Survivors of breast cancer have “a variety of concerns” following completion of treatment, according to Charles L. Shapiro, MD, of the Icahn School of Medicine at Mount Sinai.
“These concerns include physical effects from chemotherapy, like peripheral neuropathy, and psychological issues, including depression, fatigue, insomnia and financial worries,” Shapiro, who is also a HemOnc Today Editorial Board member, said.
Charles L. Shapiro
Chemotherapy-induced peripheral neuropathy is “a frequent and debilitating adverse effect” associated with commonly used chemotherapy agents, including taxanes - such as paclitaxel and docetaxel) and platinums (cisplatin, carboplatin and oxaliplatin). Other physical side effects include lymphedema, post-surgical pain syndromes, such as phantom limb pain, and graft-versus-host-disease after transplant.
Breast cancer survivors also demonstrate an increased risk for depression. One analysis found that the rate ratio for the first hospital contact for depression was 1.7 (95% CI, 1.41-2.05) during the first year after diagnosis; the ratio remained significantly elevated after 3 years. The rate ratio for redemption of prescriptions for antidepressants was 3.09 (95% CI, 2.95-3.22); this ratio remained significantly elevated 8 years after diagnosis.
Risk of depression may be increased among survivors with a high financial burden resulting from cancer. Researchers in one study considered respondents to be financially burdened if they reported borrowing money or declaring bankruptcy; worried about how they would pay large medical bills; were unable to pay the costs of medical care visits; or reported making other financial sacrifices.
Nearly 29% of patients (28.7%) reported experiencing financial burden in at least one area, with 15.8% of participants reporting at least one financial problem, 7.2% reporting two, 4.1% reporting three, and 1.5% reporting four.
A high financial strain due to cancer may also increase fears of recurrence. A greater proportion of survivors with financial burdens worried about a cancer recurrence (69% vs. 35%) and worried about how a recurrence would affect their responsibilities (70% vs. 38%).
Fear of recurrence “is a prevalent feeling,” according to Shapiro.
“All the things you took for granted when you didn’t have cancer may take on a new significance, like the aches and pains that everyone gets that go away,” he said. “For survivors, the first thought is recurrence – ‘My cancer is coming back.’”
Shapiro instructs his patients who are concerned about recurrence to call if any one of three circumstances occur. These include a novel symptom, such as a headache that is different from a typical headache experienced by the patient; a persistent symptom, like a cough that does not disappear; and any symptom that arises that leads to fear of recurrence.
“We field those calls all the time,” Shapiro told HemOnc Today. “More often than not, it doesn’t sound like a recurrence.”
PCPs, other providers have ‘incredibly important’ role in caring for survivors
The complexity of cancer survivorship makes a team-based approach to care the best strategy for these patients, according to Shapiro.
“Primary care providers can play an incredibly important role in sharing the care of cancer survivors,” he said. “PCPs provide routine health maintenance, like a cholesterol check, that is still necessary for patients with cancer.”
In the next 25 years, there will be an estimated 20 million cancer survivors, two-thirds of whom will be aged 65 years and older, according to Shapiro.
“The good news is that we’re curing more people, we have early detection, our treatments are getting better and better,” he said.
Curing more patients has led to the emergence of “a new problem,” according to Shapiro – caring for a growing number of survivors. However, this is “a good problem to have.”
As the number of cancer survivors continues to increase, “PCPs and mid-level providers like nurse practitioners will have an incredibly important role," he said.
The American Cancer Society and ASCO jointly released a comprehensive guideline regarding breast cancer survivorship. The guideline is geared toward PCPs and other clinicians who treat survivors of breast cancer and emphasizes, in part, physical and psychosocial care as well as co-management of patients, in which PCPs and oncologists work together to create a survivorship care plan for each individual.
The needs of every survivor will vary, according to Shapiro, and may change over time. The team-based care approach will help patients navigate these different concerns.
“Some survivors go on with their lives like nothing happened; others have a multitude of concerns,” he said. “Whatever the circumstances are, we’re responsible for making the right referrals and treating the survivor comprehensively. We need to empower survivors to chart their own path to wellness.” – by Julia Ernst, MS
ASCO policy statement on opioid therapy. Available at: www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2016_ASCO%20Policy%20Statement%20on%20Opioid%20Therapy.pdf. Accessed September 28, 2016.
Kale HP and Carroll NV. Cancer. 2016;doi:10.1002/cncr.29808.
Runowicz CD, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2015.64.3809.
Suppli NP. J Clin Oncol. 2014;doi:10.1200/JCO.2013.54.0419.
Disclosure: Shapiro reports no relevant financial disclosures.