Dr. Rania Habib (Host): The American Cancer Society estimates that greater than 300,000 people in the US will be diagnosed with breast cancer in 2023. Information about breast cancer and treatment is readily available, but what happens when treatment is complete and patients are trying to get back to living?

This is Flourish, a podcast brought to you by Prisma Health. I'm your host, Dr. Rania Habib. Today's episode discusses life after breast cancer, including sexual health, and we feature Carmen Hancock, an oncology-certified nurse practitioner at the Center for Integrative Oncology and Survivorship at Prisma Health. Welcome, Carmen, and thank you so much for joining the podcast today.

Carmen Hancock: Hi. I am happy to be here to discuss all things survivorship with a special focus on those going through a breast cancer journey.

Host: We are so excited to hear about this topic today. Let's begin with just some simple definition. What does it mean to be considered cancer-free or in remission?

Carmen Hancock: Yes, I think that's a great question. The American Cancer Society defines cancer as cured when treatment has eliminated the cancer from the body. We do not anticipate that the patient is going to need more treatment and the doctors do not expect the disease to come back. Remission is a period of time where the cancer seems to be responding to treatment or is under control, and remission can be partial or complete meaning that all signs of the cancer are gone.

Host: Okay. That's fantastic. Thank you for making that distinction between those two terms, because I think a lot of people find them confusing.

Carmen Hancock: Yes.

Host: Are there long-term side effects to breast cancer treatments like chemotherapy, radiation therapy or mastectomies?

Carmen Hancock: Yes, there can be for all of the breast cancer treatments. Cardiovascular disease is a big one that we think about. And there are systemic therapies that can contribute to this, like the chemotherapy that we give and some of the newer systemic treatments like the immunotherapies. Radiation can also increase the risk for cardiovascular disease.

And when we think about this, we're often monitoring for good blood pressure control and good cholesterol levels as we follow somebody long term after receiving breast cancer treatment. With chemotherapy, one of the more frustrating side effects is peripheral neuropathy, which can present as a numbness and tingling that typically affects the hands and feet. And this can be frustrating because it can affect daily activities depending on how severe the peripheral neuropathy is, that numbness and tingling. There are different ways that we can try to help manage that with medications. That side effect tends to linger and be more noticeable for patients. It can be partially reversible, and I would say as time goes on, months have passed from chemo finishing, the taxanes specifically or the chemotherapy that seems to be responsible for that, the numbness and tingling can definitely lessen.

Host: Okay. That's good.

Carmen Hancock: And with radiation therapy, with the advancements in modern radiation technology, we see a bit less of this. And I would say these side effects can be pretty uncommon at this point, but you can have damage to the tissue that's in the radiation field. So, we think about the heart and the lung. And for example with damage to the lung tissue, somebody could present with a persistent dry cough or shortness of breath as a long-term problem from that.

When we think about surgery and the complications that can occur with that, often nowadays women tend to opt for breast-sparing surgeries like lumpectomies that are then followed up with radiation therapy after. There are still many times where a mastectomy is recommended or the choice of the patient. And some of the long-term physical changes that we see with that, chronic pain can sometimes be an issue there; you think about the nerve damage that occurs with that extensive surgery; axillary web syndrome, which we often nickname cording, is really where there's scar tissue that forms and it can feel almost like there's a rope that has developed in the underarm area after having lymph nodes removed or biopsied. You can see that both as a side effect of sentinel lymph node biopsy which is less extensive where they're only biopsying or removing a couple of lymph nodes closest to the breast or you can see that with more extensive axillary lymph node dissection, where the breast cancer has spread to the lymph nodes and more of them have to be removed.

I think the biggest surgical complication that we see is secondary lymphedema. When you think about how the lymph nodes work, they help filter out proteins and substances in our lymph system. And when that chain has been interrupted, you can have backup of fluid. And that's often both with cording and with lymphedema where we lean on our physical therapy colleagues to help manage.

Host: So, you've highlighted some really common changes that occur to the body after different treatments for breast cancer. Let's focus on chemo brain. What is it and how long does it last?

