Women's Health: What happens after treatment for breast cancer?
I have noticed that while we are mostly concerned with diagnosis and treatment in medical discussions regarding breast cancer, not much interest is placed on what happens after treatment.
For many women, breast cancer treatment will remove or destroy the cancer; and while the completion of treatment can be exciting, it can also be very stressful.
Yes, there is the obvious expected relief of finishing treatment, but there is also worry about the cancer coming back (recurrence), and this is a very common cause of concern and anxiety for women who have had cancer. Other areas of concern are the long-term effects of the treatment, body image concerns, sexuality, and pregnancy after breast cancer.
It will take a while before your fears and anxiety lessen; but it may also help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives.
However, here are a few things that may help speed along the process.
When your treatment ends, your doctor will want to see you at intervals to ensure all is still well. It is very important to go to ALL of your follow-up appointments, irrespective of how good you may be feeling.
Your initial follow-up appointments are usually scheduled for every three to six months. The longer you have been free of cancer, the less often the appointments will be. After five years, they will be once a year.
If you had breast-conserving surgery (only removed tumour from the breast and not the entire breast), you will require a mammogram approximately six months after surgery and radiation treatment are completed, and then every year after that. Women who had a mastectomy (removed the breast) should continue to have their yearly mammograms on the remaining breast.
At your follow-up visits, the doctor may do particular exams, and request certain lab tests or x-rays and scans to look for signs of cancer recurrence, or side effects.
Some side effects of breast cancer treatment are short-lived (lasts only a few weeks or months), while others are more long-standing. These follow-up visits are the best time to discuss these and any other concerns with your doctor.
If you are taking tamoxifen, you should, in addition to the above, have pelvic exams (done at your gynae visit) every year. This is because these drugs can increase your risk of uterine cancer. This risk is highest in women who have already gone through menopause. Be sure to tell your doctor right away about any abnormal vaginal bleeding, such as bleeding or spotting after menopause, bleeding or spotting between periods, or a change in your periods. Although this is usually caused by a non-cancerous condition, it can also be the first sign of uterine cancer.
These follow-up visits not only serve the purpose of ensuring that you are well medically and physically, but emotionally and psychologically as well.
EMOTIONAL ASPECTS OF BREAST CANCER
During the time of your cancer treatment, you may have been going through so much that you were only focusing on getting through your treatment, and getting better.
Now you might find that you think about the possibility of the cancer returning, and the possibility of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner.
All of this can be a source of anxiety for many.
If you find that this is occurring, you will need people you can turn to for strength and comfort, and this would be an ideal time to ensure you have adequate emotional and social support.
Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, individual counsellors or books.
Almost everyone who has been through cancer will benefit from getting some type of support. However, it is not a "one size fits all" remedy. What will be best for you, will be dependent upon your situation and personality. Some people will feel most comfortable in a peer-support group, others would prefer a more informal setting, such as church, while some will feel more at ease talking one-on-one with a trusted friend or counsellor. I was even told by a cancer survivor that nothing helped her, despite trying all of the above, until she was given some cancer support books to read.
Whatever you choose your source of strength or comfort to be, just ensure you have a place to go with your concerns.
It is common to feel alone on your cancer journey, but it is not necessary or realistic to go through it all by yourself. Before long, you will realise that you too will become the source of strength for somebody just starting out on their journey, and that will be further encouragement for you to see how far along you have come.
BODY IMAGE AFTER BREAST CANCER TREATMENT
In addition to having to cope with the emotional stress that accompanies cancer and its treatment, patients with breast cancer will also find themselves dealing with changes in their appearance as a result of their treatments.
Some changes are short-term, such as the hair loss associated with chemotherapy; but even this short-term change can have a significant negative effect on how a woman feels about herself. But in these days of wigs, weaves and hair pieces being fashionable, there are numerous options available to help women cope with hair loss.
Alternatively, some women choose to wear their baldness proudly, and use it as a way to identify themselves as breast cancer survivors.
Other more permanent changes, like the loss of part or all of a breast, or even both breasts after surgical treatment, are obviously more traumatic and less of a simple fix. Some women choose to have breast reconstructive surgery after mastectomy to address this issue, while others may opt for a breast form.
If you are considering breast reconstructive surgery, it should be discussed with your doctor before surgery to treat the cancer. Decisions about the type of reconstruction and when it should be done will depend on each woman's medical situation and personal preferences, as well of the type of reconstruction desired, as there are several types of reconstructive surgery available.
A breast form is a prosthesis (artificial body part) worn either inside a bra or attached to the body to simulate the appearance and feel of a natural breast. Breast forms can be an important alternative to breast reconstruction for women who have had a mastectomy, especially if they do not want further surgery, because breast reconstruction can sometimes require several procedures to complete.
