Frequently Asked Questions
Do I need to see a particular specialist after my treatments are finished and my oncologist has released me?
Cancer survivors can, for the most part, be evaluated and treated by their primary care physician if they happen to develop medical problems after their active cancer therapy has been completed and they no longer see their oncologist on a regular basis. However, certain symptoms may reflect health problems which are related to their earlier cancer treatment or they may be signs of cancer recurrence. For this reason, it is important to keep in mind the cancer-related medical history and to ask if the symptoms may be related to the earlier cancer experience.
What kinds of specific health problems may develop after cancer treatment?
Cancer treatment often includes surgery, chemotherapy, radiotherapy or some combination. Surgery may cause physical limitations depending on the location of the resected tumor, or swelling of an extremity from blockage of the lymphatic drainage. Chemotherapy may damage the testes or ovaries; in women this may result in premature menopause while children may experience delayed or abnormal puberty. Some chemotherapy drugs may make the heart or the lungs more susceptible to abnormalities. Finally, radiotherapy may create abnormalities in the normal tissues or glands that are included in the radiation field. When a combination of treatments has been used to treat the cancer the possible side effects may be compounded.
How soon after cancer treatment can these problems develop?
Some side effects happen very quickly during or soon after cancer treatment; this is especially true for surgery. Several side-effects of chemotherapy take place during the actual treatment, are controlled by the oncologist and subside after chemotherapy is finished; however, other side-effects may not become apparent until the cancer survivor becomes older or develops some other medical condition many years after initial chemotherapy. The effects of radiotherapy on the normal tissues near the tumor, develop slowly and clinical symptoms may not be appreciated for many years after the treatment. A regular (even if infrequent) cancer-specific evaluation is helpful for at least 10 years and, preferably, lifelong.
Will exercise and diet decrease my cancer risk?
Although no diet or exercise program can guarantee protection against any disease, there are recommendations that may help reduce the risk of cancer. The American Cancer Society and the American Heart Association have developed dietary and exercise guidelines for cancer prevention. For example, moderate to vigorous exercise for at least 30 minutes each day, which can include a brisk walk, swimming, gardening, doing housework or dancing. Nutritional considerations include eating five or more servings of fruits and vegetables each day, including whole grains and legumes. Additionally, stay within your healthy weight range and avoid excess alcohol, smoking, and foods with little nutritional value.
What are some treatments for fatigue?
Fatigue is a persistent feeling of tiredness, weakness and lack of energy over a prolonged period of time. Many cancer patients will experience fatigue during treatment, and in some people, it can continue after treatment is finished. Ways to cope with fatigue include prioritizing daily activities and getting plenty of rest. It is helpful to discuss appropriate diet, exercise and stress reduction strategies with your health care provider. In chronic cases of fatigue, your doctor may choose to prescribe medications.
Are childhood cancer survivors at increased risk for new cancers later in life?
Many children with cancer survive and live long productive lives, but the late effects of cancer treatment have been a concern for many years. Results of a recent national study revealed that survivors of childhood cancer face a higher risk of getting new cancers in early adulthood, apparently related to chemotherapy and radiation treatments. The most common new cancers occurred in the breast, thyroid and brain. The highest risk for second cancers was seen in people treated for Hodgkin’s disease, and the lowest risk for second cancers was seen in survivors of non-Hodgkin’s lymphoma. Previous studies have shown that cancer treatment may cause secondary leukemia.
Are there treatments for sexual dysfunction?
Certain cancers and cancer treatments can impact the ability to become aroused and/or enjoy sex. Many of these sexual side effects are temporary, but some can be permanent. However, there is a wide range of treatments to restore normal sexual function for both men and women.
Women who receive radiotherapy for cervical cancer may benefit from some of the following treatments:
- Topical estrogen cream for the vagina
- Vaginal dilatation
- Kegel exercises to strengthen the pelvic floor muscles
- Clitoral stimulation devices (vibrators, etc.)
Counseling is helpful to educate female patients about their anatomy and to discuss sexual techniques and alternatives. Certain antidepressants can cause decreased libido in some patients, who may want to discuss lowering the dose or changing to another antidepressant with their physician. The effectiveness of Viagra for women with sexual dysfunction is still being studied.
Several medications are available to improve sexual function in men:
- Topical vasoactive substances applied to the penis to improve blood flow
- Oral vasoactive drugs like Viagra
- Testosterone replacement therapy for hormonal deficiencies
Before considering medications, sexual counseling is recommended. Research and development are currently underway to determine the role of other topical and sublingual (under the tongue) agents. Penile implants may be used when less invasive measures are unsuccessful. An experienced urologist can provide appropriate advice and treatment for erectile dysfunction.
