v4n3 - Now What?

Long-term cancer survivors not only need an internist for non-cancer-related issues but they also need an awareness that cancer treatment can bring about its own health issues, some of which are only now emerging in populations that received certain treatments years ago.

Jane Reese-Coulbourne was 36 when she was diagnosed with stage 3B breast cancer in 1990. Because it was clear from physical examination that there was significant lymph node involvement, she chose to bypass surgery and go directly into a dosing clinical trial at the National Cancer Institute. She received the protocol of drugs “to tolerance” and gave herself a daily injection of a drug to keep her blood counts up. By the end of the trial she had received 100 units of blood products.

She also achieved complete remission—never undergoing surgery because the tumors disappeared midway through the 10 rounds of chemotherapy. So, after eight weeks of radiation, Reese-Coulbourne was sent home with a prescription for Nolvadex® (tamoxifen), which she took for five years.

Breast cancer was behind her, but the lingering effects of treatment were not. She noticed her eyesight was not as good as before treatment. “Then I had a problem with my teeth breaking. I had never had a filling but now my teeth were breaking.”

At that point Reese-Coulbourne was working at the NCI with then-director Richard Klausner, MD. She researched potential causes of her teeth breaking and decided it must be related to the hormonal effects of going into menopause at 36. But eventually, Reese-Coulbourne says, most of the side effects resolved.

Then during a checkup in 1997 her blood sugar came back elevated. She started taking an oral medication for diabetes and her blood sugar returned to normal. Then a few years ago it spiked again, but this time nothing kept it in check. Her internist told her it behaved more like type 1 diabetes, usually diagnosed in children and young adults, rather than adult-onset type 2.

“They called it type 1.5 and my doctor referred me to an endocrinologist at Georgetown University Medical Center who basically said he was seeing people like me all the time—people who had high-dose chemo and diabetes as a late effect. They didn’t know why it was happening, but Georgetown did a number of bone marrow transplants and he had begun seeing this form of diabetes in those survivors.”

Reese-Coulbourne, who now works as a cancer consultant, had not heard of diabetes being a side effect. Her oncologist also had not heard of the connection. And, to date, the connection remains anecdotal, meaning no studies have been conducted to determine the connection or the cause.

The lack of research into such issues can be frustrating for survivors like Reese-Coulbourne, because, while long-term follow-up care clinics exist for survivors of childhood cancer, few programs explore long-term issues for adult survivors, most having only appeared in the past four or five years—many as a result of grants from the Susan G. Komen Breast Cancer Foundation and the Lance Armstrong Foundation. For more information and to find a program near you, go to www.livestrong.org and click on Progress.