Life after breast, prostate, and colon cancer: Primary care’s role

HEALTH PROMOTION

Maintaining a healthy body weight and a nutritionally balanced diet should be encouraged in all cancer survivors. Poor diet, lack of exercise, excessive alcohol consumption, and smoking reduce quality of life and increase the risk of cancer.²

Diet

Numerous studies have looked at dietary modifications and risk reduction, and although there is no consensus on specific dietary guidelines, there is consensus that diet modification to maintain normal body weight will improve overall quality of life.⁸ Patients should be encouraged to consume a well-balanced diet consisting mostly of fruits, vegetables, whole grains, and beans, and to limit consumption of animal protein.⁸

There is little evidence to support taking vitamins or other dietary supplements to prevent or control cancer or to prevent its recurrence. The primary care physician should assess supplement use on a regular basis during office visits.²

Exercise

Rest is an important component of the initial recovery process. Too much inactivity, however, leads to loss of physical conditioning and muscle strength. This in turn may negatively affect a patient’s ability to perform activities of daily living and may worsen fatigue associated with treatment.

Accordingly, the National Comprehensive Cancer Network recommends at least 150 minutes of moderate activity and up to 75 minutes of more rigorous activity divided throughout the week.^2,8 The regimen should include endurance and muscle strength training, which aid in balance, bone, health, and functional status. The intensity of exercise should be increased in a stepwise fashion, taking into account individual capabilities and limitations.²

Cancer survivors may need specific exercise recommendations and supervised programs to ensure safety and limit long-term side effects of their treatment. For example:

Patients with neuropathy should have their stability, balance, and gait assessed before starting a new program. These patients may benefit from an aerobic exercise program that includes riding a stationary bike rather than running.

Patients with poor bone health should have their fracture risk assessed.

Those with an ostomy bag should empty the bag before physical activity. They should avoid contact sports and activities that increase intra-abdominal pressure.

Patients suffering from lymphedema should wear compression garments when engaging in physical activity. They should undergo baseline and periodic reevaluation of the lymphedema and initiate strength training in the affected body part only if the lymphedema is stable (ie, no need for therapy for 3 months, no recent infections requiring antibiotics, and no change in circumference > 10%).²

Mental health

Health promotion should focus not only on the physical health of the patient, but also on his or her emotional and psychological well-being. As they make the transition from cancer patient to survivor, many individuals may develop or have worsening depression and anxiety due to fear of recurrence. These feelings of powerlessness can linger for years after the initial treatment.

Patients should be screened regularly for signs and symptoms of depression by asking about their family and social support. Referral to support groups, psychologists, and psychiatrists may be warranted.⁹

MITIGATING CANCER-RELATED FATIGUE

Cancer-related fatigue involves a patient’s subjective sense of physical, emotional, and cognitive exhaustion related to cancer or treatment that is disproportionate to that expected from recent daily activity.² Fatigue is a common complaint among survivors and can occur months to years after treatment ends.¹⁰

Patients should be screened for fatigue at regular intervals. The primary care physician should focus the history to include information regarding the onset, pattern, duration, associated factors, assessment of other treatable comorbidities, medications, psychological well-being, nutritional status, and pain level of each patient who complains of fatigue.

Laboratory tests for treatable causes of fatigue include:

• A complete blood cell count to evaluate for anemia
• A comprehensive metabolic panel to evaluate electrolytes, renal function, and hepatic function
• The thyroid-stimulating hormone level to evaluate thyroid function, particularly in breast cancer patients who have received radiation therapy.²

If no organic cause is uncovered, the focus should shift to lifestyle interventions as the treatment of choice. The treatment of fatigue in this situation is increased physical activity with the goals discussed above. Psychological intervention may be required with cognitive behavioral therapy, psychological and supportive therapies, education on sleep hygiene, and possible sleep restriction.

If alternative causes of fatigue are ruled out and physical and psychological support fails to reduce symptoms, the practitioner can consider a psychostimulant such as methylphenidate, but this should be used cautiously.²

SEXUAL DYSFUNCTION

Intimate relationships and sexuality are an important part of life and are affected by a variety of factors including physical health, psychological well-being, body image perception, and overall status of relationships. As a side effect of chemotherapy, cancer survivors may complain of erectile dysfunction, penile shortening, dyspareunia, vaginal dryness, decreased libido, anorgasmy, and changes in body image. These issues are frequently unaddressed, whether due to the physician’s discomfort in discussing the topic or to the patient’s embarrassment and reluctance to discuss the matter.¹¹

Breast cancer patients may experience sexual dysfunction both during and after treatment due to a combination of systemic effects of treatment, changes in physical appearance leading to impaired body image, strains on partner relationships, and psychological sequelae of diagnosis and treatment of cancer.¹² Manipulation and radiation to the breast affect sexual functioning by altering body contour and image. Additionally, chemotherapy can lead to early menopause and hormonal alterations due to endocrine therapies, which can negatively affect sexual organs.¹¹

Studies have shown that treatment with tamoxifen causes less sexual dysfunction than do aromatase inhibitors. In the Arimidex, Tamoxifen, Alone or in Combination trial, therapy with anastrozole was associated with more vaginal dryness, dyspareunia, and decreased libido compared with tamoxifen.¹²

Treatment requires a comprehensive history, a physical examination, and a discussion of relationship satisfaction with the patient.

Vaginal dryness and dyspareunia can be treated with vaginal lubricants and moisturizers. Moisturizers are effective if used multiple times per week, whereas lubricants can be used on demand. Low-dose vaginal estrogen preparations can be used in select patients with severe vaginal dryness; the goal should be discussed. Hormone replacement therapy is contraindicated in breast cancer survivors due to the risk of recurrence.¹¹

Prostate cancer survivors. Up to 70% of men felt their quality of life and sexual function were adversely affected after the diagnosis and treatment.^13,14 Erectile dysfunction following radical prostatectomy and radiation therapy remains one of the leading causes of sexual dysfunction.^14–15 Erectile dysfunction is multifactorial, with both psychogenic and organic causes. Comorbidities must be considered including hypertension, diabetes, hyperlipidemia, and smoking. Early penile rehabilitation is a proposed treatment strategy.¹⁴

First-line therapy for penile rehabilitation includes introduction of daily low-dose phosphodiesterase type 5 inhibitors as early as the time of catheter removal to within the first month after surgery. The need for daily dosing vs on-demand dosing has been controversial.¹⁵ Two large multicenter, double-blind studies had conflicting outcomes. The first reported that in men receiving nightly sildenafil (50 or 100 mg) after radical prostatectomy, 27% had increased return of spontaneous erectile function vs 4% with placebo¹⁶; the second study showed no difference between nightly and on-demand dosing.¹⁷ The consensus is that a phosphodiesterase type 5 inhibitor should be initiated early.

Second-line therapy includes intracavernosal injections and vacuum erection devices. Finally, a penile prosthesis implant can be offered to patients who have responded poorly to medical therapy.¹³

Colorectal cancer survivors suffer from sexually related problems similar to those stated above, including erectile dysfunction, ejaculation problems, dyspareunia, vaginal dryness, and decreased enjoyment.¹⁸ These patients should be provided treatments similar to those described above. In addition, they may suffer from body image issues, particularly those with a permanent ostomy.⁹

Sexual dysfunction is a multifaceted problem for patients. Encouraging couples to discuss sexual intimacy frequently helps to reveal and cope with the problems, whether physical or psychological. It is the primary care physician’s role to recognize any sexual concerns and refer to the appropriate specialist.