Carmen Hancock: Yes. That is another very frustrating side effect of breast cancer treatment. I will say, it's most often associated with chemotherapy, but there are other treatments that we give, such as endocrine or hormone therapy that's blocking estrogen production or the way it can attach to the breast tissue in the body. And I see in practice this most debilitating, I'd say, during chemotherapy or shortly thereafter. We don't fully know the mechanism or how chemo brain, what the type of damage that chemo is doing that causes these symptoms. They kind of present as memory issues or concentration problems. And they can be very impactful on daily life. They can be short term, chemo brain or brain fog is another way think about it, or it can be long term. And there are a few things that we can do to help manage that. I think first is making sure that there's not something else contributing to these cognitive brain function changes, even emotional distress, such as depression or anxiety, the lack of sleep that often accompanies going through a cancer journey. All of these things need to be teased out and worked on.

And if I have somebody that is still quite frustrated with how they are thinking and feeling about that, then I will often refer them on to Cognitive Rehab, which is where a psychologist will sit down and run a litany of tests, kind of brain puzzles, if you will, to try to identify any significant changes that differ from the average for a person of a specific age and things like that and then offer solutions, different kind of therapies to help.

Host: No, that's great that you're able to at least help them through because that would be really difficult.

Carmen Hancock: Yeah.

Host: Moving on to radiation therapy, does radiation therapy make it more likely to get other cancers later on in life?

Carmen Hancock: Yes. There is a small increased risk with some of the adjuvant radiation therapy and adjuvant means that we give the radiation, for example, after the lumpectomy to that area where the cancer was removed. There's a small and, at this point, I'd say it's a rare complication for solid tumors, things like a contralateral breast cancer or breast cancer affecting the opposite breast or a different area of the same breast, esophageal or lung cancers.

Host: Now, I'm sure you encounter different physical activity levels in your patients. For those who love to exercise, is it safe to exercise during breast cancer treatment? And what about after treatment?

Carmen Hancock: Absolutely. And actually, this is a recommendation by most cancer organizations and particularly in the breast cancer population, there is a lot of research looking at the benefits of exercise during treatment even and definitely beyond. We tend to think about the American College of Sports Medicine Exercise Guidelines, and I like to tell people that their exercise should be what they physically feel like they can tolerate as close to their baseline activity as possible. And those guidelines really recommend that all of us are getting 150 minutes a week of moderate intensity activity. And that may be modified for people while they're going through a cancer treatment. And it often feels counterintuitive to really try to focus on exercise while receiving chemotherapy and the profound fatigue that comes with that or radiation therapy. But there's a lot of research that really shows that the best way to combat that treatment-related fatigue is with exercise. So, I think of starting, you know, even if it's five, ten-minute brisk walk, trying to get that in daily, trying to do something for strengthening two days a week.

Host: I mean, I'm sure those endorphins really help combat those feelings of fatigue, so I can understand why it's very counterintuitive, but why exercise would be really helpful.

Carmen Hancock: Yeah. And we have a program at PRISMA that we call Moving On. It's an oncology rehab program where we will see patients within the first three or so years after their cancer diagnosis and treatment. This is something that we do in the rehab setting, so it's after treatment has been completed for that person. If somebody's on maintenance therapies or long-term treatment, that is okay. But we plug them into a personal trainer-led program at our Prisma gym, and it's 12 weeks, two days a week where they start at their baseline, where they're at that moment and progress along. And I think it's really helpful to jumpstart people back into a routine that is oftentimes interrupted by going through treatment, and also really to focus on the strengths rebuilding after treatment.

Host: Absolutely. And it sounds like it's a perfect way for patients to combat that fatigue that they'll often have after treatment for breast cancer.

Carmen Hancock: Yes. Absolutely.

Host: How common is it to get reconstructive surgery after treatment for breast cancer involving mastectomy?

Carmen Hancock: I'd say approximately 40% of women here in the US, and I'd also say that it's a very personal choice on whether or not somebody decides to go on to have reconstructive surgery. There are many different options for reconstruction these days and that's something that's thoroughly discussed with a plastic surgeon, once somebody's interested in getting more information about that, usually at time of diagnosis when the treatment planning is happening. And I do think there's better insurance coverage, fortunately, for reconstruction today.

