October is Breast Cancer Awareness Month, a time to remind patients to get mammograms and look for changes in their breasts. It’s also a time for healthcare providers to remember the intricacies of caring for breast cancer patients, even outside oncology settings.
Of course, there are many clinicians who treat breast cancer patients and survivors with specialties besides oncology — from gynecology to surgery, radiology and primary care and more. This is one of the many reasons communication between provider and patient is vital to fight this condition, where even simple symptoms can mean extensive complications.
I should know. During my own breast cancer treatment, which included a double mastectomy and chemotherapy, a misdiagnosed fever of 103 turned into neutropenia and severe kidney problems. (At first, my PCP thought my temperature was due to the flu, but the next day, my plastic surgeon examined my breasts and decided I should go to the ER. It was actually a yeast infection related to my breast tissue expanders, which led to a week-long hospital stay and surgery.)
Like my fever, many seemingly-minor symptoms in breast cancer patients merit an additional exam or questions by provider who encounters them, regardless of specialty. According to Kathleen Sacharian, MSN, CRNP, AOCNP, survivorship and medical oncology NP at Main Line Health in Paoli, Pennsylvania, these are most common.
Serious Fatigue, Months After Treatment
When undergoing chemotherapy, fatigue is especially common. But when a patient who finished months ago asks about the persistent fatigue, even with plenty of sleep and daily exercise, don’t simply chalk it up to past treatment.
“Patients are often surprised to learn that they can feel fatigue six months after their last treatment,” Sacharian explains. “The big challenge for doctors is that side effects can be immediate and long-term, or they may present themselves years later.
While the chemo is probably playing a role — fatigue is the top symptom breast cancer patients experience, according to Sacharian — it’s worthwhile for providers to look into the patient’s current medication regimen. SNRIs and SSRIs, among other drugs, might be exacerbating the symptom.
“We often will recommend increasing physical activity to help improve fatigue, as well as identifying other causes that may be contributing such as insomnia or anemia,” Sacharian adds.
Is It Arthritis?
“These symptoms may be related to hormonal medications that patients with hormone receptor-positive breast cancer may receive — but with a breast cancer patient, there’s always concern the cancer will metastasize,” Sacharian advises.
Even without any metastasizing, joint pain is a quality-of-life issue and increases risk of osteoporosis. Rather than eliminating the medication causing the symptom (which could facilitate the cancer’s return), Sacharian recommends prescribing exercise, NSAIDs and “whatever it takes to keep them on their medication.” You may also want to ask the patient’s oncologist about switching AIs, if this is a suspected cause.
An Itch that Cannot Be Scratched
My own breast cancer pet peeve is caused by mastectomies. Removing the lymph nodes and cutting nerves when excising breast tissue cause a loss of feeling. Basically, you can feel an itch on your skin but not the scratch to eliminate it.
This symptom, which occurs in up to 50 percent of mastectomy patients, has a name: neuropathic itch. Unfortunately, antihistamines, lidocaine patches, ice packs and other treatments do not bring relief, and the sensations can appear any time, without warning.
“Patients may experience discomfort, numbness or reduced mobility following mastectomy but often will see slow, gradual improvement,” says Sacharian. “The key is determining if it’s a short-term symptom that will fade or if the pain or swelling is a symptom of another condition that needs to be treated, such as lymphedema.”
My Rings No Longer Fit
Cancer doesn’t always mean becoming frail. Many patients actually gain weight during and after treatment. The causes range from stress, depression or reduced energy to treatment itself, including steroids and AIs.
If this symptom arises, Sacharian advises providers make appropriate lifestyle recommendations and look into whether other medical conditions, such as diabetes, may be involved.
Similarly, bloating and swelling are also concerns for breast cancer patients. While treatment may induce swelling, lymphedema among patients who’ve had lymph nodes removed is serious. Most lymphedema cases occur within the first 2 years after surgery.
Swelling in the legs and feet are common after chemotherapy, but it could also indicate “a blood clot or a heart problem,” Sacharian says.
While patients should certainly communicate openly with their care providers, clinicians, especially PCPs, should be in touch with the rest of the care team so they can work together to find the causes of concerning symptoms. You may even suggest patients carry a wallet card listing medications, surgeries, treatments and anything other pertinent information, in case they find themselves in the ER.
When working with breast cancer patients, remember to consider the less common causes of a symptom in an effort to catch more serious ailments early.