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JASCAP
JASCAP
JEET ASSOCIATION FOR SUPPORT TO CANCER PATIENTS
c/o. Abhay Bhagat & Co., Office No.4, “Shilpa”, 7th.Road, Prabhat Colony,
Santacruz (East), Mumbai – 400 055
Tel.: 2617 7543, 2616 0007. Fax: 91-22-2618 6162
E-mail :pkrjascap@gmail.com & abhay@abhaybhagat.com
JASCAP is a charitable trust that provides information on various aspects of cancer. This
can help the patient and his family to understand the disease and its treatment and thus
cope with it better.
Registered under the Societies Registration Act, 1860 No.1359 / 1996 G.B.B.S.D., Mumbai
and under the Bombay Public Trusts Act, 1950 No. 18751 (Mumbai). Donations to JASCAP
qualify for deduction u/s 80G (1) of the Income Tax Act, 1961 vide Certificate No. DIT (E) /
BC / 80G / 1383 / 96-97 dated 28.02.97 subsequently renewed.
If you are a patient, your doctor or nurse may wish to go through the booklet
with you and mark sections that are particularly important for you.
Contents
About JASCAP
What is cancer?
The organs and tissues of the body are made up of tiny building blocks called cells. Cancer
is a disease of these cells.
Cells in different parts of the body may look and work differently but most reproduce
themselves in the same way. Cells are constantly becoming old and dying, and new cells are
produced to replace them. Normally, cells divide in an orderly and controlled manner. If for
some reason the process gets out of control, the cells carry on dividing, developing into a
lump which is called a tumour.
Tumours can be either benign or malignant. Cancer is the name given to a malignant
tumour. Doctors can tell if a tumour is benign or malignant by examining a small sample of
cells under a microscope. This is called a biopsy.
In a benign tumour the cells do not spread to other parts of the body and so are not
cancerous. However, if they continue to grow at the original site, they may cause a problem
by pressing on the surrounding organs.
A malignant tumour consists of cancer cells that have the ability to spread beyond the
original area. If the tumour is left untreated, it may spread into and destroy surrounding
tissue. Sometimes cells break away from the original (primary) cancer. They may spread to
other organs in the body through the bloodstream or lymphatic system.
The lymphatic system is part of the immune system - the body's natural defence against
infection and disease. It is a complex system made up of organs, such as bone marrow, the
thymus, the spleen, and lymph nodes. The lymph nodes (or glands) throughout the body are
connected by a network of tiny lymphatic ducts.
When the cancer cells reach a new area they may go on dividing and form a new tumour.
This is known as a secondary cancer or metastasis.
It is important to realise that cancer is not a single disease with a single type of treatment.
There are more than 200 different kinds of cancer, each with its own name and treatment.
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Types of cancer
Carcinomas
The majority of cancers, about 85% (85 in a 100), are carcinomas. They start in the
epithelium, which is the covering (or lining) of organs and of the body (the skin). The
common forms of breast, lung, prostate and bowel cancer are all carcinomas.
Carcinomas are named after the type of epithelial cell that they started in and the part of the
body that is affected. There are four different types of epithelial cells:
squamous cells - that line different parts of the body, such as the mouth,
gullet (oesophagus), and the airways
adeno cells - form the lining of all the glands in the body and can be found
in organs such as the stomach, ovaries, kidneys and prostate
transitional cells - are only found in the lining of the bladder and parts of
the urinary system
basal cells - that are found in one of the layers of the skin.
A cancer that starts in squamous cells is called a squamous cell carcinoma. A cancer that
starts in glandular cells is called an adenocarcinoma. Cancers that start in transitional cells
are transitional cell carcinomas, and those that start in basal cells are basal cell carcinomas.
Sarcomas
Sarcomas are very rare. They are a group of cancers that form in the connective or
supportive tissues of the body such as muscle, bone and fatty tissue. They account for less
than 1% (1 in 100) of cancers.
Sarcomas are split into two main types:
bone sarcomas - that are found in the bones
soft tissue sarcomas - that develop in the other supportive tissues of the
body.
Treatment for breast cancer will get rid of the cancer for many women and the cancer may
not come back, so the cancer is cured.
Local recurrence
In some women, treatment for breast cancer does not remove all the cancer cells. These
cells may then grow in the breast or scars – sometimes many years later. This is known as
local recurrence. The cancer cells may grow into a lump in the skin of the breast over
where the cancer was originally removed, or in the operation scar. Sometimes the breast
cancer may re-grow in the breast tissue left after a lumpectomy.
Secondary cancers are also called metastases, so another name for secondary breast
cancer is metastatic breast cancer. The most common places that breast cancer cells
spread to are the bone, liver, lung or brain. Secondary breast cancer can also affect the
lymph glands. It is most likely to affect the lymph nodes in the armpits or the lower part of the
neck.