Host: Oh, that's fantastic because it's such a burden on the patient. It's something that probably stresses them out in addition to the actual surgery or chemo or radiation to remove the cancer, but also the effects of what they need to do afterwards. So, it's great that insurance is starting to pick up some of that cost for the patient.

Carmen Hancock: Yes.

Host: How does changing diet help a patient feel better after breast cancer treatment?

Carmen Hancock: I think that our nutrition is really core to healing as you go through a cancer treatment and well beyond. We, in our practice, lean on the American Institute for Cancer Research, AICR.org, and the American College of Lifestyle Medicine. These are both great evidence-based resources for nutrition recommendations in cancer survivors. And there's so much on the internet nowadays, that I often point people directly to AICR.org, because there's myth-busting facts and there's recipes for both prevention and survivorship. And really, all of that, the recommendations, the resounding answer to that question is making small changes towards a more plant-focused whole foods diet. And I think that seems to be the answer for most chronic diseases these days.

Host: It definitely is.

Carmen Hancock: I also think it's important to discuss supplements here. We truly believe trying to obtain nutrients from whole food nutrition is best. And unfortunately, there's a lot to say here, but there are not any supplements known to prevent cancer or decrease risk of recurrence. And supplements are often not well studied and not FDA regulated. But I do know that many patients turn to supplements and I always recommend checking out Memorial Sloan Kettering Cancer Center. They have an app and a website called About Herbs. And I think that that's a really helpful resource both for healthcare professionals working with oncology patients and breast cancer patients themselves to look at.

Host: Thank you for providing that resource. I'm going to check that out too, just to learn more about these herbs and what's behind them, so that's perfect. Let's switch gears a little bit now to mental health. How can patients manage the fear of cancer returning?

Carmen Hancock: This is a very common worry. I'd say it is a universal experience amongst cancer survivors to fear cancer returning. I think the fear of unknown is normal for everyone, but I think it's especially heightened when you've been faced with a cancer diagnosis.

Host: Definitely.

Carmen Hancock: I think it's helpful to recognize triggers and then be able to have coping mechanisms to use once a trigger has been identified. For example, many of these patients have reported anxiety when they go to the cancer center, even if it's a few years out from their diagnosis. And I think really having different ways to manage that. There's a lot of research on mind-body techniques that have been proven to be helpful in controlling that kind of fear of recurrence. And when we think about that, I often recommend cognitive behavioral therapy or even skills that can be learned there, such as setting aside a worry time or learning ways to kind of reframe those fears. And I think that that's best worked through, at least initially, with a mental health provider. Meditation has been very helpful and even meditative movement, things like yoga or tai chi, relaxation techniques. We think about deep breathing or guided imagery. And there are so many online resources for mind-body skills these days with apps and things like that. Headspace is a good one for meditation. And I think journaling is also very helpful in this setting.

Host: That's a great idea. Is it common to struggle with depression and/or anxiety after treatment for breast cancer? And what can be done to combat these problems? Would you recommend some of these similar techniques?

Carmen Hancock: Yes, it can be. I think there's an appropriate situational time period after receiving a diagnosis and particularly going through treatment where people can feel down. And I also see often that people generally start to process really everything that they've gone through once treatment has finished. And I think it's almost like a debriefing. You know, when we get the diagnosis and we, as healthcare providers, start the treatment plan in place, the ball gets rolling so fast that often people don't quite have the time to process what they're going through.

And I have many patients come to me and say, "Well, I was fine during treatment. But after, I find myself very tearful at random moments," and I think that that can be normal. I do think that there are statistics that state one out of four cancer survivors also have depression, according to the National Cancer Institute. And so, it is important to talk to your health care providers, so that we can really get to the bottom of is this a normal appropriate response or is this something that is a little bit more and needs to be managed differently.

There was a new study published earlier this year in the American Cancer Society's Journal, Cancer, that suggests for women with breast cancer, depression may actually negatively impact both the care that they receive and survival outcomes. And so, I think In this patient population, particularly, there are so many things that can affect mood and our mental health, but really staying in communication with your health care team so we can best manage that.

