In apparently healthy women, both the diagnosis of breast cancer and the subsequent cancer treatment can have a large impact on the quality of their daily life. In addition to changes in body function, the cancer patient and her male partner can experience psychological distress, depression, anxiety, reduced self-esteem, altered sexuality and reduced quality of life (QoL). Many of these changes are treatment-related and can have a long-lasting effect.
In the past, radical surgery frequently resulted in negative feelings regarding body image. Surgery for breast cancer has developed considerably in the last 30 years. Conservative treatment is now standard in early breast cancer patients, which yields good results in terms of overall survival as well as QoL. Sentinel lymph node sampling techniques decrease the risk of lymph edema, a condition seen in half the patients subjected to standard axillary lymph node dissection. Lymph edema causes enlargement of the arm and a nasty feeling of heaviness.
Postoperative radiotherapy for breast cancer has well-documented beneficial effects. Late radiation toxicity (to the heart, long, brachial plexus and shoulder joint) was seen with the older, suboptimal irradiation techniques. The toxicity of modern radiotherapy is much less, although post-radiation side-effects such as lymph edema and second malignancies cannot be totally prevented.
Chemotherapy, either alone or in combination with endocrine therapy, has recently gained more prominence within the treatment plan, especially in younger patients with endocrine non-responsive disease and in those with HER2/NEU overexpression. Chemotherapy might lead to the destruction of primordial follicles and the impairment of follicular maturation. Clinically, this could lead to irregular menses, transitional amenorrhea and to an irreversible ovarian failure, resulting in premature menopause, with hot flushes, night sweats and vaginal dryness. Premature menopause is also associated with impaired sexual functioning and psycho-sociological distress related to fertility concerns and uncertainty about late effects of premature menopause in various areas, such as cognitive function, the cardiovascular system and bone metabolism.
Adjuvant endocrine therapy affects the daily life of many young breast cancer survivors. Endocrine therapy results in prolonged survival in a subgroup of young women, but acute and long-term effects of therapy could influence QoL profoundly. Tamoxifen treatment is stopped by approximately 40% of women because of side-effects. These side-effects include vasomotor symptoms, vaginal dryness, bleeding, endometrial carcinoma and thrombosis.
Aromatase inhibitors are more recent endocrine treatment options that have shown efficacy. The side-effect profile is different to that of tamoxifen. Steroidal aromatase inhibitors appear to have beneficial effects on bone and lipid metabolism, while their non-steroidal actions may have neutral or unfavorable effects. Other adjuvant endocrine treatment options include the use of gonadotropin-releasing hormone analogs (which suppress ovarian estrogen production in pre- and perimenopausal women) and laparoscopic bilateral ovariectomy.
Thus, vasomotor symptoms are very common in women with a history of breast cancer and can result from a chemotherapy-induced menopause, or from endocrine therapy or ovarian ablation. Flushes are more frequent, more severe and longer-lasting than those seen in the general postmenopausal population.
QoL should be an important issue in the counseling of breast cancer patients. In the past decade only a dozen studies with high methodological quality have investigated QoL among long-term breast cancer survivors. Although most studies report good overall QoL, nearly all studies also report specific problems such as a thick and painful arm and problems with sexual functioning. Adjuvant chemotherapy is the strongest predictor of low QoL. In a small proportion of women climacteric and sexual complaints are deeply problematic. Aromatase inhibitors in general produce a more favorable QoL profile with a lower incidence of thromboembolism and vaginal bleeding, compared with tamoxifen use.
The general practitioner and the oncologist should give more attention to issues of QoL, especially in young women with early-stage carcinoma of the breast. Developments in the field of surgery and radiotherapy have resulted in the use of patient-tailored techniques that are conserving for the breast, with important effects for body image and sexuality. Adjuvant chemotherapy and endocrine therapy can make life difficult especially for young women. QoL issues are especially important as overall survival is extremely good in these women. As many of the adjuvant treatment modalities come with severe acute and long-lasting side-effects, it is most important to have QoL considerations play a more prominent role when considering the various adjuvant treatment options now available for breast cancer patients.