What are some treatments for menopausal issues?
Many women handle menopause very well and do not seek treatment. Symptoms include amenorrhea, hot flashes, vaginal atrophy, osteoporosis, cardiovascular changes, and psychosocial changes.
Amenorrhea: the absence of menstruation. Not all cancer treatments result in amenorrhea. It depends on the treatment regimen, the cumulative dose, and the patients' age. Amenorrhea related to chemotherapy, radiotherapy, or combined therapy may be temporary or permanent. It is caused by direct toxicity to the ovary, characterized by a sudden decrease in estrogen and progesterone levels, and increased levels of follicle stimulating and luteinizing hormones. In chemotherapy patients over age 35, amenorrhea occurs more frequently and is often irreversible. Hysterectomy and oophorectomy patients undergo immediate and permanent amenorrhea from surgically induced menopause.
There is also a psychological aspect to amenorrhea. Women who still want children may find this treatment complication distressing. Others with a history of difficult menstrual cycles may have better tolerance and even relief at the absence of painful menstruation. Pregnancy as a cause of amenorrhea must be explored, especially with patients previously treated for cancer.
Hot Flashes: a group of symptoms including a feeling of heat moving towards the head followed by facial and upper body redness, sweating, and dizziness. Other related symptoms include chills, fatigue, depression, and a rapid heart beat. Hot flashes are the most frequent symptom experienced by menopausal women, and are also a commonly reported side effect of Tamoxifen.
Hot flashes can occur several times during the day or night, interfering with daily activities and sleep. They generally last a short time, but can occasionally linger for several years. The underlying cause of hot flashes is not totally clear. During menopause, decreased levels of estrogen and progesterone apparently lead to inappropriate activity of the body's heat loss mechanism. Several treatments are used to relieve hot flashes. In addition to hormone replacement therapy (not recommended for breast cancer survivors), non-hormonal drugs include Bellergal, Clonidine, Effexor and Progesterone. Other prescription and over-the-counter medications are also used, although there is no clinical study data to support their effectiveness.
Vaginal Atrophy: during menopause, the vaginal wall may become thinner and lose its protective lubrication, causing it to atrophy and shrink. Women treated with chemotherapy or pelvic radiation are at risk for vaginal atrophy and dryness, because the treatment may place them in a menopausal state. Painful intercourse or other sexuality issues are a common complaint of postmenopausal women and their partners. Treatments for vaginal atrophy include:
- Hormone replacement therapy (HRT)
- Vaginal creams containing estrogen (not recommended for women with a history of breast cancer)
- Sexual education, including Kegel exercises, non-hormonal lubricants, and dilators
Osteoporosis: gradual bone loss that occurs with age and hastened by menopause. It is defined by measurements of bone mineral density as compared with healthy women around the age of 30. Osteoporosis usually occurs without symptoms or complaints, and the first clinical manifestation may be a decrease in height. Bone fragility (vertebral compression fracture or hip fracture) may occur with more severe osteoporosis. Individuals at higher risk for osteoporosis include thin, small-boned, Caucasian women, patients taking corticosteroids or anticonvulsant agents, and a history of long-term heavy alcohol consumption. Metabolic or endocrine disorders that may contribute to bone loss must be ruled out before diagnosis. Osteoporosis treatments include:
- Exercise and physical fitness
- Healthy lifestyle choices, such as avoiding smoking and excess alcohol
- A diet rich in calcium: milk, yogurt, sardines, eggs, broccoli, oranges, papaya and whole wheat bread
- Calcium supplements (1000 to 2000 mg per day)
- Vitamin D supplements (up to 400 IU. per day)
- Hormone replacement therapy (not recommended for patients with a history of breast cancer)
- Approved medications that prevent or improve bone loss
Several medications are available to prevent or treat osteoporosis, including bisphosphonates (Fosamax), the hormone Calcitonin (available as a nasal spray) and certain "designer" estrogen antagonists (Raloxifene). Tamoxifen also prevents bone loss in postmenopausal women.