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Breast cancer cells do not usually spread to many places in the body at once. Although it is
possible for secondary breast cancer to affect more than one place at a time, it more
commonly affects just one or two parts of the body.
Each woman's situation is individually assessed and the appropriate treatment given
depending on where the breast cancer has spread to. A woman with secondary breast
cancer affecting the bones will have different symptoms and may need different treatment
from a woman with secondary breast cancer affecting the liver.
Local recurrence
Sometimes a small number of breast cancer cells, that were too small to see, are left at the
area of the operation after surgery. If this happens, these cancer cells may grow and form a
new lump. Lumps may form in the remaining breast tissue after a lumpectomy, in the skin
near the breast after a mastectomy, or in the operation scar. However, most cancers that are
found after a lumpectomy are new cancers and not a recurrence.
The first sign of a local recurrence is usually the development of a small lump (sometimes
called a nodule) in the skin or in the scar, or there may be a lump in the deeper breast
tissue. These local recurrences can usually be treated and controlled, but it is important to
report it to your doctor as soon as you notice it. If it is left untreated the skin in the area may
break down and become sore (ulcerated).
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Secondary breast cancer in a bone can be treated. For most women, treatment can be
started long before the bone becomes weak enough to break or cause severe pain.
Treatment for hypercalcaemia is discussed on the controlling symptoms page.
from a primary breast cancer. Each condition has its own particular set of symptoms
and treatment.
The bones
A blood test will be done to check the amount of calcium in the bloodstream. Too much
calcium (hypercalcaemia) may indicate that there is cancer in the bones. You may also have
a blood test called a full blood count. This measures the number of different blood cells in
your blood and shows how well your bone marrow is working. The bone marrow is the
spongy part in the centre of most bones that produces blood cells. On their own these blood
tests can’t diagnose a secondary cancer in the bone. X-rays and bone scans will usually be
needed to confirm the diagnosis.
X-rays give a general picture of the condition of bones, but they may not be able to detect
small areas of secondary tumours.
A bone scan is a more sensitive test which may pick up tiny areas of bone that have been
affected by secondary breast cancer. A tiny amount of a mildly radioactive substance is
injected into a vein, usually in the arm, and travels around the body in the bloodstream.
Abnormal areas of bone absorb more radioactivity than normal bone and show up on a
scanner. The scan pictures are usually taken 2–3 hours after the injection.
Bone scans can’t always tell whether an abnormal area is due to cancer or other conditions
such as arthritis. For this reason, more detailed scans such as CT or MRI scans may be
needed.
The lungs
A chest x-ray may show whether there is any secondary breast cancer in the lungs and will
also show any build-up of fluid between the membranes on the outside of the lungs (the
pleura).
A CT (computerised tomography) scan may be used. This scan takes a series of x-rays
which build up a three-dimensional picture of the inside of the body. The scan is painless but
takes longer than an x-ray (about 10–20 minutes). Most people who have a CT scan are
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given a drink or injection to allow particular areas to be seen more clearly. You will probably
be able to go home as soon as the scan is over.
An MRI (magnetic resonance imaging) scan is similar to a CT scan, but uses magnetic
fields instead of x-rays to build up a series of cross-sectional pictures of the body. During the
test you will be asked to lie very still on a couch inside a metal cylinder that is open at both
ends. The whole test may take up to an hour and is painless - although the machine is very
noisy. You will be given earplugs or headphones to wear.
The cylinder is a very powerful magnet, so before going into the room you should remove all
metal belongings. You should also tell your doctor if you have ever worked with metal or in
the metal industry or if you have any metal inside your body (for example, a cardiac monitor,
pacemaker, surgical clips, or bone pins).
Some people are given an injection of dye into a vein in the arm, but this usually does not
cause any discomfort. You may feel claustrophobic inside the cylinder, but you may be able
to take someone with you into the room to keep you company. It may also help to mention to
the staff beforehand if you do not like enclosed spaces. They can then offer extra support
during your test.
The liver
Blood tests can show whether the liver is working properly, but they can’t always tell
whether any problem is due to secondary cancer or another condition. Liver scans can be
used to build up a clearer picture of what is happening in the liver.
Liver ultrasound scans are done in the hospital scanning department. The test uses sound
waves to build up a picture of the liver and can measure the size and position of any
secondary cancers in the organ. Ultrasound is painless and only takes a few minutes. CT
scans of the liver take cross-sectional pictures of the abdomen.
The brain
A CT or MRI brain scan can be used to build up an accurate picture of the brain and can
show areas of secondary breast cancer in the brain.
