Managing the Side Effects of Treatment

Evelyn Robles-Rodriguez

RN, MSN, APN, AOCN

Objectives

• To review the role and the various types of therapies in metastatic breast cancer

• To understand the possible side effects of the varied therapies

• To discuss ways to manage these side effects including lifestyle modification

• Question and answer period

HORMONAL THERAPY

What is it and what does it do?

What are hormones? • Chemical messengers that send signals

from one cell to another via the bloodstream

• They affect cells and tissues that carry the receptor for that specific hormone

• Hormones bind to the receptor protein leading to cell-specific reactions

• In breast cancer, estrogen and progesterone (released by the ovaries) can play a part in tumor growth

Why hormonal therapy in MBC? • In MBC, can stop or slow the growth of tumors • Used with with estrogen receptor (ER) positive

and/or progesterone receptor (PR) positive breast cancers

• Approximately 70-80% of breast cancers are ER+ • Best in patients who do not have disease that is

imminently threatening their life by affecting organs such as lungs or liver

• Reduces hormones in the body or interferes with the hormonal action

What are the various types of hormonal therapies?

• Block estrogen effects – Tamoxifen/Nolvadex (risk reduction, adjuvant, metastatic)

– Toremifene/Fareston (only in metastatic setting)

– Faslodex/Fulvestrant (postmenopausal with metastatic disease)

• Block estrogen production – Anastrozole/Arimidex – temp inactivate aromatase

– Letrozole/Femara – temp inactivate aromatase

– Exemestane/Aromasin – permanently inactivate aromatase

• Block ovarian function – Surgery, Lupron Zoladex

• Other types – Megace, androgens, high dose estrogen

Common Side effects of Hormones • Fatigue

• Hot flashes/cold flashes

• Vaginal discharge

• Mood swings

• Blood clots

• Endometrial cancer

Other Common Side effects • Bone and joint pain or stiffness

• Bone loss (osteopenia or osteoporosis)

• Weakness

• Insomnia

CHEMOTHERAPY

What is it and what does it do?

What is chemotherapy? • Medicines that destroy or damage the cancer cells so

that they cannot grow or duplicate

• Called systemic therapy because it travels through the bloodstream and can affect all of the body

• Can be given orally, intravenously (IV), by injection, topically or direct placement at a site

• Can be used as single agents or in combination

• Used in MBC if hormones stop working or disease is advanced or growing quickly

Goals of chemotherapy in metastatic disease

• Improve symptoms

• Get rid of the cancer cells

• Shrink the cancer cells

• Keep the cancer cells “stable” meaning no new or minimal growth

Some Commonly Used Chemo • CAF/FAC (cyclophosphamide/doxorubicin/fluorouracil)

• FEC (fluorouracil/epirubicin/cyclophosphamide)

• AC (doxorubicin/cyclophosphamide)

• EC (epirubicin/cyclophosphamide)

• CMF (cyclophosphamide/methotrexate/fluorouracil)

• docetaxel/capecitabine

• GT (gemcitabine/paclitaxel)

• gemcitabine/carboplatin

• paclitaxel/bevacizumab

• Halaven Abraxane

• Doxil Ixempra

• Cisplatin Navelbine

Common Side effects of Chemo

• Fatigue

• Peripheral neuropathy

• Nausea/vomiting

• Skin and nail problems

• Hair loss

• Mucositis/esophagitis or mouth sores

• Insomnia

RADIATION THERAPY

What is it and what does it do?

What is radiation therapy?

• Local treatment so it only affects cells in the treated area

• Can be used alone or in combination with other therapy such as chemo or surgery

• Uses high energy x-rays or radioactive materials to treat cancer

Why is RT used in MBC?

• Control or shrink the cancer

• Improve pain or other symptoms

• Lower risk of weakened bones breaking

• Reduce bleeding or affects on the skin

• Reduce pressure from the tumor

Types of Radiation Therapy

• External beam radiation

– Radiation directed from an outside machine to cells within the body (IMRT, stereotactic (3D), Cyberknife, Gammaknife)

• Internal radiation

– Radioactive material placed via a catheter into or near the tumor (high dose brachytherapy)

• Systemic radiation

– Radioactive substance that is swallowed or injected (iodine)

Common Side Effects of RT

• Fatigue

• Skin changes

• Lymphedema

TARGETED THERAPY

What is it and what does it do?

