After-cancer care: dealing with the long-term effects of cancer treatment

As more women live for many years after having had cancer, health professionals are beginning to realise that they need to support them more with the long-term side effects of cancer treatment.

Martha Hickey, professor of obstetrics and gynaecology at the University of Melbourne, Australia, was in Dublin recently to give a public lecture on these long-term side effects and to look at how Irish health professionals can help women deal with issues including infertility, early menopause, sexual problems, mood and sleep disturbances.

“Cancer treatments affect women differently from men and what we’ve done in Melbourne and Perth is to have multidisciplinary clinics where women with different cancers can come to address a number of different symptoms,” Prof Hickey said.

It all started when a breast cancer surgeon came to me and said, we've got to do something for these women

These clinics – at the Royal Women’s Hospital and Monash Medical Centre in Melbourne and at the King Edward Memorial Hospital in Perth – were the first of their kind to offer women access to multidisciplinary teams to support them with post-cancer health problems.

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“It all started when a breast cancer surgeon came to me and said, we’ve got to do something for these women. Now, these clinics are all run within existing hospital services,” she explained. Tele-health services where women can have a clinical appointment via a phone call were added to the service in 2018.

Prof Hickey has travelled to the UK, New Zealand, the United States and now Ireland to help cancer health professionals introduce similar clinics into their healthcare system.

For example, many women have sexual health problems after cancer. “The problem is that we are bad at talking about them so they are badly managed or not managed at all. Women need the opportunity to be asked about their sexual function and given help, advice and support,” said Prof Hickey.

Menopausal symptoms such as hot flushes and dry vagina are common post-cancer symptoms with which women also need support. Mood disturbances (including depression) and sleep are other issues – sometimes related to being woken up at night by hot flushes.

“One of the issues for breast cancer survivors is that they have to take anti-oestrogen therapy for up to 10 years after treatment. Research has found that 40-60 per cent of these women don’t take the medication for the required length of time because it impacts on their quality of life.” Cognitive-behaviour therapy, hypnosis and some anti-depressants are non-hormonal approaches which Prof Hickey recommends to deal with menopausal symptoms caused by cancer treatments.

Twenty-five per cent of breast cancer patients are diagnosed when they are still fertile

Infertility caused by cancer treatment is a complex issue to face in the maelstrom of coping with a cancer diagnosis and ensuing treatment. “Twenty-five per cent of breast cancer patients are diagnosed when they are still fertile and treatments for breast cancer, gynaecological cancers and blood cancers can all bring on infertility. The radiation treatment for anal-rectal cancers can also cause infertility,” she explained.

“It’s a very tough time for women and oncologists don’t [always] have time or knowledge to discuss fertility options before treatment,” said Prof Hickey. So, her team of researchers devised a “decision aid” in the form of a questionnaire so women can weigh up their personal circumstances and values around whether to protect their fertility before cancer treatment.

“We found that women can make quicker decisions and have less regret when they use this tool,” she said. Prof Hickey’s research team is developing another tool which will allow women and their doctors calculate the likelihood of infertility after cancer treatment.

Women will also need support with infertility issues post-cancer treatment. “Following chemotherapy, women’s periods might stop for five years but then, they may come back again which has implications for contraception,” she said.

This patient-led web-based programme recognises that the number of cancer survivors is increasing and hospitals don't have the capacity and GPs don't have the specialist knowledge to manage them

Researchers in Australia are also developing an online platform for women who have had cancer. This so-called Women Can project will enable women to calculate the severity of their symptoms and then get directed to more information, online treatments or hospital services depending on the severity of their symptoms.

“Women want to manage their own health. And this patient-led web-based programme recognises that the number of cancer survivors is increasing and hospitals don’t have the capacity and GPs don’t have the specialist knowledge to manage them,” said Prof Hickey.

There are about 200,000 cancer survivors in Ireland, the majority of whom are women. One in four people have physical or psychological issues following treatment.

And following discussions with Prof Hickey, cancer specialists here are looking at how clinics for women post-cancer treatment could be introduced into Ireland.

"The National Cancer Control Programme [NCCP] will conduct a Cancer Survivorship Needs Assessment to find out the most suitable model of survivorship healthcare in Ireland," said Michael McHale from the Irish Cancer Society.

“The Irish Cancer Society is working closely with the NCCP to make sure such work is done speedily and effectively, while ensuring that the needs of patients and survivors remain at the centre of all decision-making,” he said.