You will lie on a couch with your head inside a scanner for these tests. They are completely
painless and take about half an hour.
any symptoms or give any problems. Many metastases stay inactive (silent) and do not
cause problems.
Oestrogen receptors
Many breast cancer cells contain proteins known as oestrogen receptors. A cancer which
contains a certain proportion of these proteins is described as oestrogen-receptor positive
(ER+). About 6 out of 10 (60%) of breast cancers are oestrogen-receptor positive. The more
oestrogen-receptors a cancer cell has, the more likely it is to be controlled by hormonal
therapy.
If a cancer cell has very few or no oestrogen-receptors, it is called an oestrogen-receptor
negative (ER-) cancer. Hormonal therapies do not work for ER negative breast cancers.
Oestrogen-receptors are known as ER because of the American spelling of oestrogen as
estrogen.
Menopause
Whether or not you have had the menopause (change of life) is an important factor in
deciding on treatment. Before the menopause, women have high levels of female hormones
circulating in their bodies, whereas afterwards the levels of these hormones are lower.
In women who have had their menopause, most of the female hormones are produced by
converting androgens from the adrenal glands into oestrogen. This influences which
hormonal treatment will control the secondary breast cancer cells best.
Women with a high number of HER2 receptors are known as being HER2-positive
(HER2+), and they may benefit from treatment with a type of biological therapy called
trastuzumab (Herceptin®).
About 1 in 5 women (20%) have HER2+ breast cancer. These women may also benefit from
a newer type of biological therapy called lapatinib (Tyverb®), which inhibits both the HER2
receptor, and another similar receptor called EGFR.
Other issues
Other factors your doctor will take into consideration include your age and general health,
whether the secondary cancer is slow growing (low-grade) or more faster-growing (high-
grade) and which treatment, if any, you have had in the past.
The staging and grading of breast cancer is explained in our booklet about primary breast
cancer.
Chemotherapy drugs, hormonal therapies and biological therapy drugs are carried round the
body in the bloodstream so can treat cancer cells wherever they are in the body. This is
known as systemic therapy.
Radiotherapy or surgery treats one area at a time and can be very helpful in treating
individual areas of cancer, particularly in the bones or parts of the brain or the skin.
Doctors try to treat women with secondary breast cancer with the treatment that is most
likely to control the breast cancer and cause the fewest side effects.
Giving consent
Before you have any treatment, your doctor will explain the aims of the treatment to you.
They will usually ask you to sign a form saying that you give your permission (consent) for
the hospital staff to give you the treatment. No medical treatment can be given without your
consent, and before you are asked to sign the form you should be given full information
about:
the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.
If you don't understand what you have been told, let the staff know straight away so that they
can explain again. Some cancer treatments are complex, so it's not unusual for people to
need repeated explanations.
It is often a good idea to have a friend or relative with you when the treatment is explained,
to help you remember the discussion more fully. You may also find it useful to write down a
list of questions before you go to your appointment.
Patients often feel that hospital staff are too busy to answer their questions, but it is
important for you to be aware of how the treatment is likely to affect you. The staff should be
willing to make time for you to ask questions. You can always ask for more time to decide
about the treatment if you feel that you can’t make a decision when it is first explained to
you.
You are also free to choose not to have treatment. The staff can explain what may happen if
you do not have it. It is essential to tell a doctor or the nurse in charge, so that they can
record your decision in your medical notes. You do not have to give a reason for not wanting
to have treatment, but it can be helpful to let the staff know your concerns so that they can
give you the best advice.
Second opinion
Usually a number of cancer specialists work together as a team and they use national
treatment guidelines to decide on the most suitable treatment for a patient. Even so, you
may want to have another medical opinion. Either your specialist, or your GP, should be
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willing to refer you to another specialist for a second opinion if you feel it will be helpful. The
second opinion may cause a delay in the start of your treatment, so you and your doctor
need to be confident that it will give you useful information.
If you do go for a second opinion, it may be a good idea to take a friend or relative with you.
You may find it useful to have a list of questions ready so that you can make sure your
concerns are covered during the discussion
When it is used
Hormonal therapy only works for women who have oestrogen-receptor positive (ER+)
cancers. They can be effective in controlling slow-growing cancers affecting the bones, the
lymph glands, the fatty tissue under the skin or the skin itself. Hormonal therapy can also be
used for secondary breast cancer in the liver and lung.
One advantage of hormonal treatments is that they are easy to take and although side
effects can occasionally be troublesome, they are rarely serious. Another advantage is that
there are many different hormonal treatments available so if one doesn’t work, or stops
working, others can be tried. You will usually need to take hormonal therapies for a few
weeks before your doctors can tell if they are working. Many hormonal treatments are
available and more are being developed all the time.
