LIFE AFTER DIAGNOSIS

AVOIDING WEIGHT GAIN

A recent journal article reviewed the medical literature about obesity at the time of diagnosis and weight gain after diagnosis of breast cancer (Rowan T. Chlebowski, Erin Aiello, and Anne McTiernan, Journal of Clinical Oncology, 20: (4) Feb 2002, pp. 1128-1143). They found that women who are obese, or gain weight after a breast cancer diagnosis are at greater risk for complications during treatment and breast cancer recurrence and death compared with lighter women. Fewer than 20% of postmenopausal women follow the minimal Surgeon General Exercise Guidelines of exercising five days a week for 30 minutes at a moderate intensity. In another study of breast cancer survivors, almost 50% did not perform any regular leisure time exercise, and only 25% performed any vigorous activity.

It is common assumption to think that people lose weight during cancer treatment. In most instances, this is not true. Overweight women should avoid further weight gain. Everyone, whether they have a diagnosis of breast cancer or not, should be encouraged to follow the Surgeon General’s exercise guidelines of exercising every day of the week for 30 to 60 minutes at a moderate intensity. We all should follow a healthy diet that is high in low-calorie density foods such as fruits and vegetables, and low in fats and refined sugars, and high in fiber. Experts in cancer fitness and exercise can help you design an individual program which is tailored to your present level of fitness and health and your nutritional and exercise needs.

EXERCISE

Scientists continue to research the connection between exercise and one’s cancer risk. On June 7, 2005 the Rocky Mountain News reported that The World Cancer Research Fund estimated that between three to four million cases of cancer worldwide a year could be prevented by better diets, more physical activity, and maintaining an appropriate body weight.

A recent article by M.D. Holmes, et al in the Journal of the American Medical Association (JAMA, 2005; 293: 2479-2486) reported that physical activity after a breast cancer diagnosis may reduce the risk of death from this disease. The greatest benefit occurred in women who performed the equivalent of walking three to five hours per week at an average pace. Additional hours of activity or an increased pace did not seem to significantly improve their survival rate.

People who choose on their own to exercise are very different from those who do not choose to exercise. Several studies have shown that those who exercise have other good health habits. They tend to drink less alcohol, eat healthier diets, smoke less if at all, take more vitamin supplements, and take better overall care of their health. As a result, it’s difficult to be sure that the exercise by itself is having the effect (Breast Fitness, p. 62).

Choose an activity you enjoy and begin slowly. If you have been very ill or have not been exercising on a regular basis, walk for five minutes, turn around and walk back. Then try to do it twice a day. Build up gradually. Increase the time you exercise by no more than 10% each week. In other words, if you walk for fifteen minutes three times a week – a total of 45 minutes – don’t walk more than a total of 50 minutes next week. Remember that there is a fine balance between too much and not enough exercise. Exercise to the limit of your tolerance. Listen to your body. Physical activity may boost the immune system’s ability to suppress cancer cells. When one exercises, weight and body fat can be reduced, which could produce a lower estrogen level. Lower circulating levels of estrogen and progesterone, may play a role in the development of certain types of breast cancer.

FATIGUE

In people with cancer, fatigue does not go away with a nap or a good night’s sleep. It is described by many terms including tiredness, sleepiness, drowsiness, lack of energy, bone tired, confusion, poor concentration, apathy, and depression. In some instances, it’s difficult to determine which came first: the fatigue or the other feelings. Is one experiencing fatigue because they are depressed, or are they depressed because they are tired? Fatigue can impact one’s appetite, energy level, emotional well-being, and perceived quality of life.

If you are experiencing fatigue, it is important to tell your doctor or healthcare provider. You may need tests to determine why you are so tired. Some medications can contribute to fatigue and make it worse; others can help relieve the symptoms of fatigue. Occasionally, physical therapy can assist with energy conservation strategies.

Fatigue is the most frequently identified and longest-lasting side effect experienced by patients with cancer. The actual incidence of cancer fatigue varies, with reports ranging from 60 to over 90 percent. Fatigue may be a sign of the cancer itself or a side effect from cancer therapy. Many cancer patients are more concerned about fatigue than they are about cancer pain.

Exercise has been found to be beneficial. It is, however, difficult to exercise when one has little energy. Most studies recommend a moderate exercise program, increasing by no more than 10% a week. The benefits of exercise on fatigue include:

• More efficient oxygen and energy use
• Lower resting heart rate and blood pressure
• Improved joint range of motion
• Satisfaction and pride in accomplishing the activity
• Increased flexibility
• Improved muscle strength
• Better sleep patterns
• Increased sense of well being
• Greater feelings of self control

CHEMO BRAIN

The acknowledgement of cognitive (abstract thinking) limitations and its effect on patients is a recognized side effect of cancer treatment. Almost a third of women with breast cancer who receive chemotherapy after surgery complain of some degree of cognitive impairment. Higher doses of chemotherapy often result in more frequent and severe deficits. Problems may be reported with memory, concentration, word finding deficits, organizational skills, arithmetic/problem solving, and reasoning. These deficits may last for a few weeks or years. Fearing that memory problems may be a sign of metastasis to the brain, some people are hesitant to discuss these problems with their physician. Compensatory strategies can improve one’s ability to organize information, maintain attention, and recall words and information. In some instances, speech therapy and/or medications may be helpful. Again, it is important to tell your health care provider about any cognitive problems you might feel you are experiencing.

