Introduction
Treatment-derived health problems
Side effect | Characteristics | Attitude/recommendation |
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Lymphedema | 10–30% of patients who have undergone axillary node removal and 3–10% of patients treated with selective sentinel node biopsy [10] In recent years, the strategy of substituting axillary lymphadenectomy for axillary radiation is being assessed, without losing effectiveness and with a decreased risk of lymphedema [12] | Preventive measures (hygiene, hydratation, avoiding weights, and wounds) Rehabilitation In some cases, lymphedema surgery may be considered |
Ovarian failure and menopause-related symptoms | ||
Repercussions of ovarian function | 20 and 80% of women may present amenorrhea secondary to chemotherapy, which may be permanent. The risk depends on the schedule administered and patient’s age at the time of chemotherapy administration | Offer fertility-preserving methods Refer to Reproduction Services prior to systemic treatment administration [13] |
Sexual activity | Decrease in libido or vaginal dryness are attributable to both the ovarian failure young women undergo after chemotherapy or hormone therapy and the side effects themselves of hormone therapy (gonadotropin analogues, SERM, aromatase inhibitors) The change in body image and local pain secondary to surgery can also cause dysfunction of sexual activity | Psychological support Use of vaginal lubricants The use of vaginal tablets or hormone creams is controversial |
Hot flashes secondary to menopause | They are the result of induced menopause and are aggravated by hormone treatments Both tamoxifen and aromatase inhibitors (anastrozole, letrozole, exemestane) can cause or aggravate hot flashes | If severe, treatment with velafaxine or gabapentin can be used Acupuncture has demonstrated efficacy |
Risk of endometrial disease | Women who receive tamoxifen for a long period have a higher risk of suffering endometrial cancer, although these neoplasms are general diagnosed very early have a good prognosis | In patients receiving tamoxifen, annual gynecological examinations are recommended. Postmenopausal women should be evaluated preferably by a gynecologist if they present vaginal bleeding |
Bone health | Spontaneous or induced menopause (secondary to chemotherapy, gonadotropin analogues, or oophorectomy) involves decreased bone mineral density This effect can be relevant in young women with early menopause Hormone treatment, especially aromatase inhibitors in postmenopausal women produce a faster decline in bone mineral density with an increased risk of osteoporotic fractures | In menopausal patients, a baseline densitometry is recommended when starting endocrine therapy. Depending on the results, patients should be referred to a Bone Metabolism Service or follow ASCO/ESMO recommendations [16, 17]. Patients who are given aromatase inhibitors should receive calcium and vitamin D supplements. If osteoporosis is detected, add bone resorption inhibitors Recommend aerobic exercise Quit smoking |
Joint pain | This is a very common side effect, particularly in patients treated with aromatase inhibitors | Increase frequency and duration of physical exercise Minor analgesics Acupuncture can be beneficial |
Limited mobility of the scapulohumeral joint on the same side as the breast lesion | One side effect that can present long term following axillary radiation is decreased mobility of the scapulohumeral joint on the side that received radiation secondary to fibrosis in the pectoral muscle of the side affected [18] | Moderate, but constant physical exercise in the limb that received radiation On occasion, if improvement is not seen, the help of Rehabilitation Specialists should be requested |
Overweight | Weight gain is common during treatment for breast cancer, especially in women in whom menopause is induced or who follow hormone deprivation treatment Furthermore, overweight has been recognized, not only as a risk factor for breast cancer but also as an unfavorable factor for relapse [19] | Monitor and control weight Low calorie diets Physical exercise (150 min/week) Psychological support |
Cardiotoxicity and other vascular toxicities | Control concomitant diseases (hypertension, diabetes, obesity) Promotion of healthy lifestyles Refer to cardiology if signs of heart failure appear | |
Yearly incidence of ventricular dysfunction of approximately 9% that exceeds 40% in patients over the age of 75 years or having prior heart disease | ||
Toxicity due to anthracyclines is sometimes detected late and is more serious and often irreversible compared to toxicity due to trastuzumab [20], which tends to be reversible | ||
Cardiotoxicity due to trastuzumab usually appears during the active treatment phase and indicates that treatment must be withdrawn, although a high percentage of cases recover without sequelae. In women who have presented heart failure, there is no complete evidence as to whether it is possible to discontinue long-term cardiological treatment [22‐24] | ||
Deep-vein thrombosis (DVT) or pulmonary thromboembolism can be a side effect of tamoxifen and, less often, of aromatase inhibitors | If deep-vein thrombosis develops, refer patient to the oncologist to evaluate the advisability of continuing endocrine treatment | |
In patients who have received complementary radiation therapy, especially in the case of tumors on the left side and when the internal mammary chain has been radiated, long-term follow up must be carried out, given the risk of late cardiac toxicity. Nevertheless, the more modern radiation techniques with three-dimensional planning and dose intensity modulation have made it possible to lower the incidence of this type of side effect [25, 26], although risk factors should be strictly controlled and the advisability of stress testing should be assessed [15] | ||
Neurotoxicity | This is a side effect associated with the administration of taxanes. Sensory neurotoxicity in the form of paresthesia and pain in the hands and feet causes great discomfort | Detect toxicity early There is no specific treatment Duloxetine, gabapentin, and pregabalin can improve symptoms |
Ocular toxicity | Though uncommon, tamoxifen can increase the risk of cataracts | Refer to ophthalmologist if symptoms of blurry vision appear |
Asthenia | Asthenia is a highly prevalent symptom in breast cancer that often persists after competing treatments [27] The use of a visual numeric scale is recommended to quantify the degree of asthenia and should be monitored | Rule out organic cause Psychoemotional support Physical activity |
Cognitive impairment | Although there are few studies, many patients report memory loss or losing the ability to concentrate after chemotherapy that can last more than 20 years after treatment Methods are being investigated that enable us to diagnose and follow-up on this side effect | Assessment by Neurology Concentration and visual memory exercises Reading |
Skin changes (dryness, alopecia, others) | Following treatment with chemotherapy, some women do not recover all their hair or present side effects of the skin and related structures, such as the nails | Evaluation by Dermatologist |
Risk of second neoplasms | Patients who have undergone radiation therapy are at increased risk for a second neoplasm related to treatment with radiation. This phenomenon usually occurs many years after having received radiotherapy. The tumors that appear most often are neoplasms of the lung or angiosarcomas of the chest wall [28, 29] | Factors related to lung cancer should be avoided, especially with respect to smoking |
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Overweight avoidance Weight gain has been associated with a worse treatment response and greater risk of relapse.
