Late Effects of Treatment in Cancer Survivors

What are the Long Term Side Effects of Cancer Treatment?

three women who are caner survivors
What late effects do cancer survivors experience?. istockphoto.com

As cancer survival rates improve, late effects of cancer treatment are becoming increasingly important.  These symptoms, at least one of which is present in more than half of cancer survivors, have received less attention until recently, as our focus has been on the treatment, and hopefully cure, of the disease. These conditions may persist and/or arise months, years, and even decades after treatment, and can significantly lower the quality of life for people who have survived cancer.

Since the 1970's there has been a 3-fold increase in the number of cancer survivors living in the United States, with an estimated 13,500,000 survivors in the United States in 2012, and 30 million survivors worldwide. In the United States, 3 percent of the adult population has survived cancer for 5 years or more. 

If you are wondering if you fit the definition of a cancer survivor, a survivor is defined as anyone who has been diagnosed with cancer - beginning on the day of diagnosis and continuing through the remainder of their life. What are some of these symptoms and conditions, and what help is available?

Heart Disease

Heart disease is a leading cause of illness and death among cancer survivors. This article focuses on adults treated for cancer, but it's important to note that people treated for cancer as children or adolescents are 8 times more likely to experience heart disease than people of the same age who have not been treated for cancer.

Several treatments for cancer can predispose to heart disease, and often people with cancer receive a few of these treatments combined. Some of the most common causes include:

Cancer treatments can affect the heart in different ways and result in different conditions. Some of these include:

Cardiomyopathy - Cardiomyopathy (weakness of the heart muscle) leading to heart failure is the most common cardiac side effect of cancer treatment.  Chemotherapy medications, especially drugs such as Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide) are not uncommonly associated with heart failure. If you were treated with medications in these categories, your oncologist may have ordered an echocardiogram to evaluate your cardiac ejection fraction prior to beginning chemotherapy.  

Radiation to the chest, for example for Hodgkin's disease, left-sided breast cancer, or lung cancer, is another important cause of heart disease. A study published in 2007 suggested that 10 to 30 percent of people treated with chest radiation are likely to experience heart disease within the next decade.

This study needs to be interpreted with caution, however, as newer radiation techniques (heart sparing techniques) that reduce radiation to the heart have been developed since that time.  

That said, heart failure can often begin with only vague symptoms such as fatigue, a decrease in endurance, swelling in the legs, or shortness of breath with activity. If you have received these medications or have had radiation therapy to your chest, ask your oncologist if she would recommend a cardiac consult. Some cancer centers now have cardio-oncology programs to address these concerns, especially if you have a personal or family history of heart disease, or other heart disease risk factors such as diabetes. And, even if you think your symptoms are nothing, it is always better to be safe than sorry when it comes to your heart.

Coronary artery disease - Some cancer treatments can damage the lining of heart vessels leading to premature heart disease. As noted above, this is especially true in children, adolescent, and young adult cancer survivors. 

Arrhythmias - Cancer treatments may also damage the "electrical system" of the heart resulting in abnormal heart rhythms (arrhythmias.)  If you experience lightheadedness, palpitations, or feel like your heart is beating slow or instead racing, make sure to let your doctor know.

Fatigue

While not as serious as heart disease, cancer fatigue is an all-too-common symptom affecting the majority of cancer survivors. In addition to the quality of life issues, fatigue may be a risk factor in lower survival. Cancer fatigue is difficult to understand if you haven't experienced it yourself; it's not the kind of tiredness that can be relieved with a good night of rest or a cup of coffee. Tension with loved ones may develop as your friends and family expect you to return to your pre-cancer self after treatment. If you are finding this frustrating, you aren't alone. Check out these tips for coping with cancer-related fatigue, and, better yet, print the article and hand it to family and friends who "just don't get it."

But first, have a good conversation with your doctor. There are some causes of fatigue caused by cancer treatments that may be treatable. One example is long-standing anemia following chemotherapy. Another example is hormonal changes. Radiation therapy to the head and neck can result in low thyroid hormone levels (hypothyroidism) which can cause or contribute to fatigue in addition to causing other symptoms. In contrast to hypothyroidism, chemotherapy may also result in hyperthyroidism (an overactive thyroid) which may cause weight loss, a tremor, and anxiety that can be severe.

There are many other causes of fatigue following cancer treatment, some that are treatable, others that are not, but your doctor will only know to examine you and order necessary tests if you speak up. If you have an overwhelming desire to cover your head with your pillow when your alarm announces morning, talk to your doctor.

Insomnia

Insomnia is common among cancer survivors and often persists for years beyond treatment. While this symptom may sound trivial to some, chronic insomnia not only reduces the quality of life but raises the risk of further physical and psychological problems. Research has found that cognitive behavioral therapy for insomnia (CBTI) can significantly improve this symptom for many people with cancer.

