Pain, Fatigue, Cognitive Deficits in Breast Cancer Survivors

An Expert Interview With Patricia Ganz, MD

Barbara Boughton

September 22, 2011

September 22, 2011 — Editor's note: The medical and psychosocial needs of cancer survivors have been the subject of increasing research in recent years. After breast cancer, some women experience persistent pain, fatigue, lymphedema, cognitive difficulties, and sleep disorders, which can last for years. Late effects of cancer treatment also include vaginal symptoms that affect sexual health, increased risk for diabetes and osteoporosis, and, for a minority of women, cardiovascular disease.

These health concerns and quality-of-life issues, as well as treatment solutions, were highlighted at the 2011 Breast Cancer Symposium, held September 8 to 10 in San Francisco, California, and cosponsored by the American Society of Clinical Oncology, the American Society of Breast Disease, the American Society of Breast Surgeons, the American Society for Radiation Oncology, the Society of Surgical Oncology, and the National Consortium of Breast Centers.

Researcher and presenter Patricia Ganz, MD, professor of health services in the School of Public Health and director of the division of cancer prevention and control research at the Jonsson Comprehensive Cancer Center at the University of California at Los Angeles (UCLA), spoke with Medscape Medical News about the quality-of-life issues in breast cancer survivors that were discussed at the conference.

Medscape: Which healthcare issues affecting breast cancer survivors were discussed at the 2011 Breast Cancer Symposium, and which do you think needs the most attention?

Dr. Ganz: There is more recognition now that the late effects of breast cancer treatment cannot be ignored, yet we need more. The focus of most clinician visits is to find out whether there's been a recurrence of breast cancer, but often persistent symptoms like fatigue, cognitive problems, pain, and sexual difficulties are not addressed. There is also increased risk for cardiovascular disease and psychosocial needs among these women. Our responsibility is to create a coordinated healthcare treatment plan for each cancer survivor so that her primary care physician is aware of all her health needs and what needs to be done. Just because she's had breast cancer doesn't mean we can ignore her cholesterol or diabetes.

Medscape: What are the most significant gaps in healthcare for breast cancer survivors?

Dr. Ganz: Quality-of-life issues are often not addressed. There are therapies that have evidence-based support for their efficacy in breast cancer survivors, such as cognitive behavioral therapy for depression and sleeplessness, and physical activity and yoga for fatigue. But many patients don't get referred for these services, particularly for psychosocial issues. It's a tragedy waiting to happen.

This is a problem in general for all cancer survivors, not just those treated for breast cancer. For some clinicians, it's a "don't ask, don't tell" situation. If they don't ask, then they don't have to worry about doing something about their patients' psychosocial issues, particularly in small communities where there are few mental health professionals.

In my research, I've found that most breast cancer survivors can often do quite well emotionally afterward. But there are subsets of women that can be persistently anxious and distressed. For instance, a 35-year-old single woman who has had breast cancer may be worried about sexuality, fertility, and dating, and may feel afraid to leave her job and risk losing her health insurance. We need to do a better job of identifying and screening breast cancer survivors who may be depressed. In our UCLA clinic, we give all survivors we see a standardized questionnaire that assesses symptoms of depression.

Medscape: Have there been any advances in the past few years in the treatment of symptoms, such as cognitive problems?

Dr. Ganz: There have not been any real key advances in the last few years that are evidence based. There just haven't been a lot of studies on this issue. But researchers are trying out a number of different interventions. I've tested rehabilitation interventions such as retraining. Others have tried treatments such as methylphenidate (Ritalin)-type drugs and modafinil. But we are at the beginning of studying these interventions, and there are no good published randomized trials on their effectiveness.

In the research I've done, we've found that cognitive problems are most significant right after patients finish treatment, and it tends to get better over time. But for about 25% to 30% of breast cancer survivors, cognitive symptoms persist, sometimes for years afterward. These patients are usually high-functioning individuals, so the changes we're talking about are relatively subtle. But it creates difficulties in their lives. They may have trouble multitasking, for instance, or learning new things — skills that are governed by the brain's executive function.

Medscape: The question of how to treat problems like vaginal dryness and gynecologic symptoms after breast cancer treatment is controversial. What did the discussion of these issues reveal at the 2011 Breast Cancer Symposium?

Dr. Ganz: At the symposium, we had an extensive discussion about the use of vaginal estrogen. The presentations highlighted research that showed that vaginal tablets and estrogen rings have low systemic absorption. But there were clinicians at the forum who were concerned about the use of any estrogen in breast cancer survivors. It's not a settled question, particularly for women who take aromatase inhibitors.

The goal is to keep estrogen levels very low in breast cancer survivors. If a woman is on tamoxifen, I don't hesitate to use vaginal estrogen. But for women on aromatase inhibitors, I will usually monitor estradiol levels. For these women, I don't encourage the use of vaginal estrogen unless they are having very troublesome symptoms, such as frequent urinary tract infections. Then the use of vaginal estrogen becomes a real health and quality-of-life issue. So we try to monitor estradiol levels regularly.

Medscape: What do you think should be the next steps in improving treatment for the late effects of breast cancer treatment?

Dr. Ganz: We need to know more about who is at risk for problems such as cognitive deficits and depression, and we need more evidence-based research on how to prevent and treat these long-term effects. Posttreatment healthcare also needs to be standardized and disseminated to physicians' offices. Only 20% of cancer patients are treated in tertiary centers, and many are in small communities where there is not good coordination of healthcare.

We really have to upgrade the knowledge of primary care providers about cancer survivors. In the near future, we're going to have a shortage of oncology specialists, and survivors won't be followed by oncologists as they are now. Primary care providers need to have the knowledge and skills to feel comfortable assuming the care of cancer survivors, including those who have been treated for breast cancer.

In 2006, Dr. Ganz received funding from the Lance Armstrong Foundation to establish a survivorship center of excellence, the mission of which is to improve the quality of life and quality of care for cancer survivors in the Los Angeles region.

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