The choice of hormonal therapy will depend upon whether you are pre or postmenopausal.
Your doctor will be able to discuss which type of hormonal therapy treatment is best for you,
based on all your relevant medical details.
Anti-oestrogens
Tamoxifen
Tamoxifen works by preventing oestrogen in the body from attaching to breast cancer cells
and encouraging them to grow. It is used for both pre and postmenopausal women.
Tamoxifen has been the most widely used hormonal therapy for breast cancer and it has
been shown to be highly effective in reducing the chance of the cancer coming back. It can
also be very effective in controlling secondary breast cancer for many women. Tamoxifen
treatment can be continued for as long as it is effective in preventing the cancer cells from
growing.
It is available as tamoxifen and Nolvadex® and is taken as a daily tablet. The side effects
may include:
hot flushes and sweats
a tendency to put on weight (although this may be due to other effects such as going into
the menopause)
dryness of the vagina or an increased discharge from the vagina.
For many women, these side effects are mild and may reduce over time. However, some
women continue to find the side effects of tamoxifen are a problem. If this happens, it is
helpful to discuss this with your doctor as there are sometimes ways of reducing the effects.
We have a booklet on breast cancer and menopausal symptoms which has helpful tips.
In postmenopausal women, tamoxifen can slightly increase the risk of womb cancer, blood
clots in the leg or lung, and strokes. Although this sounds very frightening, these effects are
very rare and are usually curable and treatable. The benefits of tamoxifen in treating breast
cancer outweigh the risks of side effects for most women.
Women who have secondary breast cancer in a bone may find that tamoxifen makes the
bone pain worse for the first few days. This is known as tumour flare and it soon eases, but it
is important to know that it might happen and that it is a temporary side effect of the drug.
You should tell your doctor if it happens.
Fulvestrant (Faslodex®)
Fulvestrant is a newer anti-oestrogen drug that is only used to treat postmenopausal women.
It is given as an injection once a month. It may be used after treatment with tamoxifen or
aromatase inhibitors. It may also be used if women can’t take tablets or may forget to take
tablets. The side effects are similar to tamoxifen.
Letrozole (Femara®) is also taken once a day as a tablet. Side effects are usually mild,
and are similar to those of anastrozole.
Exemestane (Aromasin®) is also taken as a tablet once a day. The side effects tend to
be mild and are similar to anastrozole, but it may also cause diarrhoea in some women.
Progestogens
If the secondary breast cancer cells are not controlled by tamoxifen or aromatase inhibitors,
artificial progesterone (progestogen) treatment may be used instead. Progesterone is a
hormone that occurs naturally in women. Progestogens are stronger than progesterone and
can be given as tablets or by injection into the muscle of the buttock. The commonest ones
are megestrol acetate (Megace®) and medroxyprogesterone acetate (Farlutal®, Provera®).
You may be given injections by your doctor or nurse.
Progestogens tend to cause more side effects than aromatase inhibitors. Although some
women may feel slightly sick, most women find that progestogens increase their appetite.
This may make them put on some weight, particularly in the stomach area. Some women
also notice mild muscle cramps or slight vaginal bleeding (spotting). Rarely, progestogens
can cause breathlessness. If this happens you should let your doctor know.
Pituitary downregulators
Drugs known as pituitary downregulators reduce the production of oestrogen-stimulating
hormones from the pituitary gland.
This lowers the level of oestrogen in the body. Pituitary downregulators can be used to lower
oestrogen levels in women who have not yet had their menopause. Stopping the ovaries
from producing oestrogen is sometimes called ovarian suppression. Using a pituitary
downregulator has the same effect as removing the ovaries or giving them radiotherapy, but
the effect is reversible. As a result, many doctors now recommend these drugs, rather than
removing the ovaries with surgery or giving radiotherapy to stop them working.
They only work for oestrogen-positive breast cancers. The most commonly used pituitary
downregulator for women with breast cancer is goserelin (Zoladex®). Goserelin brings on a
temporary menopause, so many of its side effects are similar to those of the menopause and
include hot flushes and sweating, joint pain, lowered sex drive, headaches and mood
changes.
Many younger women find the symptoms of an early menopause difficult to deal with.
Although some menopausal symptoms can be uncomfortable, many can be effectively
treated.
Ovarian ablation
In women who have not yet had the menopause, it is sometimes possible to stop the growth
of their secondary breast cancer by stopping the ovaries from producing oestrogen. This is
known as ovarian ablation, and can be done either by removing the ovaries with an
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operation or by giving three or four radiotherapy treatments to the ovaries. In both cases, the
ovaries stop producing female hormones, which brings on the menopause.
When surgery is used, periods stop immediately. You will need to stay in hospital for 1–2
days.
