Effect of breast cancer treatment

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1 Effect of breast cancer treatment on the bones 1 Effect of breast cancer treatment on the bones This information is from the booklet Managing the late effects of breast cancer treatment. You may find the full booklet helpful. We can send you a free copy see page 5. Contents Bone thinning Radiotherapy damange to bones Pain in the joints (arthralgia) More information and support Bone thinning After the menopause, all women have an increased risk of bone thinning (osteoporosis). But after breast cancer, some women are at a greater risk. This is because breast cancer treatments can reduce the amount of oestrogen in the body and oestrogen helps to keep bones healthy and strong. The following treatments for breast cancer can increase the risk of bone thinning: Chemotherapy, if it brings on an early menopause. This treatment uses anti-cancer (cytotoxic) drugs to destroy cancer cells. Stopping the ovaries from working by removing them or by giving radiotherapy, or using drugs called LHRH analogues such as goserelin. Radiotherapy uses high-energy rays to destroy cancer cells. Hormonal therapy with aromatase inhibitors (anastrozole, exemestane or letrozole), which slow down or prevent cancer cells from growing. Before treatment with an aromatase inhibitor, national guidelines recommend that women have their bone health (density) checked by a DEXA scan using a very low dose x-ray. DEXA is short for dual energy x-ray absorptiometry. These scans only take about 15 minutes. You lie on a couch while the scan is done. There are no injections involved. You don t have to undress, as long as there aren t any metal fastenings, such as zips, in the area to be scanned.

2 Effect of breast cancer treatment on the bones 2 Your bone density can be monitored during and after treatment. Depending on the results, you may be prescribed calcium and vitamin D supplements and/or bone strengthening drugs (bisphosphonates). These help to minimise the risk of problems. If you have a history of osteoporosis in your family, ask your cancer specialist about using bisphosphonates to help prevent osteoporosis. There is some research evidence that bisphosphonates may help to prevent the risk of the cancer coming back in the bones (secondary bone cancer). Your doctor or specialist nurse can give you more information and may ask you to take part in a research trial. What you can do Regular exercise, a healthy diet and stopping smoking can help to keep your bones healthy. We can send you more information about all of these. Exercise Exercise makes your bones stronger. Regular exercise that forces you to work against gravity (weight-bearing) is best. Good exercises to try include: walking or hiking climbing stairs dancing gentle weight-lifting. Swimming isn t so helpful, as your bones aren t supporting your weight while you swim. If you already have osteoporosis, avoid exercises that put too much strain on your bones, such as jogging. A physiotherapist or your breast care nurse can give you further advice about exercise after breast cancer. Diet It s important to make sure that you get enough calcium and vitamin D in your diet. Low-fat dairy products, eggs, green leafy vegetables, nuts, and whole fish (such as whitebait and sardines) are good sources of calcium. Vitamin D is essential to help the body absorb calcium. It s found in oily fish, eggs and food with added vitamins, but we mainly get it from sunlight. Most people get enough vitamin D by getting out and about in the summer months. If you have naturally dark skin, you need more sunlight to make vitamin D because of the pigment in your skin. A well-balanced diet and exposure to enough sunshine will usually give you all the calcium and vitamin D you need. If you re not getting enough calcium or vitamin D, taking supplements may be helpful. Your specialist can advise you about this. Drinking too much alcohol can interfere with the balance of calcium in your body, so stick to sensible drinking guidelines.

3 Effect of breast cancer treatment on the bones 3 The National Osteoporosis Society can give you more information about the prevention of osteoporosis and treatments visit nos.org.uk Breast Cancer Care also has a helpful leaflet. Visit breastcancercare.org.uk/information-support/publications to order or download it. Radiotherapy damage to bones Rarely, radiotherapy weakens the bones in the treatment area, such as the ribs and collarbone. Radiotherapy can reduce the blood supply to bones. This makes them thinner and increases the risk of a bone breaking, but this is very rare. If you have any symptoms, such as bone pain, always get them checked by your doctor. Usually the symptoms will be caused by something else. Treatment can involve taking painkillers or anti-inflammatory drugs. Sometimes calcium supplements, vitamin D or bisphosphonates and antibiotics are given. We can send you information about controlling cancer pain. Pain in the joints (arthralgia) Women taking aromatase inhibitors (such as anastrozole, letrozole and exemestane) may have joint pain and sometimes muscle pain. This is probably caused by a fall in oestrogen levels. Joint pain is also a common symptom of the menopause. Pain is most common in the hands and feet but can also occur in the knees, hips, lower back and shoulders. It may be there all the time or come and go. Some women notice that their joints are stiffer in the morning, when they first get up. If you ve recently started taking an aromatase inhibitor, the pain may settle over the next few months as your body adjusts to changes in hormone levels. Treatment for joint pain Doctors can prescribe several different painkillers for joint and muscle pain. These include: simple painkillers, such as paracetamol anti-inflammatory painkillers, such as ibuprofen opiate-based medicines, such as codeine or morphine for severe pain. If the pain is difficult to cope with your doctor may suggest changing the type of aromatase inhibitor you take. If that doesn t work, switching to tamoxifen. Tamoxifen causes fewer problems with joint pain. There is evidence that after taking an aromatase inhibitor, switching to tamoxifen doesn t increase the risk of breast cancer coming back. Aromatase inhibitors are very good at reducing the risk of breast cancer coming back. You should not stop taking your treatment without first talking things over with your cancer specialist. There is usually something that can be done to improve the pain.

4 Effect of breast cancer treatment on the bones 4 Small studies suggest that for women with lower levels of vitamin D, taking vitamin D3 supplements may improve symptoms. Talk it over with your doctor before taking a supplement. Research has shown that regular exercise can help to strengthen the muscles around your joints. This can help to keep them flexible and reduce pain. Non-weight-bearing exercises, such as swimming and cycling, may feel less uncomfortable and will help keep your joints healthy. Small studies have also found that acupuncture may help to reduce pain from joint symptoms. Some hospitals and primary care practices offer acupuncture on the NHS. Remember, the needles should not be used on the arm of the affected side. Research is going on to discover if a drug called glucosamine, often used to treat arthritis, may help some women. You can buy this over the counter in health shops and pharmacies, but it s not suitable for everyone. It may alter blood sugar levels, so may not be suitable for people with diabetes. Talk to your GP or cancer specialist before taking it. What you can do It s important to let your doctors know if joint or muscle pain is a problem for you. Your doctor can prescribe drugs to help control the symptoms and look at other ways of improving them. Try to keep active and do some regular gentle exercise. If you re having lots of problems with pain, a referral to a physiotherapist for advice and treatment is sometimes helpful. Your doctor can arrange this for you. If you re having difficulty carrying out daily tasks, you can ask to be referred to an occupational therapist (OT). They ll be able to assess your needs and recommend aids and equipment to help you. Some women find complementary therapies, such as massage, helpful. Some hospitals offer massage on the NHS.

5 Effect of breast cancer treatment on the bones 5 More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. Visit macmillan.org.uk or call us on , Monday to Friday, 9am to 8pm. You can order a copy of Managing the late effects of breast cancer treatment, or any other cancer information, from be.macmillan.org. uk or by calling us. Hard of hearing? Use textphone , or Text Relay. Speak another language? We have telephone interpreters. We provide information in a range of languages and formats. Visit macmillan.org.uk/otherformats or call us. We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or third-party information or websites included or referred to in it. Macmillan Cancer Support Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ Revised in March Next planned review in 2018.

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