Addressing Side Effects of Metastatic Breast Cancer Treatment With Open Conversations

Having an open conversation with the care team is important to address side effects related to the treatment of metastatic breast cancer, an expert explained during a presentation at the CURE Educated Patient® Breast Cancer Summit.

Patricia Jakel, oncology nurse consultant and associate professor of nursing at UCLA School of Nursing, and co-editor in chief for CURE’s sister publication, Oncology Nursing News, is also an advocate, as she is a breast cancer survivor who finished treatment a year ago.

Jakel said that side effect management should not just take place during active treatment.

“Survivorship should start at the minute that you’re diagnosed, because these side effects are going to continue,” she said. “I’m a year out, and I can talk to you about fatigue from a personal standpoint, I can talk to you about nausea.”

Fatigue

When Jakel asked the audience how cancer-related fatigue feels, some responses she received included not being able to get out of bed, feeling lethargic, sleeping 10 hours and feeling like you can sleep another 10 hours. The effects of cancer-related fatigue go beyond the physical impact, as it can also affect a patient’s emotions and cognitive abilities, among others.

There can be several explanations for cancer-related fatigue including biochemical causes, proinflammatory cytokines from treatment and sleep disorders. Jakel added that anxiety and depression can keep patients from sleeping well. Other causes of fatigue involve the treatment itself, comorbid conditions, malnutrition, anemia, decreased activity and pain, some of which are associated with the average age of breast cancer diagnosis.

“The average age of breast cancer [diagnosis] is 62,” Jakel said. “I know I have a lot of lovely young survivors in the room, but the average age is 62. So we’re already having problems with sleeping, and we already have comorbid conditions.”

Jakel highlighted the importance of having the cancer team assess your fatigue using a scale from 0 to 10.

“Make sure when you come into the clinic — doesn’t matter if you’re on active treatment, you’re newly diagnosed or you’re a survivor — have people ask you [about your fatigue],” Jakel said. “We should be asking you about your fatigue. How bad is your fatigue? What makes it better? What doesn’t? It should be part of our assessment.”

Several tactics may help with cancer-related fatigue including exercise, good nutrition, increased water intake and potentially some complementary therapies like massage, acupuncture and cognitive behavioral therapy. Some pharmacologic approaches may also be considered like antidepressants, although psychostimulants may not be used as much since steroids may interact with cancer treatments. Supplements may also help with fatigue, although they should be discussed with the care team.

“Really talk to your providers, talk to your [physician assistant], your nurse practitioner, your physician, because not all supplements are safe with what [medications] you’re taking,” Jakel said.

Nausea and Vomiting

Although nausea and vomiting are common side effects of cancer treatment that can impact a patient’s quality of life, Jakel noted that patients rarely vomit nowadays.

“We have things that we can do, but the chronic nausea can be a problem,” Jakel said. “It happens because of serotonin. Serotonin is released because of your treatments, because of radiation therapy, because of your cancer and because of anxiety. Serotonin goes up to your brain, stimulates your vomiting center, and your nauseated and/or vomiting. When we block those pathways, that’s when things are really successful.”

Some risk factors for nausea and vomiting include medications like certain chemotherapies, physical causes, history of morning sickness and motion sickness, metabolic causes and being a woman.

“It really depends on the type of medication you're taking,” Jakel said. “You think, oh, these oral medications, I can take these for my breast cancer. Guess what? A lot of them have nausea and/or vomiting associated with them. So you still have to be vigilant in making sure you're getting the proper treatment.”

There’s a variety of different antiemetics (drugs to treat nausea and vomiting), one of which Jakel said patients should be getting any time they are receiving any kind of treatment: the serotonin antagonists, or the 5-HT3s. There are other options as well including antipsychotics like Zyprexa (olanzapine).

“People are afraid of it because it’s labeled as an antipsychotic,” Jakel noted. “It works wonders for chronic nausea. You take it at bedtime, and it actually helps you sleep.”

She added that drugs like the 5HT3s, for example, can cause constipation.

“What happens when you get constipated? You have more nausea, you feel worse, your stomach hurts more. So be aware of that,” Jakel said.

There are some natural options for patients who are interested in going that route for nausea/vomiting relief including ginger, lavender and peppermint.

Constipation

Another side effect of breast cancer treatment is constipation, which can also be caused by a presenting symptom of cancer, tumor progression or may possibly be unrelated to cancer or treatment.

Although laxatives can help relieve constipation, Jakel made a note about the stool softener Colace (docusate sodium).

“Colace really doesn’t work by itself,” she said. “You have to do a combination. You have to do a stimulant, a stool softener. Sometimes patients like to take fiber. What do you have to do if you take fiber? Drink water. … You have to drink so much water because that fiber will turn into cement in your colon. So do a combination.”

Besides pharmacological interventions, patients may also find benefits in increasing physical activity, trying to maintain usual bowel habits during hospitalization, and increasing fluid/fiber intake.

Sexual Side Effects

Approximately 50% of cancer survivors report ongoing problems with sexual functioning, Jakel mentioned during her presentation. Despite this high rate, Jakel mentioned her personal experience with how many clinicians discussed this side effect with her.

“I was a patient at UCLA for seven years,” she said. “How many providers do you think asked me? Now, a footnote, they were all my friends, they were all my coworkers. But in seven years, how many of them do you think asked me about sexuality and sexual function? Zero. … And I don’t think it’s different just because they’re my friends and they’re my coworkers. Nurses are really bad at it.”

The incidence of side effects can affect both men and women. In fact, 64% of women report no sexual desire, 48% report low desire and some women reported dyspareunia, or painful intercourse due to vaginal dryness, Jakel discussed.

Some contributing factors to this side effect include endocrine manipulation with aromatase inhibitors and tamoxifen, body image and early-onset menopause.

“We can recommend lubricants, but you should talk to your provider,” Jakel explained. “Even things that say they don’t contain estrogen sometimes have a pseudo-estrogen in their formulary. So you don’t want that to happen. And you can have some low-dose estrogen. Again, it depends on your type of cancer and a conversation [with your provider].”

Some side effects from endocrine therapy can include hot flashes, menopausal symptoms, blood clots (although rare), loss of libido, osteoporosis, joint pain and vaginal dryness. These side effects may decrease long-term adherence to oral endocrine therapies, but some approaches that may be helpful for joint pain include weight loss, acupuncture, exercise and integrative therapies like yoga. If the patient does not respond after two or three lines of therapy to address joint pain, a referral to a specialist may be needed.

“I remember sitting in a restaurant in Portland when I first started when I first started letrozole (Femara),” Jakel recalled. “I jumped around [treatments] because I had a recurrence. I was on letrozole crying because my knees hurt so badly. I thought it was the boots I was wearing. Talk about denial, ‘Oh, it must be these boots I have on.’ No, not so much.”

She added that an east-west medicine doctor she went to for acupuncture recommended tart cherry juice for the joint pain caused by aromatase inhibitors. Jakel said taking a supplement of tart cherry juice helped her joint pain a lot, but strongly urges a discussion with providers before considering this as an option.

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