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Healthy diet and exercise Epidemiological studies have proven a benefit for patients following a low-fat diet together with at least 150 min of vigorous physical activity per week [10]. The recommended diet is high in fresh fruits, vegetables, and legumes (at least two pieces of fruit per day); patients are also recommended to lower their intake of red meat (to 1–2 times per week) and processed meats and increase consumption of blue fish, olive oil use and consume dairy products, as well as take advantage of all the elements comprising a Mediterranean diet.
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Smoking avoidance
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Moderate alcohol intake It is recommended that women abstain from drinking more than 20 g of alcohol per day. The following beverages equal 20 g of alcohol: 250 ml of beer, one glass of red wine (150 ml), or a quarter of a glass (25 ml) of a higher grade liquor (e.g., gin, whisky, anise, and tequila).
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Use of complementary therapies Some of these therapies could interfere with patient treatment. Acupuncture must be properly performed and with necessary aseptic measures to minimize the risk of infection. Complementary or integrative therapies cannot substitute for a specific antitumor treatment.
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Awareness of symptoms that indicate possible relapse or second tumors The following symptoms should be monitored: persistent bone pain that increases with movement and fails to remit with rest, persistent cough, dyspnea, asthenia, anorexia, or unexplained weight loss, vaginal bleeding in postmenopausal women, change in intestinal rhythm, rectal bleeding, or persistent headache or other neurological deficit. Thus, an early diagnosis can be made.
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Confirmation of compliance with antiestrogenic hormone therapy Control and positive reinforcement to maintain the prescribed treatment even over prolonged periods (5–10 years).
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Return to work Support and guidance appropriate to the patient’s stage of evolution. In the case of complementary treatment, it is recommended that patients wait for a reasonable time so that they can recover from the side effects of treatment.
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Active alertness of the appearance of symptoms suggestive of heart disease.
Proposal of joint primary care and specialized care follow-up (Table 2)
Risk group | Definition | Recommendation |
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Low risk | Hormone-sensitive tumor Size ≤ 2 cm (category pT1) No axillary metastases Low risk according to genomic platform Carcinoma “in situ” | Clinical check-up every 6 months, alternating with primary care (PC) for 5 years After 5 years, only PC will be responsible for check-ups Yearly mammogram |
Intermediate risk | Hormone-sensitive tumor Size between 2 and 5 cm (category pT2) No nodal metastases or axillary metastases involving between 1 and 3 nodes Intermediate risk according to genomic platform | Check-up every 4 months together with PC for the first 2 years Every 6 months until the fifth year Only PC will be responsible for check-ups after that Yearly mammogram |
High risk | Tumor not expressing hormone receptors Tumor with HER2 amplification High risk tumor according to genomic platform Tumor with metastases in more than 3 axillary nodes Tumor treated with neoadjuvant therapy Locally advanced tumor | Check-up every 4 months together with PC for 5 years After 5 years, every 6 months together with PC until 10 years Only PC will be responsible for check-ups after that Yearly mammogram |
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History aimed at ruling out warning signs of relapse or the presence of sequelae, comorbidities, or second neoplasms.
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Adherence to adjuvant endocrine therapy when indicated.
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A physical examination that includes examination of the breasts and adjacent node regions.
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Bilateral, yearly mammograms in two projections, after conservative surgery of the breast or if the breast has been reconstructed. Annual follow-up visits will be maintained throughout their lifetime because these patients, unlike the healthy population who undergo biannual mammograms in screening campaigns, have a 5–10% probability of developing local relapse or a second neoplasm within 10 years post-treatment; this higher risk remains throughout their entire lives. Mammograms can be performed within the scope of PC or with the aid of the specialist in Obstetrics and Gynecology.
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Recommendations for prevention and health promotion.