Regardless of what your preference may be, speaking with your doctor or other members of your health-care team is a good starting point.
SEXUALITY AFTER BREAST CANCER
It is common for women to have concerns about sexuality after breast cancer. Physical changes which occur during and after treatment will make most women less comfortable with their bodies. Also, some treatments, such as chemotherapy, can change your hormone levels and may negatively affect a woman's sexual interest and/or response. Additionally, for women in their 20s or 30s who are seeking to choose a partner or have children, a diagnosis of breast cancer can be especially difficult.
Surgical treatment for breast cancer, particularly removal of the breast, can damage a woman's feeling of attractiveness. Our culture has taught us to view breasts as a fundamental part of beauty and femininity. If a breast has been removed, a woman may worry about whether or not her partner will still find her attractive. She may also be worried about not being able to enjoy sexual stimulation in the affected breast.
However, even after having a breast removed, some women still enjoy being stroked around the area of the healed scar - whereas other women may actually dislike being touched there and may no longer even enjoy being touched on the remaining breast and nipple. Some women who have had a mastectomy may also feel self-conscious in certain sexual positions where the area of the missing breast is more visible.
PLEASE NOTE: Although there may be emotional and self-esteem effects, breast surgery does not decrease a woman's sexual desire, nor does it decrease her ability to have an orgasm. According to recent research, most women with early-stage breast cancer will have good sexual satisfaction and emotional adjustment within a year after their surgery, and can boast a similar quality of life to women who never had cancer.
But we cannot forget the partner in all this, because the cancer diagnosis can be very distressing for the partner, as well. Partners are usually concerned about how to express their love physically and emotionally after treatment, especially surgery. But breast cancer can be a growth experience for couples, especially when partners take part in decision making, and go along to treatments.
PREGNANCY AFTER BREAST CANCER
Some treatments for breast cancer, such as certain chemotherapy drugs, may affect a woman's ability to have a baby (fertility). Still, many women are able to become pregnant after treatment. The best time to talk with your doctor about future fertility desires is before starting breast cancer treatment.
The concern about pregnancy after breast cancer is due to the fact that many breast cancers are sensitive to estrogen. Due to the high level of this hormone during pregnancy, there has been concern that if a woman has been treated for breast cancer, this might increase the chance of the cancer coming back. However, studies have shown that pregnancy does not increase the risk of the cancer coming back after successful treatment.
Still, it is advised that breast cancer survivors wait at least two years after all treatments are finished before trying to get pregnant. The best length of time to wait is not clear, and in some patients, breast cancer can come back after the two-year mark, so each case is different.
Each woman's decision to wait should be based on things such as her age, fertility, desire for more pregnancies, type of breast cancer, risk of an early relapse, and the potential effect estrogen may have on her risk of a breast cancer coming back.
Women taking chemotherapy, or hormone therapy, should talk with their doctors before trying to become pregnant. These drugs can affect a growing foetus, so it isn't safe to get pregnant until all treatments are complete.
Stopping treatment early can increase the risk of the cancer growing or coming back.
Another important thing to know is that chemotherapy for breast cancer can also damage the ovaries, sometimes causing immediate or delayed infertility. Cancer treatment can also cause women to delay trying to get pregnant. These factors together often mean that a woman has less chance of getting pregnant after breast cancer treatment.
All women who have or have had breast cancer, and are thinking about having children should talk with their doctors about how treatment could affect their chances for pregnancy. This discussion should also cover the risk of the cancer coming back. In many cases, counselling can help women sort through the choices that come with surviving breast cancer and planning a pregnancy.
The best time to have this discussion is before treatment.
So many times, women with breast cancer focus only on treating the cancer that they forget about other possible aspects and future implications of their treatment, like pregnancy. Many times, just slowing down, writing down your concerns and expectations, and discussing them with your doctor before starting treatment, can help in choosing the best-suited treatment option for you, in order to achieve your desired outcome.
And, always remember all is not lost. I once had a patient referred to me, after surgical treatment for breast cancer; and she was in a panic. She had a positive pregnancy test, and was supposed to be starting chemotherapy and radiation treatment. It was recommended that she do not continue with the pregnancy, but she was determined to have her baby, and made it clear from day one. We honoured her request and we delivered for her a healthy baby boy at 36 weeks' pregnancy (pregnancy is 40 weeks). She returned to her treatment shortly after, and is happy every day with her beautiful baby boy, and making clear to us her desires and expectations early on.
- Dr Rhonda Reeves is the obstetrician/gynaecologist at Southdale Medical & Gynae Centre, Shop 6, Southdale Plaza. Email: firstname.lastname@example.org