bone marrow. But again, I have not seen it, it’s been reported, but one has to weigh the benefit against the risk of leukemia. If the benefit is again high of chemo, 10, 15, 20% even in some cases 30, 40% then to many patients as well as us, it’s acceptable.
In terms of hormonal side effects. I mentioned two drugs Tamoxifen and the aromatase inhibitors. Tamoxifen is the older drug which has been around for 20, 25 years and we have used it in the advanced disease, early disease. We now even use it for prevention because its FDA approved for prevention in women who don’t have breast cancer. But we know Tamoxifen blocks estrogen and unfortunately because of that, it induces menopausal symptoms, so our patients have hot flashes, fluid retention, weight gain, muscle aches and pains. Now not everyone has everything, as you might know. These are reported and many of my patients wouldn’t have any problems at all, and some people have different degrees of one or the other. I don’t think I have a patient who has all of the reported side effects. So it’s a pretty tolerable drug.
What we can do about it? I think when you stop the drug, it goes away. However, Tamoxifen is very effective in reducing the risk of the recurrence of breast cancer or treating advanced disease. So again one has to weigh the benefits and risks and maybe not stop the drug if it’s working. There is no magic treatment to replace the menopausal symptoms because it blocks estrogen and that’s what we want to do. So we wouldn’t be giving estrogen back to overcome the symptoms, because we’re trying to block it, estrogen, we don’t want estrogen in the body. Therefore it is a little bit difficult to manage that.
Two major side effects of Tamoxifen is blood clot risk and uterine cancer risk. So for blood clots we tell our patients if there’s a strong family history or a person who has blood clots, we don’t give Tamoxifen, that’s number one. Number two, is if for example, our patients fly and they’re on the plane, we tell them to get up and walk around every hour or so and keep active so that there will be no blood clot formation. The other major side effect is uterine cancer. And what is recommended is that patients have yearly gynecology exams just to make sure that there is no thickening in the uterus lining, which then can lead into cancer, uterine cancer.
I have to say though that many studies have shown even though the risk of uterine cancer is higher in women who take Tamoxifen, all of the uterine cancers found are actually stage one, because patients have screened for it and the treatment of it is hysterectomy so, and then patients are cured. So even though there are more cases, nobody really suffers from the disease because it’s taken care of with the surgery.
The second group of drugs, the aromatase inhibitors as I mentioned, Arimidex, Letrozole, or Exemestane, are different than Tamoxifen. The mechanism is different but it does the same thing. It again depletes estrogen in the body because we don’t want estrogen in ER positive disease it can feed the tumors, so we’re trying to get rid of it and the aromatase inhibitors do that. It is only used in post menopausal women, I have to say that, and because like Tamoxifen, it blocks estrogen. It can be used in menopausal symptoms, hot flashes, fluid retention, muscles aches and pains and because it blocks estrogen different than Tamoxifen, it can actually decrease the bone mineral density. So we are very proactive and to manage this we do mineral bone densities before and during treatment with Arimidex and then if indicated, you use bone builders such as Fosamax and of course vitamin D and calcium.
However, the aromatase inhibitors don’t cause endometrial cancer and don’t cause blood clots. And they are about 20% better than Tamoxifen, so I can tell you that at least in, at our institution, when we discuss those two drugs, 80 to 90% of our patients opt to take the aromatase inhibitor over Tamoxifen because of the better efficacy and the better side effect profile.
And again, many of these symptoms such as the muscle aches and pains and joint pain and hot flashes really go away once the drug is stopped. If not, during the treatment we have drugs available to take care of hot flashes. We have, we can prescribe non-steroidal anti inflammatory drugs for the muscle aches and pains. Exercise helps, swimming helps, healthy balanced diet and drinking fluids sometimes can help as well, these are some comments I actually received from my patients as well.
So I think we went over a number of treatment approaches and the side effects and how we handle those in the clinic. The only thing I want to add is that again, drugs can induce different side effects in different people. I think there’s a lot of going on in the body and how the body reacts against the drugs, so therefore we cannot predict. We see what happens and then we try to manage to the best we can because the drug at the end is helpful and we don’t want to stop the drug.
And furthermore, we also advise our patients to go to support groups and maybe share the experiences, what worked, what didn’t work, even either within the institution, support groups, or support groups such as this lovely one (Breast Cancer Network of Strength) which is doing this program tonight, or Susan Komen has the website giving out information. Again as I mentioned the ShareRing Network, Sisters Network and reast Cancer Survivor Coalition for example are just a few which comes to my mind right now, but there are a number of websites which actually addresses and some of them have chats also where patients can actually discuss with each other what works and what didn’t work for them.
I think I went over a little bit of time, but I don’t want to take away a lot from your questions. I’m ready for the questions.
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