Peripheral Neuropathy

Peripheral neuropathy - damage to nerves leading to the arms and legs that are often permanent -  is a very frustrating late effect of cancer treatment. This condition affects roughly a third of people with cancer, and its incidence is increasing. Symptoms may include numbness, tingling, "pins and needles" pains, and cold intolerance typically found in a "stocking-and-glove" distribution. Decreased sensation in the hands and feet can interfere with simple activities such as buttoning clothes, or difficulty placing your feet, resulting in falls. Many chemotherapy medications can cause neuropathy, but most commonly occurs with drugs such as Platinol (cisplatin) and Taxol (paclitaxel.) Treatment often involves the use of medications such as topical gels, antiepileptic drugs, antidepressant medications, and sometimes narcotic medications for severe pain. Alternative therapies, such as massage, acupuncture, and guided imagery may offer significant relief for some people. Research is ongoing looking at ways to prevent neuropathy from occurring during chemotherapy.

Cognitive Impairment

Popularly coined "chemobrain," cognitive challenges following chemotherapy have received attention in recent years. Symptoms such as difficulty multi-tasking and difficulty concentrating may begin during chemotherapy and persist for months or years. Radiation therapy to the head and neck regions for head and neck cancers, brain tumors, brain metastases and prophylactic cranial irradiation (PCI) (used for some people with lung cancer) can also contribute to these symptoms. For some people, trying to focus on one task at a time, keeping lists to compensate for memory gaps, and doing "brain exercises" such as sudoku may be helpful. For others, consulting with a neurologist or psychologist may be recommended when symptoms are interfering with daily life.

Post-traumatic Stress Disorder

Post-traumatic stress disorder in cancer patients is another condition which has recently received more attention among cancer survivors. This condition, which is better known as occurring among those who have been exposed to war, or rape victims, for example, is thought to be present in as many as 35 percent of patients following treatment. The treatment for PTSD can involve several modalities, but the most important step is in recognizing this oft underdiagnosed condition in the first place.

Anxiety

While depression is no more common among cancer survivors than those who have not experienced cancer, anxiety is a significant problem. One study looking at almost 50,000 cancer survivors found that 18 percent of these people suffered from anxiety after treatment was completed. This anxiety did not appear to decrease with time, and, in fact, those who were 10 or more years out from treatment had an especially high rate of anxiety. A fear of cancer recurrence is one form of anxiety that is a concern that most, if not all cancer survivors experience from time to time.

If you are finding that anxiety is a concern for you, talk with your doctor. This symptom does not necessarily mean you need a prescription medication, and in contrast, alternative therapies such as acupuncture, massage, breathing exercises, and guided imagery, may help you cope with this symptom while benefiting you overall as well.

Infertility

Concerns about fertility may pale in comparison to the diagnosis of cancer, but are a very real concern for young adults with cancer. These articles discuss how cancer treatments may affect fertility for both men and women.

Osteoporosis

Many chemotherapy and hormonal treatments can lead to bone loss. This, in turn, can lead to fractures. It's important to talk to your doctor about measuring your bone density if this has not been done, as well as checking your vitamin D level, as a vitamin D deficiency can lead to osteoporosis as well as other conditions. In addition, some research suggests that for some cancers the risk of recurrence may be lower for people who have adequate vitamin D.

Sexual Dysfunction

Sexual dysfunction is a very common, and equally frustrating problem among people who have survived cancer. Cancer can cause physical and hormonal changes which limit sexual enjoyment, and of course, the emotional upheaval which plays upon these physical changes. This article on nurturing your sexuality during cancer treatment discusses some of the causes, as well as tips for enhancing your sexuality post-treatment that you may not have crossed your mind.

Secondary Cancer

Many cancer treatments are designed to damage the DNA of cells in order to cause the death of cancer cells. Unfortunately, normal cells are often affected in the process, which can result in the development of cancer years and decades later. Chemotherapy, especially drugs such the alkylating agents, for example, Cytoxan (cyclophosphamide,), topoisomerase inhibitors (for example, Etoposide), and anthracycline agents (for example, Adriamycin (doxorubicin) pose the highest risk of secondary cancers. Radiation therapy may also predispose to secondary malignancies in the future. It's important to keep in mind that the risk of these cancers usually pales in comparison to the benefits of these treatments in treating primary cancer.

Other Late Effects

Cancer treatments can affect nearly any region or organ system in the body. Lymphedema, kidney damage, pulmonary fibrosis, tooth decay, hearing loss, and cataracts, to name only a few concerns, are more common among those who have survived cancer than among the general population.

Being An Advocate for Yourself After Treatment - Your Survivorship Care Plan

It's very important that oncologists and primary care physicians work together to form a smooth transition for cancer survivors. Many oncologists work with their patients to complete a "survivorship care plan" which reviews follow-up information, symptoms to watch for, and other information for survivors going forward. If you don't have a survivorship care plan, ask your oncologist to work with you to complete one. Here is an example of a template of a care plan developed by the Minnesota Care Alliance, It can't be stressed enough how important it is to have copies of your medical records on hand to carry with you.  

Since the concept of "cancer survivorship" is relatively new, many cancer survivors still find themselves falling between the cracks after treatment. More than once I've heard the remark that someone was dismissed by their oncologist, leaving them with the feeling that they should just be thankful that they survived. But as noted above, the majority of people who have survived cancer have some lasting effects. It's important that any issues you have are addressed - but the only way that medical professionals will know of your concern is if you speak up.

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