And what the patient can do, I think, is, yes, many of the things we just talked about. Cognitive behavioral therapy is very effective. Sometimes antidepressants are needed, whether that's short-term or long-term. That's something that depends on the person's medical history and things like that. Support groups I think can be helpful too. I think there's a lot to be said for shared storytelling and experiences.

Host: Why are sexual health issues common after breast cancer and how can it be overcome?

Carmen Hancock: Yes. This is one of my personal favorite things to talk about with our cancer survivors. We actually have a sexual health visit at the Center for Integrative Oncology and Survivorship called a SHE visit. It's a Sexual Health Evaluation for our female cancer survivors.

Host: That's fantastic.

Carmen Hancock: Yes. And then, myself and one of the other nurse practitioners, actually the director, both provide these visits. And I think that there are many reasons that sexual health changes are common. You know, often when you think about breast cancer, the majority of breast cancers affect perimenopausal or menopausal women. So, there are often underlying changes that are happening over time. And then, the majority of these breast cancers are what we call hormone-sensitive and require hormone blockers. And so, that can worsen a lot of menopausal changes, and that's where I think you see the impact on hot flashes sleep disturbance on our sexual health and decreased libido. Vaginal dryness is a big one that I talk to women about. And I could go on and on about this specific topic, but there's a lot that can be done to help optimize somebody's sexual health after a cancer diagnosis. And I think that bringing it up to your healthcare team, you know, I hate to put the responsibility on patient for that, but really we don't do a great job in our healthcare system asking about sexual health. And I think that hopefully that will change.

Host: Definitely. It's so important.

Carmen Hancock: Yeah, I mean it's really one of the biggest quality of life things that we need to be thinking about and we, as healthcare providers, need to be asking about at these follow up visits. There's often so much to talk about and I think female sexual health in particular has been under-researched for a long time. There are exciting changes with that. I think there are a lot of people pouring into that area. And really, I think healthcare providers are getting a little bit better about asking about and talking about the changes that can be seen with sexual health. But I also think the patient, just knowing that it's a very common issue after cancer treatment to see changes in your sexual health, bringing that up so that the healthcare providers are aware and can help plug you into resources and help improve that.

Host: I love the fact that you're giving all these suggestions for mental health and sexual health. Because like you said, it can often be embarrassing for the patient to bring up these topics. So, I really love the fact that you guys are focusing on that. That's fantastic.

Carmen Hancock: Yes.

Host: How can friends and family best support a loved one who's a breast cancer survivor?

Carmen Hancock: Yeah. I think asking that person what they need at that moment is really helpful. I think leaning in and asking about resources that might be available, support services. For example, here in the Center for Integrative Oncology and Survivorship, we've put together a whole booklet on caregiver support that can give ideas and things like that. And also, we've had caregiver support series where our social worker has, provided virtual options for information about this.

Host: That's fantastic. Last question. How do nurse navigators and the Center for Integrative Oncology and Survivorship help after breast cancer treatment finishes?

Carmen Hancock: Yeah. We are fortunate to have a wonderful team of nurse navigators who I think are essential to helping keep people plugged into their healthcare team and really take some of the burden off of patients long after their treatment finishes by being available to ask about symptoms that have come up later and things like that.

As far as support services that we have, we have the Cancer Support Community Calendar, which is something we roll out quarterly and has both virtual and in-person options for things ranging from strength training led by a personal trainer to yoga, meditation, a journaling support group. So many good mind-body options, tangible things that we've talked about so far. And we also are fortunate here in Greenville to have the Cancer Survivors Park Alliance downtown that helps host many of these activities when they are in person.

Host: That's great.

Carmen Hancock: Yeah. And we have our Greenville Cancer Society and some of the surrounding areas have their own local cancer societies that often run support groups in person for people to come and have that community support too.

Host: That is fantastic. You guys are really showing a wonderful dedication to integrative health at your center. And we thank you so much for your expertise today, Carmen.

Carmen Hancock: Yes, of course. Thank you for having me. I wish we could talk about this all day.

Host: I know, you can tell you have such a wonderful passion for it. So, we really appreciate all of your expertise.

Carmen Hancock: Thank you.

Host: For more information and to listen to additional episodes of Flourish, please visit prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm your host, Dr. Rania Habib, wishing you well.