When radiotherapy is given to the ovaries, women usually have one more period, which may
be heavy. Periods then stop completely. Contraception should be continued for three months
after radiotherapy.
Unlike pituitary downregulators, these treatments will mean that a woman will no longer be
able to have children. This definite end to being able to have children can be very distressing
to women already coping with secondary breast cancer.
Healthcare staff will understand the emotional effect this treatment can have on women. You
may find you want time to discuss the treatment with your partner, or someone close to you,
before deciding to go ahead. You can also contact our cancer support service to talk through
your feelings.
How it is given
Chemotherapy is usually given as a series of treatments known as cycles. Drugs may be
given weekly or every three weeks. Your complete treatment may last for several months.
Although some chemotherapy drugs can be given as tablets or capsules (orally) to be taken
at home, most are given by injection into a vein in the arm (intravenously). Chemotherapy
into a vein is usually given in the chemotherapy department as a day case.
Bruising or bleeding
Chemotherapy can reduce the production of platelets, which help the blood to clot. Let your
doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood
spots or rashes on the skin, or bleeding gums.
Sore mouth
Some chemotherapy drugs can make your mouth sore and may cause small ulcers. Regular
mouthwashes are important and the nurses will show you how to do these properly.
Poor appetite
If you don't feel like eating during treatment, you could try replacing some meals with
nutritious drinks or a soft diet. Our booklet on diet and cancer has some useful tips on coping
with eating problems.
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Hair loss
Hair loss is a common side effect of some chemotherapy drugs. This can be very distressing
for some people. However, there are many ways of covering up hair loss, including wigs,
hats or scarves. You may be entitled to a free wig from the NHS. Your doctor or the nurse
looking after you will be able to arrange for you to see a wig specialist. If your hair falls out, it
should start to grow back within 3–6 months of the end of treatment.
Tiredness
Chemotherapy affects people in different ways. Some people find they are able to lead a
fairly normal life during their treatment, but many become very tired and have to take things
much more slowly. Just do as much as you feel like and try not to overdo it.
Although they may be hard to deal with at the time, these side effects will gradually
disappear once your treatment is over.
Early menopause
Some women may find that chemotherapy makes them have their menopause early. See
the page 'possible effects on your sex life' for more information.
Trastuzumab (Herceptin®)
Trastuzumab (also known as Herceptin®) is a type of drug known as a monoclonal
antibody. It works by binding to particular proteins – HER2 receptors – on the surface of
breast cancer cells. This slows down or stops the cancer cells dividing.
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Herceptin® can only control a breast cancer if the breast cancer cells have a large number
of the HER2 receptors on their surface (see treatment overview). Around 1 in 5 (20%) of
women will have a large number of receptors − this is known as being HER2-positive. Your
doctor may have your cancer cells tested for HER2 protein.
The National Institute for Health and Clinical Excellence (NICE), recommend that women
with secondary (advanced) breast cancer can be given:
Herceptin® in combination with paclitaxel (Taxol®) chemotherapy. This combination is
only given if you haven’t previously been treated with chemotherapy for advanced breast
cancer, and if you aren’t suitable to be treated with chemotherapy drugs known as
anthracyclines, such as epirubicin and doxorubicin.
Herceptin® on its own if you have already had at least two different courses of
chemotherapy for advanced breast cancer, including an anthracycline chemotherapy and
a taxane chemotherapy, such as paclitaxel (Taxol) or docetaxel (Taxotere®). Hormonal
therapy should also have been tried if appropriate.
Herceptin® is usually given once every three weeks. It is given as a drip (infusion) into a fine
tube (cannula) inserted into a vein.
Lapatinib (Tyverb®)
Lapatinib is a newer type of biological therapy known as a growth inhibitor that is effective
against cancers that have large numbers of HER2 receptors on the surface. Growth
inhibitors interfere with the way that cancer cells 'communicate' with each other and can
affect the cancer’s ability to develop.
Lapatinib is a tablet. It is given in combination with the chemotherapy drug capecitabine
(Xeloda®), which is also a tablet. The National Institute for Health and Clinical Excellence
(NICE) has not yet recommended the use of lapatinib in the treatment of advanced breast
cancer. As a result it may not be possible to get the drug on the NHS.
Pain
There are different types of painkillers which vary both in their strength and in the way they
work. Some painkillers are better for certain types of pain and some suit certain women
better than others. If you are taking painkillers it is better to take them regularly, even if you
are not in pain when the next dose is due. This is because painkillers not only relieve pain at
the time, but work to prevent the pain coming back.
Painkillers can be taken as tablets or liquids by mouth, or as suppositories, which are
inserted into the back passage. Some are also given as injections under the skin.