What is targeted therapy?

• Treatments used to treat specific targets that some cancer cells may have

• Some can work like antibodies (immune therapy)

• Less likely to cause harm to normal healthy cells

Commonly Used Targeted Tx in MBC • Afinitor (everolimus)

• Avastin (bevacizumab)

• Herceptin (trastuzumab)

• Ibrance (palbociclib)

• Kadcyla (T-DM1)

• Perjeta (pertuzamab)

• Tykerb (lapatinib)

Common Side Effects of Targeted Tx • Fatigue

• Mouth sores

• Diarrhea/constipation

• Muscle or joint aches

• Nausea/vomiting

• Decreased appetite

• Hair loss or thinning

• Rash

• Peripheral neuropathy

SIDE EFFECTS

Can we control them?

What is a side effect?

• Undesirable outcome

• Effect of a therapeutic treatment

• Can occur at the beginning, middle or after the end of treatment

Who Gets Side Effects? • Anyone can

• Not everyone has same side effects or suffers them the same

• You may not suffer from all the side effects you hear about

• Some side effects are unique to an individual

• Make use of the recommended treatments

Treatment and Side Effects

• What to do

– Speak to your care provider

– No question is bothersome or stupid

– Use your resources at home, family, neighbors, communities

– Speak to other survivors and look for other resources

Treatment and Side Effects

• What to avoid

– Isolating yourself

– Suffering with or hiding your symptoms

– Talking to negative people

– Listening to myths in the community; get the facts before stressing yourself out

MANAGING SIDE EFFECTS The more common side effects

and tips on how to manage them

Hot Flashes • Intense, sudden feeling of heat on your face

and/or body; some people get cold flashes

• Can be accompanied by rapid heart rate, sweats, nausea, dizziness, headache, anxiety or weakness

• Can vary in time of duration, frequency and intensity

• Most common 6-8 AM and 6-10 PM

• 10-15% of women have severe episodes

What causes hot flashes • Hormonal changes (drop in estrogen) as during

menopause

– 85% of women in US who are perimenopausal and 1-2 years after they stop

– 20-50% continue to have these for many years

• Lifestyle and dietary choices

• Medications such as hormonal therapy

– Occur in 50-75% of women on Tamoxifen and/or chemo and usually improve after 1st 3-6 months of therapy

Avoid Triggers • Try to identify what makes them worse

• Common triggers

– Alcohol

– Caffeine

– Spicy or hot foods or drinks

– Hot tubs, saunas, hot showers

– Hot rooms or beds

– Weather

– Smoking

Other Tips – Dress in layers; cotton best

– Avoid wool, synthetics, silk, turtlenecks

– Drink plenty of fluids and keep ice water at hand

– If possible, keep your room environment cool

– Use cool cloth behind your neck

– Keep a fan at hand

– Take cool showers before bedtime

– Use cotton PJs and sheets

Lifestyle Changes

• Start an exercise program which can help combat fatigue and improve general well-being

• Try relaxation techniques for stress reduction (relaxation and breathing exercises, meditation, guided imagery, massage, yoga)

• Change your diet – losing weight and a low fat diet may help (being thin leads to worse symptoms)

• Consider acupuncture

If all fails - medical treatment • Blood pressure medication can decrease

severity and frequency – Clonidine 0.1 mg patch weekly or Aldomet 250 mg

bid • Antidepressants can reduce hot flashes

– Effexor 12.5 mg bid can decrease them by about 50% in 60% of women (usually 75 mg daily); 80% decrease within 1st week

– Paxil 10 mg daily in 1st week, then 20 mg daily • Avoid SSRIs if taking tamoxifen (prozac, paxil,

zoloft, celexa, lexapro) as can interfere with changing tamoxifen to its active form

