More than 60 percent of breast cancer survivors report at least one treatment-related complication even six years after their diagnosis, according to a new study led by a researcher from the Perelman School of Medicine at the University of Pennsylvania. The findings are part of a special issue of Cancer devoted to exploring the physical late effects of breast cancer treatment and creating strategies to prevent, monitor for, and treat these conditions in the nation's 2.6 million survivors of the disease.
"Our work provides the first accounting of the true magnitude of the post-treatment problems suffered by breast cancer patients, and serves as a call to action for proper monitoring and rehabilitation services to care for them," said Kathryn Schmitz, PhD, MPH, an associate professor of Biostatistics and Epidemiology who serves as a senior scientist on the committee overseeing creation of a surveillance model for breast cancer survivors. "We can no longer pretend that the side effects of breast cancer treatment end after patients finish active treatment. The scope of these complications is shocking and upsetting, but a ready solution for many of them already exists in rehabilitative exercise."
Schmitz, a member of Penn's Abramson Cancer Center, points out that previous studies to determine the prevalence of post-treatment complications typically examined just one issue. The new findings, instead, provide a full snapshot of the complications women may experience following the chemotherapy, surgery, radiation treatment and hormonal therapy to cure their disease and keep it from returning. The results reveal that these problems rarely exist in isolation: Many women with the painful limb-swelling condition lymphedema, for instance, may also struggle with fatigue and bone health challenges.
Schmitz collaborated with an Australian research team to follow 287 Australian women with invasive, unilateral breast cancer for a median of 6.6 years, prospectively assessing the women for treatment-related physical and functional complications at set points throughout the study. Areas of study included postsurgical complications, skin reactions to radiation therapy, upper-body symptoms and functional limitations, lymphedema, weight gain, and fatigue. Sixty percent of the women were still experiencing one of these problems at six years after their diagnosis, and 30 percent were still struggling with at least two issues. Most of the problems appeared within the first year patients were assessed, but the prevalence of most impairments except lymphedema and weight gain -- decreased over the course of the study.
Writing in the lead editorial of the special issue of Cancer, Schmitz and her colleagues outline the myriad barriers that lay in the way of properly monitoring breast cancer survivors for the problems uncovered in the new study. Patients may have fragmented care, receiving different prongs of their treatment at different hospitals; patients and providers may believe certain problems are "expected" and "normal" and not appropriate for treatment; and unlike orthopedists and cardiologists who frequently send patients for physical rehabilitation to ensure their complete recovery, oncologists and surgeons are often poorly linked to physical therapy professionals, limiting the number of patients who are aware of or referred for these services.
In the face of these challenges, an expert panel laid out a model for prospectively surveying breast cancer survivors and formally incorporating rehabilitation and exercise experts into cancer survivorship programs. Research increasingly shows that post-treatment complications can be minimized and even prevented altogether when caught early and addressed through various rehabilitation regimens. "When early signs of impairment are noted and that impairment has a high probability of worsening if allowed to progress, which ultimately may result in a worse, permanent disability, there is an ethical obligation to treat the condition," they write.
The question of how best to implement the proposed rehabilitation and surveillance remains to be addressed. The panel plans to work through the American Cancer Society with stakeholder groups to answer questions about how to educate patients and clinicians about the plan and fully implement it. The American College of Surgeons Commission on Cancer has published guidelines that will require that all accredited cancer treatment centers provide treatment summaries and survivorship health care plans to all their patients by 2015. The proposed surveillance and rehabilitation model could serve as a framework for meeting those pending guidelines. "In the meantime," Schmitz says, "breast cancer survivors should be empowered to ask their doctor for a referral to physical therapy and exercise programs."
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