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Ernest Rosenbaum, MD
Once you have had cancer, your life is never the same. Even for those, who are cured, which is now approximately 63% of cancer patients, the psychological and physical trauma of the cancer experience leaves short- and long-term lasting effects, both on the personality and approach to life, and it does temper some judgment decisions, as well as creating an appreciation for living in many. Today, approximately ten million Americans are cancer survivors, and this number is going to increase dramatically over the next few decades.
It is interesting that even years after the cancer experience, patients who survive often suffer delayed or late side effects of treatment, including infertility for many, memory and learning disorders and changes, premature aging, depression, heart disease for some, anxiety and emotional changes, including fear of when the next shoe will drop, and of experiencing the feelings of possible death.
Fortunately, the response rate for many cancers has increased dramatically, as well as the chance of being cured for breast, prostate, gynecological cancers, colon cancer and hematologic malignancies. Of note is that more children survive than adults.
Figures from the National Cancer Institute have shown the five-year survival rate has increased in older adults aged 50-85 more than any other group, and this represents about 70% of patients with cancer. Thus, many now consider cancer, in part, a chronic disease of the aged. This is reflected by the incidence of a 43% five-year survival in 1975 to 64% in the year 2002 for adults; whereas, children are seeing a five-year survival rate rising from 58% in 1975 to 82% in the year 2000. This is because of improvements in diagnosis, earlier detection, and newer innovative treatments.
There are several phases a patient goes through. Phase one is the symptomatic phase, which may take weeks, to months, or a year or more, depending on the severity of the symptoms. The second phase is the diagnostic phase, which usually takes days to a few weeks, when one or more tests give conclusive evidence of a specific cancer diagnosis. The third phase is the treatment phase, which can last anywhere from days, when surgery is the major treatment, to multiple weeks, depending on the length of radiation treatments, to months if chemotherapy or hormonal therapy is employed.
Following these phases, hope plays a major role. Depending on one's luck and good fortune, a cure or remission may be accomplished with an extended survival that may last a few to many, many years, depending on the durability of the remission/cure. Again, hope is tempered by fear and fate, as well as the supportive care programs that help nourish and kindle the will to live and hope.
In the meantime, side effects of either cancer and/or the various therapies employed cause side effects, such as fatigue, loss of appetite and weight, pain, nausea, and/or vomiting, etc.
During the four phases above, constant support is necessary to make life easier and feasible for the cancer patient. This support comes from family, friends and professional services that help one cope with the fears and anxieties during these phases, as well as during the months and years of the remainder of one's life. With time, there is improvement, and recovery does occur, although, life can never be quite the same. The doctor is the team leader, and the team consists of nurses, who are delivering a great deal of the primary care, along with physical therapists and nutritionists, clergy, financial planners, psychologists, all who play a role in cancer survivorship supportive programs.
Surviving through the first three phases of symptoms, diagnosis and treatment causes the patient, family and friends much anguish and problems frequently complicated by enduring side effects. In addition, despair and psychological problems, which had been before the cancer diagnosis and treatment, come to the forefront, making life more difficult. Issues include sexuality, additional problems due to age, the effects of chemotherapy, changes in body image, and pain.
It is important to plan for the future by taking care of all important affairs, including legal wills, ethical wills, directives, and family planning with a legacy of love.
Quality of life is affected by prolongation and persistence of therapeutic side effects and persistent morbidity.Contralateral breast cancers occur in 0.5-1.0% per year.
Side effects of surgery and radiation therapy include arm lymphedema, brachial plexopathy, resulting from direct damage of nerves, neurons, and gleocells from fibrosis and microvascular injury. This plexopathy not only affects sensory and motor function, but causes disability of the functions of the arm. Radiation pneumonitis occurs in 1-5% of women following breast cancer radiation. There is also cardiovascular damage of the microvasculature of the myocardium and coronary arteries, suffering endothelial damage and fibrosis. Lastly, we see occurrence of secondary cancers. Contralateral breast cancers occur in 0.5-1.0% per year. An estimated 10-15% of new cancers are truly secondary cancers. The two major types are acute myelogenous leukemia post adjuvant chemotherapy and myelodysplastic syndrome post-alkaloiding agent and/or radiation therapy with a three- to ten-year latency.
Adjuvant hormonal therapy reduces the rate of breast cancer recurrence by approximately 47% with a 26% reduction in the risk of death using Tamoxifen. At the same time, Tamoxifen, having estrogenic antagonistic effects, has caused an increase in endometrial carcinoma (4 times increased use of hysterectomy in such patients) but a stabilization or improvement in bone mineral density and a decrease in serum lipids, mainly in postmenopausal women. Spontaneous thrombosis is shown in a two-three fold increase.
Side effects of chemotherapy include not only chronic fatigue but premature menopause with ovarian failure, sexual dysfunction, cardiac dysfunction, cognitive dysfunction and secondary malignancies. The ovarian failure, in part, depends on age and use of certain chemotherapy drugs, such as the alkaloid agent, Cytoxan. There is an increased incidence for those over age 40 of approximately 70%, and 40% of those women under 40 receiving CMF. Paclitaxol is not associated with ovarian failure. In women under age 40, amenorrhea took approximately six to sixteen months, and in those under age 40, two to four months when treated with six cycles of CMF. Menopausal symptoms are due to a rapid decrease in estrogen levels, as well as infertility, bone loss and cardiovascular risks being more striking as compared to the gradual onset of menopause as a natural course in a woman's life history. Vaginal atrophy secondary to estrogen deficiency causes dryness, dysparunia, and atrophy of the urethral epithelium and bladder, resulting in genitourinary symptomatology. Some symptomatic aid is available through non-hormonal vaginal lubricants, such as Vagifem, Nordisk, Estring (Pfizer), and Premarin cream (Wyeth).
Vasomotor symptoms - hot flashes - are prevalent in about 70% of women during menopause. These include sleep disturbances, fatigue, irritability, depression, concentration difficulties, psychological and emotional symptomatology. Venlafaxine (Effexor), Fluoxetine (Prozac) may help reduce about 50% of the hot flash symptomatology. Transdermal Gabapentin, oral Clonidine and Bellergal (Novartis) are of help, although vitamin D has not been proven better than placebo.
Experimental methods to reduce infertility include prior embryo preservation, involving oocyte cryopreservation or ovarian tissue freezing, and are being evaluated for pregnancy post chemotherapy. Subsequent pregnancies have not been shown to alter prognosis, and postadjuvant chemotherapy has not been related to congenital anomalies. Newborns and children, as they grow, appear normal with typical development. It is wise to wait one to two years following adjuvant chemotherapy before conceiving, as many recurrences of breast cancer occur in the first two years.
About a 40% deficit occurs in cognitive function six months to ten years following adjuvant chemotherapy. Chemo brain is a term used by survivors to describe the cognitive defects.
- Cardiac toxicity is due to several types:
- 1) Anthracycline-induced 2) Acute-, chronic- and late-onset toxicity
- This is due to mild cardio damage and is directly related to cumulative dosage of anthracycline. When the dose is less than 300 mg/m2 minimal toxicity occurs in less than 1%. Approximately 26% of patients receiving over 500 mg/m2 anthracycline had cardiomyopathy and 48% with a dose over 600 mg/m2.
There are many entities in the complex of friends, family and people, who dedicate themselves in the fight against cancer. The medical team, working in conjunction with the patient, family and friends, enters into a battle where it's not just the inner strength, positive attitude and a support network, but the coordination of the complex group gives the patient a chance to overcome and survive cancer. There’s a saying, Do what's right, because it’s right.
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