SURVIVORSHIP IN BREAST CANCER AND POST TREATMENT CHALLENGES

Dr Syapiq Long is an early career medical oncologist. He graduated from the Royal College of Surgeons in Ireland and moved to Australia in 2015 to complete his training in medical oncology.

He is currently working as a joint fellow at the Calvary MARTA and Breast Cancer Trials in Newcastle. And we spoke with him about survivorship and some of the challenges that patients face after completing their treatment.

“So today my talk will be about survivorship. And just briefly I think it’s becoming more relevant in this day and age, particularly with the increasing number of breast cancer survivors. We’re seeing the oncologists, and all of the doctors are doing so well at picking up breast cancer early and our improved treatments to the fact that we’re having increasing number of breast cancer survivors.”

“But also, I think there are some overlooked issues that cancer survivors can have that maybe we need to bring some awareness about, and that’s why I’m doing the talk today about it.”

What are some common challenges that breast cancer survivors face after completing their treatment and how do these vary from individual to individual?

“I suppose certainly there’ll be a huge variation as to the individual experience particularly around the challenges that the survivors have. But overall, the challenges are broken up into physical, social, and psychological challenges. And I do feel genuinely that some of this is an area of unmet need.”

“Most survivorship care involves us as oncologists treating the physical aspects of long-term effects of treatment, but rarely I think are the psychological and social aspects dealt with, in a comprehensive manner. And that’s down to various issues, particularly healthcare systems and the limited capacity and resources to deal with them.”

“But some of the physical challenges, for example, things like the menopausal symptoms that come with the treatments, chemotherapy and hormonal therapies, things like heart flutters, weight gain, night sweats, fatigue or tiredness from the treatments that they have.”

“Also, some of the sexual issues that come with the treatments, sometimes the loss of the ability to have a child and become pregnant, or some of the physical issues. That’s just skimming the surface, obviously. But some of the psychological issues as you can appreciate are the anxiety that comes with treatment, and the mood related problems that come with feeling low and depressed from having such a diagnosis, as well as the fear that cancer can come back at any time.”

As you can appreciate also, this will impact the individual socially, the relationships that you might have and your ability to continue to work. And so, I think we probably don’t deal with enough with these psychosocial issues as well as we should do. And I think that it’s good to bring awareness to them.”

How can a treatment team best support breast cancer patients who participate in clinical trials, especially in addressing the challenges that they face post treatment?

“Trial coordinators are probably the primary people that will make contact with participants who have completed their treatment, and these are the cancer survivors. And, you know, they will usually be the first ears that will hear all the problems that patients have been facing. And I think they are a good point of contact to, as their name suggests, they coordinate the care for patients.”

“So, finding out about their problems, identifying it, and then bringing it to the attention of the relevant teams, be it the oncologist, the general practitioner, or other health disciplines that might be able to assist, including physio, exercise physiologist, social worker, etc.”

“But obviously that’s all down to the resources that are available at the center that’s involved. But it’s a call of action for trial coordinators to be aware about all these issues so they can take initiative.”

What are some strategies or resources that trial coordinators can implement to best assist breast cancer survivors when coping with issues like fatigue, anxiety, fear of recurrence?

“I think initially patients will come out and I’ll tell you about all these problems. I suppose most of the time things like fatigue, anxiety, fear, recurrence, you know, a lot of it can be dealt with, through self-management strategies and things that we do all the time, such as listening to them, referring them to some mindfulness resources that are available on the internet. And I think for more complex cases, thinking about where we can make referrals to the relevant, allied health services, particularly psychologists when we talk about anxiety and fear of recurrence.”

“So, they have other strategies to rely on in terms of helping with their treatment. And I think from a fatigue perspective, certainly exercise and encouraging healthy living and promoting a healthy lifestyle after cancer treatment can help.”

“There have been suggestions that depending on what level of intensity of exercise when we talk about low to moderate exercise, there was a set number that was given, but it worked out at roughly about 30 to 40 minutes of low to moderate intensity exercise. So that’s exercise which doesn’t put you out of breath, but you are doing something like walking at a reasonable pace. Whereas at a high intensity of exercise, where, for example, you have more difficulty in completing sentences, a shorter period with 20 to 30 minutes is sufficient.”

“We’re still finding out a lot more about how we dose or prescribe exercise. And I think, you know, certainly an exercise physiologist and having access to that type of service would be very beneficial for patients.”

And could you highlight some clinical trials that are specifically focused on addressing the needs of breast cancer survivors after completing treatment?

“I’ll highlight some breast cancer trials that have looked at some survivorship issues, not specifically exercise, but for example the POEMS trial, which looked at the use of an injection given subcutaneously every month, when patients are on chemotherapy treatment to essentially prevent or to shut down their ovaries, and somewhat protect them, to allow a quicker recovery after they’ve completed their treatment.”

“And it’s shown that women who had these injections during the time of the chemotherapy, it did allow for them to still parent a child and have a pregnancy. And in some ways it did preserve their fertility as well.”

“So, you know, I think that there are trials like that that have been done in the past. I don’t know of all the specific trials that are happening in the current space, but certainly I think these are some of the initiatives that need to be taken, particularly more trials that look at addressing some of the survivorship issues, some that are even more challenging, such as cognitive dysfunction that can happen after chemotherapy and also neurotoxicity like peripheral neuropathy, which is quite common amongst breast cancer patients after their chemotherapy.”

Looking ahead, what advancements or new research areas do you forsee in supporting breast cancer survivors through clinical trials and survivorship programs?

“I mean we’re in the digital age and I think there’s a lot of potential to look at some digital tools that can particularly look at symptoms that patients are self-reporting and encouraging patients to self-report their symptoms as a result of long-term effects of treatment and potentially look at providing some self-management interventions where appropriate, and subsequently make referrals if their symptoms are severe.”

“I think that’s potentially one of the avenues that is possible, particularly when we talk about where we can advance in terms of survivorship research. I think there’s also some scope to look at how we collect data around the health quality and how we can best apply that to look at better interventions that we can propose for survivors to address some of the survivorship issues.”

“I think that might be a better place to start before we look at newer interventions. It’s trying to see how we can collect better data around some of these issues.”

What are your hopes for the future of breast cancer research?

“I think the model of Breast Cancer Trials, you know, try and save lives. I can see that we need to improve our treatments that we have, but not necessary to give more treatments to patients because they come at a cost. As we can see from the survivorship perspective patients are surviving, but unfortunately cost to their quality of life.”