It is important to tell your doctor if the painkillers you are taking aren't easing your pain. Your
doctor can either change the dose or change the painkillers to one that will be more effective
for you.
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Pain caused by secondary breast cancer cells in a bone can be severe. Radiotherapy is very
good at easing this type of pain, but can take 2–3 weeks to work. Often, drugs containing
morphine are needed while the treatment is being planned or while you are waiting for the
radiotherapy to work.
Some women find that morphine makes them feel drowsy when they first start taking it, but
this usually only lasts for a day or so. Taking morphine may make some women feel sick at
first and they may need an anti-sickness tablet (anti-emetic) prescribed by the doctor for the
first few doses. Morphine also commonly causes constipation.
Besides painkillers, a number of other drugs can be very helpful in relieving pain. If the pain
is due to secondary breast cancer cells in a bone, drugs known as non-steroidal anti-
inflammatory drugs (NSAIDs) can be very helpful. These drugs are often referred to as
anti-inflammatories and have few side effects other than sometimes irritating the lining of
the stomach.
Drugs known as bisphosphonates can also help to relieve bone pain. They may be given
into a vein (intravenously) in the outpatient department every 3–4 weeks. Some
bisphosphonates can be taken as tablets, but some of these must be taken on an empty
stomach an hour before food and may cause stomach upsets.
Bisphosphonates can help to strengthen bones and lower the risk of fractures. They can also
reduce high levels of calcium in the blood (hypercalcaemia) as well as reducing pain.
Your doctor can also prescribe sleeping tablets, or a mild relaxant, which may be particularly
helpful if you are having trouble sleeping because of the pain. Anxiety and lack of sleep can
make pain worse. For this reason some women also find that practising relaxation
techniques helps them feel more comfortable.
Heat and gentle massage can also help ease aches and pains. A good long soak in a warm
bath, a well protected hot-water bottle, and some baby oil or lotion massaged into the skin
can often make a difference.
Being in pain can make you feel very low and it is important to let your doctor know if the
drugs prescribed aren't working. It is also important to keep in mind that there are many
different ways in which pain can be controlled. There are also special NHS pain clinics run
by doctors and nurses expert in treating pain. You can ask your doctor to refer you to a pain
clinic if your pain is not controlled by any of the above methods.
Breathing problems
Breathing problems may happen either if the secondary breast cancer spreads to the linings
on the outside of the lungs (the pleura) or if the cancer has spread to the lungs themselves.
Cancer cells can irritate the sensitive pleura and cause a pocket of fluid to build up (known
as a pleural effusion).
This fluid can press on the lung, making it harder to expand the lungs fully, and so cause
breathlessness.
Pleural effusions can be treated by passing a narrow tube into the chest, between the ribs, to
drain off the fluid. This is done by first numbing the area with a local anaesthetic, then
passing the tube through the skin and betweenhe ribs to reach the outside of the lungs. The
tube is stitched securely to the skin on the chest and the other end is connected to a
drainage bottle. The tube may be left in overnight, or longer, to drain off as much fluid as
possible. This may mean you need to spend a few days in hospital.
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Once the pleural effusion has been drained the breathlessness will ease. The effusions can
be drained as often as necessary and sometimes a procedure called pleurodesis can be
done. This sticks the two linings of the lung together so that fluid cannot collect there.
If the cancer cells have spread to the tissue of the lungs, morphine can be used to relieve
the breathlessness. It can be very frightening to feel breathless, and anxiety and fear can
make breathlessness worse. Morphine makes people feel relaxed, which also helps to
control the breathing rate.
It is less effort for your lungs to expand if you are upright rather than lying completely flat.
Using extra pillows in bed or getting a large triangular support pillow (which can be bought
from most department stores) can help you stay more upright when you are in bed or resting
on a sofa. If treatment reduces the number of cancer cells, this will also help with
breathlessness.
Tiredness
You may find that you easily become very tired and that your body is no longer as strong
and reliable as it once was. This can be due to the cancer itself or because of the side
effects of treatment. It may feel as though you have no strength and everything is more of an
effort.
It can be difficult to adjust if tiredness makes it difficult for you to drive or take part in sports,
or if you have to walk more slowly than before. It will take time for you to get used to these
changes and to accept having to rest, or not being able to do activities that you once took for
granted.
If you have little energy, save it for the things you really want to do. Very often, re-organising
your daily activities can be helpful. It can also help if you set aside a time to rest every day.
Practical aids such as wheelchairs can also be useful. You may feel that by using a walking
stick, frame or wheelchair you are 'giving in' to your illness, but they can greatly improve your
life and allow you to move around more easily than you could on your own.