Bone, joint and muscle pain • Mild to severe pain and aches in the bones

and joints that can be worse in the morning

• Can include stiffness

• Common with hormonal therapy and present in about half of patients taking AIs

• Can be worse in patients with known history of arthritis

• Can be debilitating in some patients

Tips to manage • Exercise

• Eat a healthy diet and maintain a healthy weight

• Use hot or cold packs to reduce muscle spasms and inflammation

• Try Tylenol or ibuprofen

• Try glucosamine with chondroitin supplement

If affecting quality of life

• Talk to your doctor about switching hormonal therapy

• Consider testing for other sources of pain

Other things to consider

• Acupuncture

• Massage

• Yoga

• Reiki

• Shiatsu

• Music therapy

Peripheral Neuropathy

• Causes – Irritation or damage to nerves

– Causes nerves to have difficulty communicating

– Can lead to weakness, pain, numbness, tingling, pins and needles, difficulty walking, feeling clumsy

Peripheral Neuropathy

• What to do

– Tell your care provider immediately of any symptoms

– Meds for pain such as neurontin or elavil

– Avoid things at home that could make you trip

– Keep home well lit

– Test temperature of water with area not affected

Peripheral Neuropathy • Other things to try

– PT/OT

– Capsaicin

– Massage, biofeedback, acupuncture

– B complex vitamins

– Exercise (water aerobics)

– Cold or heat

– Eat a diet high in antioxidants (bright colored fruits and vegetables)

Peripheral Neuropathy

• What to avoid

– Ill fitting shoes

– Socks that don’t allow your feet to breathe

– Tight socks, shoes or gloves

– Touching things you are not sure of the temperature with affected hands or feet

Osteopenia and Osteoporosis

• Bone thinning or loss

• Increases risk of fractures

• AIs can worsen

• Other worsening factors can include menopause, being small and thin, family history

How to manage • Obtain baseline bone density scan and then every two

years • Take calcium (1000 mg) – helps maintain bone health

and strength • Take Vitamin D (800 IU) – helps body absorb and retain

calcium • Weight bearing exercise • Eat healthy/maintain healthy weight – underweight

more prone to bone loss and fracture • Biphosphonates slow bone loss and may help promote

new bone growth • Prevent falls

Vaginal Dryness • Decreased estrogen leads to thinning of

vaginal membrane, lack of elasticity and decrease in lubrication production

• Can lead to painful sexual intercourse

• Yeast infections and bacterial vaginosis common

• UTIs can also occur more frequently

• Occurs in about 10% of women

Tips for Management • Try water-based lubricants (AstroGlide, KY,

Moist Again, Femglide, Durex, Wet, generics)

• Try moisturizer (Replens)

• Avoid irritating products including douches

• Talk to your doctor about vaginal estrogen products if all else fails (Estring, Vagifem)

• Treat yeast infections

Painful Intercourse

• What to do if painful intercourse

– Lubricants

– Change positions

– Set the mood

– Communicate with your partner

Insomnia • Frequent problems going to sleep or

staying asleep

• Common after diagnosis and with treatment

• Other causes include Diagnosis

– Anxiety, depression, pain, nausea

hot flashes, stress

Tips for management

• Try to go to bed and wake up at the same time each day

• Associate bed only with sleep

• Go to bed only when sleepy

• Keep your bedroom dark and quiet

• Try chamomile tea, warm bath, warm glass of milk

• Consider relaxation therapy, meditation, prayer or massage

• Try earplugs

What to avoid – Long naps and/or naps during the day

– Exercise 2-3 hours before sleep

– Caffeine products before bedtime

– Drinking lots of fluid before bedtime

– Alcohol before bedtime

– Thinking about what you need to accomplish when you lay awake

– Staring at the clock

– Smoking before bedtime

Fatigue • Most common side effect experienced by

cancer patients

• Overwhelming sensation of tiredness

• Not improved by sleeping or resting

Fatigue

• What to do

– Use your resources!!!

