Every step of the way

Palliative medicine or palliative care is specialised medical care aimed at improving quality of life not only for the person with a serious illness, but also for their families. Traditionally this focused on care in the advanced stages of disease that could no longer be treated. We now know that palliative care is appropriate at any stage of illness and can be provided along with treatment that is meant to cure.

Being diagnosed with breast cancer is scary because decisions regarding treatment have to be made and family and friends have to be informed. Sometimes there is the added financial burden of treatment costs and lack of income due to the loss of working hours. During this time symptoms of depression and anxiety can be overwhelming. Added to this, treatment side effects like nausea, vomiting, fatigue and hot flushes can be debilitating.Worries about the future, your body image and sexuality can compound physical problems.

Palliative care deals with all of these issues and considerations. A good medical support team will be able to address these problems and ease the burden of suffering for someone who was recently diagnosed with breast cancer.

Helpful hints to tackle common problems

Hot Flushes

Anyone who has had a hot flush will tell you that these can seriously affect your quality of life, especially if they occur in rapid succession or wake you up at night. After a breast cancer diagnosis, hot flashes may appear for two reasons:

• Abruptly stopping hormone replacement therapy, once cancer

is diagnosed.

• As a result of the therapy itself, like Tamoxifen or Zoladex.

We know that estrogen provides the most effective relief from hot flushes but of course, after a diagnosis of breast cancer, this cannot be used.

Non-hormonal/lifestyle solutions

1. Learn to recognise and avoid triggers.These can be different for every woman, so learn what triggers yours and then avoid it. Examples are: anxiety, anger, alcohol, caffeine, spicy food, hot showers, smoking or overheated areas.

2. Keep your core temperature as cool as possible. Warm air increases a woman’s core body temperature and is more likely to trigger a hot flush. Try this:

  • Dress in layers with clothes made from natural fibres like cotton that absorbs moisture from the skin.
  • Sleep on cotton sheets with one foot uncovered.
  • Keep a bottle of cool water handy.
  • Carry a fan with you.
  • Take a cool shower before bed.
  • Keep a frozen pack under your pillow and turn the pillow often.
  • Invest in air conditioning or a ceiling fan.

3. Maintain a healthy body weight. According to research, a body mass index (BMI) of 27kg/m2 or more is associated with a greater frequency of hot flushes.

4. Stop smoking.

5. Daily exercise is associated with fewer hot flushes and also shorter duration of hot flushes. Be careful though, strenuous exercise can trigger hot flushes if you are unfit by raising your core temperature. So start slowly and increase the level of exercise gradually.

6. Practice relaxation techniques. Anxiety is associated with more severe hot flushes. Try yoga, meditation or breathing exercises.

7. Non-hormonal medications your doctor can prescribe. These are:

Clonidine: a blood pressure pill that may work.

Antidepressants like fluoxetine (Prozac) and venlafaxine (Venlor).

Anti-seizure medication like gabapentin.

Anxiety/depression  

Before considering medication to tackle this, join a breast cancer support group in your area. Studies have shown that support groups that share experiences openly and honestly, are associated with increased survival and decreased tumour recurrence rate. A support group is a safe place to learn how to ask for what you need or even discover what those needs are in the first place.

Demystifying breast cancer and informing yourself about treatment options and side effects can go a long way to alleviate the anxiety generated by the “unknown”. Rally the support of loved ones. Spend time with them and be affectionate. Hugs release oxytocin and endorphins (hormones) which make us feel good. Discuss fears around body image and sexuality with your partner. Be guided by similar experiences of other cancer survivors. Don’t be afraid to be open and frank. Live each day to the fullest. Take time to appreciate everything around you and savour it.

Be careful when taking antidepressants. In the right circumstances using this type of medication can lead to remarkable changes in your quality of life. However, some antidepressants including Paxil, Wellbutrin, Prozac, Cymbalta and Zoloft can interfere with the body’s ability to convert Tamoxifen into its active form preventing you from getting its full benefit.

Sexual dysfunction 

The most common problems encountered are vaginal dryness, painful intercourse and loss of libido or sexual desire. These symptoms are more likely to be present if Tamoxifen or Arimadex are part of the treatment plan.

Difficulty in becoming aroused and reaching orgasm is a frequent complaint. Loss of desire may be directly related to lower estrogen, progesterone and testosterone levels brought on by breast cancer treatment. Also, other factors may contribute to difficulty with “feeling sexy”, especially hair loss from chemotherapy, weight gain, tiredness, nausea and the psychological stress experienced from a diagnosis of breast cancer.

If you are having problems with sex, you might want to try downplaying the importance of orgasm at least for a while. Try concentrating on the pleasure from touching, kissing and imagery rather than on orgasm. Placing less emphasis on having vaginal orgasm may actually allow it to happen sooner than expected.

For most women with breast cancer, estrogen and progesterone supplementation to improve sexual problems are not recommended. It is not clear if testosterone replacement therapy is completely safe because this hormone can be converted to estrogen by the body. Discuss this issue with your doctor, if you continue to struggle with low libido. In some instances, if testosterone levels are very low, small amounts of supplementation can be used.

Painful intercourse can destroy interest in sex faster than anything else. This can result from painful vaginal ulcers caused by certain kinds of chemotherapy (5-fluouracil), infections related to antibiotic or steroid usage and also from low estrogen levels due to Tamoxifen or Zoladex treatment.

Water-based or silicone lubricants such as K-Y jelly or Astroglide can improve dryness and pain.Vaginal moisturisers (such as Replens) hydrate the tissue when inserted into the vagina, at least three to five times per week. These lubricants assist in improving dryness, itchiness, elasticity and irritation.

Counselling and sex therapy can be useful in helping you understand the impact a breast cancer diagnosis will have on sexuality. It certainly helps if your partner is actively involved in these discussions as well.

Some studies suggest strengthening the pelvic floor to increase blood flow to the pelvis may be helpful in improving arousal and may even have possible restorative effects. Stratergies for addressing pain and promoting pelvic floor health include pelvic floor exercises and the use of vaginal dilators to improve elasticity.

The safety of vaginal estrogen is unknown. While it is clear that lowering estrogen levels is ideal to prevent cancer recurrences, the absolute estrogen level to minimise risk is unclear. Clinical trials investigating this issue are currently underway. At present, vaginal estrogen is prescribed under special circumstances.

 

MEET THE EXPERT

Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog “vaginations by Dr E” on www.vaginations.co.za

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