Managing Side Effects Associated with Breast Cancer Diagnosis and Therapy

Clinical Pearl: Use of clinically approved screenings for distress and conversations with partners or caregivers can provide a more holistic view of a patient’s emotional health compared with just a direct one-on-one conversation.

GS is a 37-year-old premenopausal woman with no significant past medical history who presented to her gynecologist with a palpable right breast lump. She is G2P2 and has completed childbearing. She had a mammogram and an ultrasound that showed multiple right breast masses and enlarged lymph nodes in the right axilla. Ultrasound-guided biopsy of her breast mass confirmed grade 2 invasive ductal carcinoma (ER+, 95% strong intensity; PR+, 3% weak intensity; and HER2-). Ultrasound-guided biopsy of the right axillary lymph node showed metastatic metastatic ductal carcinoma. At her initial office visit with medical oncology, she reported midline back pain without any known injury. A CT of the chest, abdomen, and pelvis and a nuclear bone scan were ordered. Her chest CT showed a sclerotic lesion on the T8 vertebral body compatible with osseous metastatic disease, and her bone scan showed metastatic lesions in the thoracic spine and bilateral ribs. The patient underwent a T8 bone biopsy that confirmed metastatic carcinoma of breast origin that was ER+/PR+/HER2-.

Suppression of ovarian function (SOF) using 3.6 mg of goserelin injection every 28 days was initiated, and then CDK 4/6 inhibitor and letrozole were subsequently added. Education was provided on the potential side effects of each therapy. The patient developed mild side effects after the first cycle of goserelin, including mild headache and vaginal dryness which she reported as tolerable. She also admitted to feeling really overwhelmed and having worsening depression symptoms and crying frequently and wondered if this was related to her treatment. Her husband has noticed that she seems visibly emotional and depressed several days per week and worries that the patient might not be able to continue with therapy.

The AP conducted a distress screening with findings of a low distress rating. The AP discussed with the patient and her husband that headaches, vaginal dryness, and mood change are associated with the patient’s current therapy plan. The patient expressed an interest in treatment for the symptoms and verbalized a willingness to continue with therapy. Shared decision-making resulted in a plan for the patient to take acetaminophen for severe headaches, use vaginal moisturizers, lubricants, and gel for vaginal dryness, and undergo a trial of venlafaxine for mood changes. The AP scheduled a follow-up appointment in 4 weeks for reassessment and initiated a referral to social work to provide information on local support groups.

The patient had repeat CT and bone scans 3 months later that showed no disease spread and improvement in her bone lesions. She was tolerating therapy, felt side-effects had improved, and was feeling well. She will continue this combined treatment, as long as tolerated, until disease progression.

Fertility Preservation in a Premenopausal Patient

Clinical Pearl: Conversations regarding fertility preservation should be initiated as early as possible, as use of Suppression of ovarian function (SOF) during chemotherapy has been shown to be successful for premenopausal women.

CC is a 30-year-old premenopausal woman who presented with a palpable mass in her right breast. A bilateral mammogram showed a 1.6-cm mass in the lower outer quadrant of her right breast. An ultrasound-guided biopsy was completed, and pathology was consistent with a grade 3 triple-negative invasive ductal carcinoma. She was seen by a medical oncologist who recommended neoadjuvant chemotherapy with four cycles of doxorubicin and cyclophosphamide and four cycles of paclitaxel, followed by surgery. Fertility preservation was discussed at her initial office visit, and she expressed that prior to her breast cancer diagnosis, she and her husband had been hoping to conceive in the next year. Because of this, the patient strongly desired fertility preservation prior to starting chemotherapy.

She was seen by a cancer center oncofertility AP for a consultation and was referred to an outside reproductive medicine practice to begin the egg harvesting process, which typically takes 2-3 weeks.¹ Embryo cryopreservation is a long-established method of fertility preservation, as is mature oocyte cryopreservation. Both of these processes require ovarian stimulation followed by egg retrieval, which would occur before SOF and chemotherapy. Although ovaries can be stimulated during or immediately after chemotherapy, the quality of the eggs harvested might not be as good as those that are harvested prior to therapy. Ovarian tissue cryopreservation, which entails removal of the entire ovary or corticol biopsies for cryopreservation, is an experimental technique for patients who require immediate treatment.²

Part of this patient’s fertility-preservation plan was for SOF during chemotherapy. One week prior to chemotherapy 3.6 mg of goserelin was initiated and it was continued every 28 days through the completion of chemotherapy. After neoadjuvant chemotherapy, she completed a right breast lumpectomy and adjuvant radiation. One year after completing all her treatments, she became pregnant. She had a normal pregnancy and delivered a full-term baby boy.

Resources

1. DukeHealth website. Fertility Preservation for Cancer Patients. Accessed August 23, 2023. https://www.dukehealth.org/treatments/obstetrics-and-gynecology/onco-fertility
2. Smith KL, Gracia C, Sokalska A, Moore H. Advances in fertility preservation for young women with cancer. American Society of Clinical Oncology Educational Book. 2018;27-37.