– Keep a journal

– Balance rest and activities

– Exercise

– Eat a balanced diet

– Drink plenty of fluids

– Reduce stressors

Nausea & Vomiting

• Other causes besides cancer treatment

– Anxiety

– Pain

– Constipation

– Some other meds

Nausea & Vomiting • What to do

– Use nausea meds as prescribed

– Use meds to treat other symptoms

– Drink 6-8 glasses of fluid/day

– Eat dry, bland foods (crackers, pretzels, ginger cookies, toast, cereals)

– Eat small meals (6 vs. 3 per day)

– Try cold foods

– Try peppermint or ginger tea

– Suck on mints or hard candies

Nausea & Vomiting

• Other things to try

– Rinse your mouth before and after meals

– Eat in cool rooms with fresh air

– Stay upright 1-2 hours post eating

– Meditation, relaxation techniques and guided imagery

– Acupuncture

Nausea & Vomiting

• What to avoid

– Strong smells, sights or sounds

– Fatty, fried or greasy foods

– Citrus fruits, juices and tomatoes

– Eating hot and cold meals at same time

– Drinking liquids with meals

– Excessive activity and movement

Lymphedema

• Causes

– Accumulation of fluid in the soft tissues

– Can be due to surgery, radiation therapy, infections, overuse of arm post treatment, other trauma

Lymphedema

• What to do

– Moisturize

– Keep hands clean, avoid harsh soaps

– Use rubber gloves

– Protective clothing when gardening

– Electric razor

– Bug repellant

– Sun protection

Lymphedema

• What to avoid – Hot baths, showers

– Hot tubs, saunas

– Heating pads

– Carrying heavy things

– BPs, needle sticks

– Tight clothes, jewelry

– Alcohol, smoking

– Manicures

Skin & Nail Problems

• Causes

– Chemo

• Many changes resolve once the chemotherapy is completed

– Radiation

• Your radiation therapy team will give you creams and ointments to use during your treatment

Skin & Nail Problems

• What to do

– Skin

• Wash with warm water and mild, unscented soap

• Can use deodorant

• Use electric razor

• Avoid tight clothes or harsh fabrics

• Protect yourself when out in the sun

• Protect yourself from heat and cold

Skin & Nail Problems

• What to do

– Skin

• Use moisturizers

• Avoid perfumed or scented lotions

• Drink lots of fluids

Skin & Nail Problems

• What to do

– Nails

• Avoid manicures that cut cuticles

• No artificial nails

• Wear gloves

• Use moisturizers for your hands

• Can use nail polish

• Try tea tree oil

Hair Loss • Causes

– Some chemotherapy

– Area treated with radiation

– Usually around 2 weeks after your first treatment

– Can affect all the hair on your body

– New hair 3-5 months after treatment completed

– Can come back differently

Hair Loss

• What to do

– Consider cutting your hair short or shaving your head

– Use wigs, scarves, hats, hairpieces, turbans or going “natural”

Hair Loss

• If hair expected to thin:

– Use soft bristle brush and gentle shampoo

– Avoid hair dryers, curling irons, hot rollers

– Avoid coloring or bleaching

– Avoid perms

– Avoid braids or ponytails

– Sleep on satin pillowcase

Mucositis/Esophagitis

• Causes of mouth sores and pain with swallowing

– Some chemo

– Infection

– Poor mouth care

– Dehydration

– Alcohol, tobacco

Mucositis/Esophagitis

• What to do – Oral rinses before and after meals and at

bedtime • 1 tsp of salt to 32 oz water or ½ tsp salt and 2 tbsp

of bicarbonate in 32 oz warm water

– Use soft-bristle toothbrush

– Keep lips moist

– Use non-abrasive toothpaste

– Increase fluids

Mucositis/Esophagitis

• What to do if you use dentures

– Clean dentures daily

– Remove dentures at night

– Do not wear dentures if ill fitting

– Do not wear dentures if have sores

Mucositis/Esophagitis

• What to avoid

– Mouthwashes with alcohol

– Lemon or glycerin swabs

– Hot, spicy, acidic, citrus or greasy foods

– Alcohol

– Hard or coarse food

– Carbonated beverages

– Cigarettes, cigars, pipes

Final Words

• Cancer and its treatment is unique to each individual

• The side effects of therapy can be managed

• Modify the things you can in your daily life

• Establish great communication with your health care providers and loved ones

• You are not alone – know your resources

TAKE CARE OF WONDERFUL YOU!