PAIN

Cancer pain has been defined as “whatever the patient says it is, lasting for however long the patient says it lasts. Approximately one-third of patients who undergo active treatment for cancer, experience pain. The pain may be acute (of a recent onset) or chronic (lasting for some time). It may be linked to cancer (either from treatments or from the disease), or non-related (arthritis, low back pain, etc.). Patients often are afraid to talk to their healthcare provider about pain because they fear it is an advancement of the disease. Numerous drugs and treatments are effective in pain management. Pain that is untreated can lead to depression, anxiety, fatigue, decreased quality of life, sleep problems, and even cognitive problems. Your physician may prescribe physical therapy. Relaxation strategies, meditation, and imaging have also been helpful. Communication with your healthcare provider is critical. They cannot help you unless you are willing to discuss your pain.

REHABILITATION

Often one does not think of rehabilitation in the natural course of cancer treatment. Recovery is different for every individual, based on the extent of the disease, treatment provided, and response to that treatment. Women who have had a mastectomy and immediate breast reconstruction may need special exercises. Physical therapists can help improve movement in your arm and shoulder. Lack of movement can cause pain and stiffness. Exercise should begin slowly and gently. Some exercises can even be done in bed. You cannot immediately return to the level of movement you experienced before your surgery. Gradually, you can become more active.

Physical therapists can also assist in pain management. If you experience fatigue, occupational therapists and physical therapists can address energy conservation techniques. They can develop programs to increase your level of fitness and perception of well-being. Feel free to discuss the possibility of a physical therapy consult with your physician.

LYMPHEDEMA

When lymph nodes are surgically removed to determine whether or not breast cancer has spread, an interruption in the lymphatic flow occurs. Radiation therapy may also damage otherwise healthy lymph nodes and lymphatic channels. These procedures are necessary for your cancer treatment. Following them; however, fluid may accumulate in the arm, resulting in swelling - or lymphedema.

The exact incidence is not known, but it is estimated that about 10 to 20% of women who have had an axillary dissection for breast cancer develop lymphedema sometime in their lifetime. Patients undergoing just a sentinel lymph node procedure have a 3% chance of developing lymphedema. It can occur immediately or many years later. It is not clear why it happens to some and not to others. Being aware that this might occur is one of the best ways to limit its occurrence. If it does happen, you might notice swelling, pain, "heaviness," or loss of function in the involved arm. If the problem is recognized and treatment begins early, the likelihood for improving the condition is much greater than if the lymphedema is allowed to progress. The following practical precautions might be helpful.

Be informed. Don't worry unnecessarily about lymphedema. However, any swelling, skin breakdown, weeping, or reddened area in the arm from which your nodes were removed must be taken seriously. Use gloves when gardening, especially when handling plants with thorns or stickers. When flying long distances on an airplane, you might want to consider wearing a compression sleeve. When having a manicure, don't have your cuticles clipped too closely. When shaving your underarms, use an electric razor. Use your arm naturally but do not overstress it. Be aware that activities requiring vigorous, repetitive movements may aggravate the condition. Carry your purse, briefcase, or golf bag over your unaffected shoulder.

Once a person develops lymphedema, the swelling is not easily resolved. This fluid must be directed to another part of the body where functioning lymph nodes can process it. HCA.Inc has developed a comprehensive program where physical and occupational therapists use a number of interrelated techniques to treat lymphedema. Therapy includes education, skin care, lymphatic massage, multi-layered bandaging, individualized exercise, and self-management techniques. The treatment plan is individualized for the needs of the person. If you cannot find a qualified therapist in your area, contact Connie Carson, Ph.D. by email at concarson@aol.com.

INTIMACY

Although many women have difficulties with sex and intimacy following breast cancer, it is one of the least discussed topics. Many healthcare professionals won't bring it up, thinking that it is not an issue, if you are not complaining about it. It is common to feel that your body has betrayed you. Surgery may have permanently altered your body and your self-esteem. It may be difficult to resume sex with your partner. Many women have difficulty looking at or touching their scars. It often takes a while to feel good about oneself. On the other hand, some women have reported that a sexual relationship is even more important following their surgery than it was prior to their diagnosis. They have an increased need for a sexual relationship, to help them regain a sense of wholeness. It takes time to resolve these feelings. It is important to communicate your feelings to your partner. Hopefully, they can help you in your healing.

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