From Mark Levine, the Doc with Pink Tights

The New Norm – Part III

In my last article about the “new normal,” I indicated I would discuss several cases to illustrate issues that can arise in women who have completed their primary treatment and are continuing on with their lives.

Some may have completed their treatment within the last 12 months, while for others the breast cancer was treated five years previously. For some, the breast cancer is a distant memory, while for others, it is never far from mind. Below is an example:

A 34-year-old teacher has undergone chemotherapy, a mastectomy and radiation six months ago. Her hair is growing back, her energy level has improved, and she has tingling in her fingers. Her periods have stopped and she is suffering from hot flashes. She has a two-year-old daughter and a very supportive husband. She has gained 15 pounds since she first was diagnosed with breast cancer. She is hoping to go back to work in a few weeks, but is not sure she will be able to manage.

There is no doubt that this individual’s life has been disrupted by the cancer experience. She has a supportive family, which is very important in her recovery. In a young woman with breast cancer, issues of intimacy, body image, and fertility arise.

The woman in the scenario has undergone premature menopause. She suffers from vaginal dryness and pain on intercourse. Her partner is patient and loving. In the last visit to the cancer centre, they talked with the nurse about the issues around sexual relations. The nurse explained that during the cancer treatment, there is often a lack of interest in sex because of side effects and low energy.

However, as physical wellbeing improves, so does energy and potential interest in sex. The nurse recommended lubricants such as Replens. Sometimes, this is not enough. Then, interventions that supply estrogen to the local vaginal area are sometime discussed, such as Vagifem and Estring. The former is a tampon with estrogen that is inserted several times per week in the vagina and the latter is a ring that is inserted in the vagina and lasts about 12 weeks.

Women often wonder whether any of the estrogen can leak into the blood stream and cause cancer cells to grow. I tell them I don’t think so, but I am not 100% sure. For many of these women, any doubt steers them away from these approaches. I encourage patients to raise issues of sexuality with either me, my nurse or with their family physician.

Young breast cancer patients of childbearing age often must deal with the issue of fertility and having children. Chemotherapy will often cause menopause, sometimes temporary and sometimes permanent. The patient in the scenario already has one child, but perhaps she and her husband had wanted another child. I think of this as a “loss” for the patient which can result in sadness and depression.

A woman should not be afraid to discuss this issue, which is very personal, with her care team. Although this will not reverse the biologic processes that have resulted in infertility, recognizing that it is an issue and discussing it can help the patient cope.

Finally, I would like to touch on the issue of body image. Our patient has had a mastectomy and has gained weight. This can lead to low self-esteem, lack of energy and depression.

My nurse or I will ask the patient how they feel about themselves. Will they look at their chest in the mirror? Do they show their partner the surgical scar? Breast reconstruction is a topic for a future article.

I will talk to the patient about not being overweight. I gently point out that there is some scientific data that suggests that women who have had breast cancer and are overweight have a higher risk of their cancer coming back.

I will encourage patients to exercise, such as walking, swimming, going to the gym. I recommend a healthy diet and will encourage the patient to meet with a dietician if she is interested.

Returning to our case, the patient is anxious about returning to work and the stress of teaching. What she is not saying is: “Will the stress of work cause my cancer to return?” My answer is categorically “NO!” A lot has been written about the relationship between stress and cancer, but there is no evidence that there is an association.

Teaching is stressful and I would encourage the patient to return to work part-time and then gradually increase her hours to fulltime. This will allow her to gain confidence and cope with a significant change in her life.