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Sometimes the cancer or the treatment can cause anaemia, which can lead to tiredness. If
this happens you can be given a blood transfusion, which can quickly give you more energy
and reduce the tiredness.
Constipation
Constipation can be caused by strong painkillers or by too much calcium in your blood
(caused by secondary breast cancer cells affecting a bone). Constipation can also occur if
treatment has made you lose your appetite and you are not eating as much as before.
Having fibre in your diet, drinking plenty of fluids and walking will help, but you may also
need to take a medicine to stimulate the bowel (a laxative). Your doctor will be able to
prescribe a suitable one for you. Your nurses can also advise you on ways to prevent or
relieve constipation.
Difficulty in sleeping
It is not uncommon for women with secondary breast cancer to have difficulty sleeping.
There can be many reasons for this. For example, pain may keep you awake, and it can be
difficult to sleep when you have a lot on your mind.
Sleeping tablets are often very effective. You can also try some home remedies for
sleeplessness − hot milky drinks before bed, a glass of spirits in the evening, warm baths
with soothing bath oils, or a relaxing body massage to relieve muscle tension.
Other therapies such as gentle massage can be carried out by relatives or carers and can
help them to support the person.
Physical contact and touch can be among the most powerful forms of support for people who
are faced with uncertainty, fear or pain, whether emotional or physical. Touching someone
gently can express how much you care about them.
Many hospices and hospitals offer complementary therapies alongside conventional care.
These may include:
aromatherapy
colour and sound therapy
massage or reflexology
relaxation, visualisation or guided imagery techniques
acupuncture.
Diet
Your body needs extra nutrients and calories during and after treatment for cancer. It is
important to try to keep eating well even if you haven't got much of an appetite. Eat little and
often. Make the most of ready-prepared meals for you and your family while you haven't
much appetite or energy for cooking. If possible, get someone else to prepare your meals.
Staying in hospital
It may take some time to recover from treatment for secondary breast cancer. For some
women treatment may involve a stay in hospital. Being inactive like this for even a few days
may leave you feeling physically weaker and perhaps nervous about how you will manage
when you go home. In this case it may help to spend some time with the hospital
physiotherapist and occupational therapist.
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The physiotherapist can design a programme of exercise for you and work with you to build
up your muscle strength and your confidence. The occupational therapist can help you
regain the confidence to manage at home and can offer practical advice.
Going home
Before you go home, you and your family may wish to talk to a hospital palliative care nurse
(sometimes called a Macmillan nurse), the ward manager or hospital social worker. They
can help with any immediate problems, including any financial worries you may have.
Your hospital doctor or discharge planning team can ring your GP's surgery to let them know
you are going home. They should also tell them about your condition and any treatment that
needs to be continued at home. The hospital nurse can refer you to a community palliative
care nurse (Macmillan nurse) to continue your care at home.
Work
It can be hard to judge the best time to return to work. Your decision if and when to go back
is likely to depend mainly on your type of work and whether your income is affected.
It is important to do what is right for you. Although it is not usually possible to cure secondary
cancer, many women can lead full and active lives for months or years.
Getting back into your normal routine can be very helpful and you may want to return to work
as soon as possible. Many women find that going back to work as soon as they feel strong
enough gives an opportunity to forget their worries, as they become involved with their job
and colleagues again. Talk to your employer about the situation − it may be possible for you
to work part-time or job-share.
On the other hand it can take a long time to recover fully from treatment for secondary breast
cancer and it may be many months before you feel ready to return to work. Don't feel
pressurised into taking on too much, too soon.
Your consultant or GP will be able to help you decide when and if you should return to work.
Hospices
Hospices provide day care services for people with cancer and can often give short-term
care or respite care, as well as care for people in the last few weeks of their life.
Hospices specialise in the control of pain and other symptoms and in supporting the person
with cancer and their family. People can go into a hospice for a short time to have any pain
or other symptoms controlled before going home again. Hospices are not just places where
people go to die, although many people think that this is the case.
Many hospices are purpose-built in pleasant grounds and are designed to be attractive and
comfortable. Many have kitchens, sitting rooms and accommodation for relatives. Activities
are provided for people who are well enough to take part. They are smaller and quieter than
hospitals and work at a gentler pace.
Accommodation and care in a hospice is always free of charge. Some are set up by the NHS
and others are funded by charities. Sometimes there is a waiting list, but this is not usually
longer than a few weeks. Many hospices also have nurses who go out to visit people in their
own homes, and day care centres for people who are living at home.
Nursing services
Whether you have been in hospital or not, you may benefit from a visit from a district nurse,
a palliative care or Marie Curie nurse, or a hospice nurse. The hospital nurses or your GP
can make the arrangements for you. It is also possible to have a private nurse at home, but
this can be expensive. Nursing agencies are listed in your local phone book.