Cardiovascular Changes: heart disease can be a major health issue for postmenopausal women, related in part to the estrogen deficiency. For cancer survivors, radiation to the chest area or certain types of chemotherapy may exacerbate cardiovascular problems, which may require a cardiologist for definitive diagnosis and treatment. The role of hormone replacement therapy (HRT) in preventing or improving cardiovascular disease has been debated in recent years. In addition, HRT is generally not recommended for women with a history of hormone-sensitive malignancies. Risk factors for cardiovascular disease include:
- A family history of coronary disease at a young age
- A history of claudication or stroke
- Diabetes mellitus
- Physical inactivity
Psychosocial Issues: menopause may also cause mood changes, depression, fatigue, anxiety, impaired memory, decreased libido, altered self-concept, and altered body image. It is important to keep in mind that many of these problems resolve with time. Therapies or activities that may help relieve these symptoms include:
- Avoiding smoking and excess alcohol
- Group Psychotherapy
- Antidepressant medications
- Brisk walking or other aerobic exercise for 3 or more hours a week
What can be done if cancer-treatment induced side effects are detected?
Effective interventions are available to treat most cancer-therapy related complications, including medical management, physical therapy or even corrective surgery, depending on the individual situation. Obviously, the earlier a problem is uncovered, the more effective the therapy.
Does cancer cause thyroid problems?
Thyroid problems may be seen in those who have had radiation to the head and neck areas, and in those who have received interleukin, interferon or other biological agents. Thyroid problems are not generally seen with traditional chemotherapy agents alone.
Is there any connection between radiation treatments for thyroid disease and breast cancer?
Over the past several years, we have realized that areas of the body heavily radiated for cancer treatment are at risk for developing secondary diseases. Though thyroid cancer and other thyroid problems are relatively uncommon, if they do occur, they tend to occur in young women. One treatment shown to be effective is radioactive iodine for both benign and malignant thyroid disease. The radioactive iodine is transported through thyroid tissue by a protein called the sodium iodine transporter. Some tissues in the body have this particular transport protein, including breast tissues. There is some concern that women who have had thyroid cancer might later develop breast cancer more often than expected, but it's difficult to determine whether or not it is treatment-related.
Do cancer treatments affect my mental functions?
We are beginning to receive some information about effects of cancer treatment on the memory. Generally, surgery does not affect thinking skills, unless it's performed on the brain. Young children who receive radiation therapy to the brain may experience difficulties keeping up with their peers in school.
Chemotherapy, while it works on rapidly dividing cells, also affects normal cells. Once nerve cells in the brain have developed, they divide very slowly, if at all. In this sense, it's believed that brain cells are most protected from the effects of chemotherapy. However, some patients inform us that they have altered mental function, and this is an important consideration.
Does MD Anderson offer any programs for the evaluation of cancer survivors?
At MD Anderson, we recognize that cancer survivors have unique health needs which require careful evaluation and regular surveillance. Some cancer survivors may develop specific treatment related problems as outlined above; knowing what these side effects may be will provide for timely diagnosis and effective treatment. In other cancer survivors, the health needs may not be unique but their treatment choices are special because of their cancer experience ( for example, a breast cancer survivor who needs to avoid estrogen replacement at the time of menopause).
We feel that it is very important that cancer survivors have access to experienced specialists who can anticipate and treat problems thoroughly and effectively; such a service is available in our dedicated Thyroid Cancer Survivorship Clinic.
Do insurance companies cover such evaluations?
Many insurance companies and health care providers recognize the importance of prompt detection and treatment for cancer related late effects and approve such an evaluation. In some cases restrictions may apply especially with respect to where testing and interventions should be carried out; such requirements can be worked through so that health coverage restrictions do not prevent a cancer survivor from an evaluation through the Life After Cancer Care Clinic at MD Anderson Cancer Center.
Who would benefit from the Thyroid Cancer Survivorship Clinic and what does the program involve?
The Thyroid Cancer Survivirship Clinic program has been developed to serve former patients who:
- have been treated for thyroid cancer in the past
- who are considered free of disease, and
- have been released from their oncologist specialist to the care of their primary care physicians.
Such an individual can request an outpatient evaluation with the specialists at the Thyroid Cancer Survivorship Clinic. Such consultation is likely to include a complete history and physical examination with special attention to thyroid cancer and cancer-treatment specific potential problems and additional tests or consultations with MD Anderson specialists depending on the individual patient needs.
If special problems are identified, several approaches are available: the Life After Cancer Care team may discuss directly with the patient or his/her primary physician and make recommendations for treatment. Alternatively, needed care may be offered here, at MD Anderson, depending on what is most appropriate in each individual case.
Working with the primary care physician, a periodic evaluation as well as institution and monitoring of appropriate therapy can be carried out.