One expert discusses how cancer and its treatments can have many lasting side effects on patients, from depression to peripheral neuropathy.
Cancer and its treatments can bring with it a number of side effects – from depression and fatigue to the infamous “chemobrain.” As more patients are continuing to live longer after their treatment, it is becoming apparent that these effects can last well into survivorship .
Matthew Carlson, M.D., an assistant professor at UT Southwestern Medical Center, recently sat down with OncLive , a sister publication of CURE , to discuss the long-term effects that chemotherapy and other cancer treatments can have on individuals.
Let’s talk about depression. What can health care providers do better manage this?
Carlson: I think it’s important having a high index of suspicion. The NCCN guidelines recommend screening patients who are in surveillance for depression. So, you should ask them, "In more days than not, have you had low mood or trouble sleeping or basic depressive symptoms ?" And those simple screening questions can then prompt us to dig a little deeper and hopefully help the patient with the depression, because that can have long-term effects as well.
Do you feel that this is being done often enough?
The answer to that is unfortunately probably not. We probably don’t screen just because we see the surveillance patient, we ask them how they’re doing, and unless they bring it up, at least for me personally, I don’t do it as often as I should, I’ll admit. But it’s something that I’ve paid more attention to, and we’ve considered adding some screening questionnaires to our practice.
Another common long-term effect is fatigue. Can you discuss some strategies to handle this?
Fatigue is common in post-menopausal women, it is common in patients who have cancer and in patients who had chemotherapy. It’s also common in patients with heart and thyroid disease and anemia, and all sorts of other things.
When a patient complains of fatigue, we have to dig a little bit and get to the root of what’s causing that because it may not just be from the chemotherapy. It may be from thyroid disease or depression or poor sleep and diet. It may be from any number of things that we can actually fix. That’s why this is an important side effect to pay attention to.
Now, if we rule out all those other things, there are some medications we could use to help with giving them a little bit more pep. That’s actually something like methylphenidate, which they use for kids with ADD, but it really does give patients a lot more energy. There are some other less-proven things, like American ginseng, that actually has some good data behind it, but it’s not approved [by the Food and Drug Administration (FDA)] or regulated by the FDA.
In terms of neuro-cognitive dysfunction, is there any research about the benefit of cognitive behavioral therapy?
Neuro-cognitive dysfunction, or chemobrain , is a little bit difficult to figure out. The assessment tools don’t always correlate well with what the patients complain of. Cognitive behavioral therapy can help patients with their quality of life, but the studies don’t really pan out as well as far as the objective measurements. But in my estimation, if the patient is happier and feels that her quality of life has improved, then I’m happy.
You also mentioned peripheral neuropathy. What is currently being done in this space?
That’s a big one. We use a lot of taxanes in our treatments, and one of the things that we very commonly see during treatment is peripheral neuropathy . In a good proportion of patients, it doesn’t go away. Unfortunately, there are a lot of small studies or retrospective studies on a whole host of different treatments or preventative measures to try to either reduce those symptoms after the fact or to prevent them altogether. Unfortunately, we haven’t found anything that really pans out.
In our practice, we are very fortunate to have a physical medicine and rehabilitation physician. That’s her focus. So, we’re able to send a lot of patients to her, and in talking to her, she oftentimes will recommend some specific physical therapy exercise and refer them to a physical therapist. There is some data to show that it improves the outcomes – it decreases the falls and increases patients’ quality of life on survey scores. Anecdotally, I’ve seen patients leave pretty happy, but for some patients it doesn’t work quite as well.
What are the glaring challenges here in terms of symptom management?
It’s a chronic thing. It’s very bothersome to have constant pins and needles in your hands and feet. There’s even numbness, where patients can have trouble doing activities of daily living, such as fastening buttons or putting in earrings and things of that nature. That really becomes somewhat bothersome, and it can even become dangerous if they have a lot of numbness in their feet and don’t feel the ground under their feet and then are subject to fall.
It is a big issue and, unfortunately, not a lot is being done. I think they are actively looking at different agents to decrease the risk – things that we can give during chemotherapy to reduce the incidence of that during chemo, and therefore would very likely decrease it after as a long-term side effect. But progress has been slow. Patients With Gynecologic Cancers Want to Discuss Sexual Health
Nearly 90 percent of women experienced sexual dysfunction; however, providers were not openly communicating about this side effect, according to survey results.
Radiation therapy to the pelvis is commonly used to treat women with gynecologic cancer, but it comes with side effects that can affect quality of life, especially disruptions to sexual health.
Vaginal dryness, vaginal irritation, vaginal scar tissue, yeast infections and infertility are a few effects that patients can experience, all of which can affect intimate relations . However, these concerns are not always addressed by health care providers.
To better understand communication and sexual dysfunction in women after radiation therapy, researchers surveyed 75 patients from the Department of Radiation Oncology at Michigan Medicine who had received a diagnosis of endometrial, cervical, uterine, vulvar or vaginal cancer. Most of the women were white, married, heterosexual and Christian. They were asked about their attitudes/beliefs surrounding sexual health, quality of life and sexual function.
“The perception is that for patients (gynecologic cancer), sexual health is not as important because they are just happy that their cancer has been dealt with,” Shruti Jolly, M.D., associate professor, associate chair of community practices and chief of brachytherapy services at Michigan Medicine, said in an interview with CURE . “I think more and more (people), especially women, are focused on long-term quality of life, and sexual health is a major part of that because it not only affects them but also affects their partner. They want to have these discussions and if the provider isn’t open then they don’t happen.”
Researchers found that most women (89.8 percent) experienced sexual dysfunction. In addition, a majority (78.7 percent) felt that sexual function is an important part of overall health.
However, the survey results also showed a lack of communication between providers and patients. Of women who saw a primary care physician, 58.7 percent reported never or almost never being asked about their sexual health. Only 4 percent reported always or almost always being asked. Compared with women who saw an OBGYN, 22.7 percent said they never or almost never were asked about their sexual health and 17.3 percent reported being asked always or almost always.
However, 62.8 percent of patients felt providers should inquire about sexual health regularly. And surprisingly, most women surveyed did not feel embarrassed to talk about sexual health — 12 percent reported embarrassment around provider discussions.
“Sexual health cannot be ignored, and it is quite complex. It’s not just about intercourse,” Jolly said. “Increasingly cancer centers are providing sexual health services like we do at the University of Michigan. We routinely refer patients — sometimes before treatment — to talk about what to anticipate.”
Women should make it known that sexual health is a major concern and try their best to have open communication with their health care team, Jolly explained. “This is a very common concern,” she said. “Providers aren’t routinely educated on how to talk about these issues and that puts more pressure on the patient to bring up these discussions.”
Researchers concluded that educating patients and providers is a necessity. “Patients need to feel empowered to push these discussions forward,” Jolly said.
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