Our booklet on caring for someone with advanced cancer gives more information on
services available to support you.
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Early menopause
An early menopause can be caused by chemotherapy or hormonal therapy. This can lead to
uncomfortable menopausal symptoms, such as hot flushes and dryness of the vagina. As
the early menopause has been caused by treatment, any symptoms may appear suddenly
and will be more severe than those for women who have a natural menopause. This can be
very distressing.
Some of the most common effects are discussed below.
Hot flushes
Hot flushes often happen at night and can make you feel very uncomfortable. Although they
don't have a direct physical effect on sex, if you are feeling irritable and uncomfortable you
will obviously feel less like making love.
You may feel more comfortable if you wear loose cotton nightclothes, or sleep naked, and
have cotton sheets or a light duvet on the bed. Leaving a window open in the bedroom at
night may also help you to feel cooler. This distressing symptom will pass gradually as your
body becomes used to the lack of oestrogen.
Tiredness
If you have fatigue (continual tiredness that is not relieved by rest) and do not have much
energy it might help to make love differently. Less energetic positioning, where your weight
is well supported, can reduce strain. You may prefer shorter sexual contact rather than
longer sessions.
These are things you can talk about together. You could try identifying times when you feel
most energetic and set aside some of this time for lovemaking.
Vaginal dryness
You may have vaginal dryness due to lower levels of oestrogen. This means that the vagina
cannot produce enough moisture when you are sexually aroused. It may make intercourse
difficult and uncomfortable.
This can be helped by a number of creams and gels that can be applied directly into the
vagina. Replens® is a non-hormonal cream available from most chemists. It is applied 2–3
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times per week and works for about 72 hours at a time. The cream binds to the vaginal wall
and the water held within it re-hydrates the cells and boosts the blood flow in the vagina.
Ovestin®, Ortho-gynest®, and Premarin® are available on prescription from your doctor.
They contain a very small amount of oestrogen and can be used as a cream or a pessary.
The effect in the vagina is short lasting. Vagifem®, also available on prescription, is a tablet
that can be inserted into the vagina up to twice a week. It also contains a small amount of
oestrogen. Although the amount of oestrogen in these products is very small there is a small
risk that they may increase the amount of oestrogen in the body. As a result, women who
are taking aromatase inhibitors (such as Arimidex®) should talk to their doctor before using
hormonal vaginal creams, gels and pessaries.
Water based lubricants such as KY Jelly, Senselle®, Astroglide® and Sylk® which can be
brought at a chemist, can help to increase moisture levels, making sex easier. Some women
prefer to use glycerine: it is cheap and not embarrassing to buy as it has many uses.
Infertility
Loss of their ability to have children causes a great deal of distress to many women. They
may grieve deeply for the loss of their chance to have a child or to have more children.
Women may also feel less feminine.
Sometimes these emotions are too strong to cope with alone. It may help to talk over your
feelings with your doctor or specialist nurse. A trained counsellor can be invaluable in
helping you work through emotions which threaten to get too much for you. Your partner
may also have feelings of sadness and may benefit from being included in such discussions.
They may want to see a counsellor on their own.
Our cancer information and support service can tell you more about counselling and let you
know about services in your area.
Communication
Communication is an important part of a healthy sexual relationship. It may help to overcome
sexual problems if you talk about your concerns with your partner and plan ways to cope
with any problems which will suit both of you.
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Symptoms
Controlling symptoms is important. Anti-sickness drugs and painkillers are very effective and
you could try to plan your doses so that they have a maximum effect when you most like to
make love.
The most important thing to remember is that there is no medical reason for you to stop
making love if you have secondary breast cancer. Cancer is not contagious and sex will not
make your cancer worse.
You can fill this in before you see the doctor or surgeon, and then use it to remind yourself of
the questions you want to ask, and the answers you receive.
1. _______________________________________
Answer _______________________________________
_____________________________________________
2. _______________________________________
Answer _______________________________________
_____________________________________________
3. _______________________________________
Answer _______________________________________
_____________________________________________
4. _______________________________________
Answer _______________________________________
_____________________________________________
5. _______________________________________
Answer _______________________________________
_____________________________________________
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To help other patients and their families we need and intend to extend our Patient
Information Services in many ways.
Our Trust depends on voluntary donations. Please send your donation by Cheque or D/D
payable in Mumbai in favour of “JASCAP”.
This JASCAP booklet is not designed to provide medical advice or professional services and
is intended to be for educational use only. The information provided through JASCAP is not
a substitute for professional care and should not be used for diagnosing or treating a health
problem or a disease. If you have, or suspect you may have, a health problem you should
consult your doctor.
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JASCAP