Beyond Breast Cancer

By Christine Baker

Most women diagnosed with breast cancer experience emotions such as shock, anger and distress. For Dr Christine Baker, former Director of the Brisbane Royal Women's Hospital Breast Screening Service with more than 40 years' experience working in the field, it was no different. Despite her extensive knowledge about breast cancer causes and treatments, she asked, 'Why has my body let me down?'

Beyond Breast Cancer is the result of Christine's comprehensive research into ways in which breast-cancer survivors can help themselves post treatment. She stresses that, along with regular breast checks, survivors should take charge of their health to limit any recurrence. Divided into three parts, this book discusses the relationship between cancer and the body, the consequences of treatment, and how to devise a survivorship care plan. A 'Helpful Advice' section in each chapter identifies what actions you can take to ensure a healthier future.

Beyond Breast Cancer arms you with the knowledge to become more proactive and empowered in planning how to recover, restore and rebuild your health.
 

• Language: English
• Publisher: Christine Baker
• Release date: Jul 20, 2022
• ISBN: 9780645435016

Christine Baker

Dr Christine Baker’s formal qualifications and research background in health planning made her the perfect  candidate to help set up the state government’s mobile breast screening service for women in Queensland. With more than 40 years’ experience working in breast screening services and as a survivor of breast cancer herself, Christine is ideally suited to write a book called Beyond Breast Cancer.

Book preview

Introduction

Nearly every woman who is diagnosed with breast cancer queries how she might improve her survival or prevent a recurrence. I was no different when I was diagnosed with breast cancer in 2004. At that time, I had been involved in screening and diagnostic breast clinics for over 22 years. But my own diagnosis still came as a big shock.

As a doctor with extensive experience in the screening and diagnostic side of breast cancer, I knew more about breast cancer than most women. I knew what standard treatment options were available: surgery, radiotherapy, maybe chemotherapy, with possibly some adjuvant treatment such as tamoxifen or an aromatase inhibitor. What I didn’t know was what I could do personally to improve my survival or prevent a recurrence.

I was aware that my survival would most likely be dependent on the final pathology, namely, the size of the cancer, nodal involvement, receptor status and evidence of any possible metastases. Fortunately, my breast cancer was under one centimetre in size, I didn’t require any chemotherapy, and I also decided to have a mastectomy, so no radiation was required in my case.

But like most women with breast cancer, I was angry and upset that it had happened to me. My anger finally resolved after a few months of daily 30-minute walks, which I later found out from my research is beneficial after a breast cancer diagnosis. The other concern nagging at me was, why had my body let me down? Why hadn’t my body been able to stop this cancer developing? But I had it wrong; I had asked too much of my body.

My lifestyle prior to the breast cancer diagnosis was exceedingly busy. I was full-time director of a breast screening clinic in Brisbane, including two days a week as director of a regional service, developing and managing the breast screening mobile service, and relocating the existing North Brisbane service to a new site. At the same time, I was assisting with the health of elderly parents, going through a divorce, undertaking tertiary study, and to top it all off, adhering to advice from a colleague, I had started on hormone replacement therapy (HRT). I had not looked after my body!

Having become aware of the Australian College of Nutritional and Environmental Medicine (ACNEM) and their more biomedical approach to medicine, I became a member of ACNEM and began studying towards their certificate in Nutritional and Environmental Medicine. The first subject was Epigenetics and Nutrigenomics – how nutrition and the environment may alter the genome (DNA), which ultimately is reflected in our health status. Damage to the DNA is where breast cancer begins, so I had started my research in the correct area.

As I began to research breast cancer survival for myself in medical journals, I was overwhelmed by the number of articles, and the complexity and extent of information available. One article led to another through references, so Pub Med was well used.

It soon became obvious to me that as our body is extremely complex, there is a close interaction and a synergy between all functions in the body. For example, weight is the result of metabolism, nutrition and physical activity, which can then influence the immune system. A healthy immune system can protect against disease from foreign invaders.

After completing breast cancer treatment, we need to repair, restore and return our body to the best it can be, so that it works like a well-oiled machine to deliver optimal health and wellness.

Our whole body in some way is affected by a cancer diagnosis, so the systems and body functions most involved are the subject of the first part of this book. The second part is devoted to explaining how treatment for breast cancer may have long-term consequences of which survivors need to be made aware. Finally, the concept of a comprehensive survivorship health care plan for wellness is discussed, with information on how to develop your own plan to improve your overall health.

The information in this book is not intended to replace any advice or treatment recommended by your medical specialists, or general practitioner (GP). Your treatment has been developed by your specialists to give you the best outcome for your stage of the disease. I will not be recommending, discussing or comparing treatment options.

The main aim of this book is to give you control over your health into the future. The information and knowledge I provide about what you can do to improve your health after completing your breast cancer treatment will enable you to transition to your own health care plan.

You have done everything asked of you to finish your breast cancer treatment. Now it’s time to become engaged in your future health and wellness.

I hope this book ‘opens the door’ for you by giving you information and answers about what you can do for yourself, what regular tests and check-ups you need from your GP and specialists, and why you need to be so vigilant in the future.

Background

‘Once a person is determined to help themselves,

there is nothing that can stop them.’

– Nelson Mandela

Idecided to write this book about 4 years ago because many women were asking me how to look after themselves once they had been diagnosed with breast cancer. When I was diagnosed in 2004, there was little information available on how best to look after yourself once your treatment was completed. However, cancer councils had breast cancer volunteers who visited women in hospital. When the volunteer who visited me told me she had had breast cancer 25 years previously, I thought, if she can survive that long so can I.

After treatment, I was advised to see my specialist yearly, have a yearly mammogram and/or ultrasound, and check my breasts each month for any new signs or symptoms. This is standard advice to all women who have been treated for breast cancer.

Breast care nurses were invaluable to women having chemotherapy, for example, explaining about symptoms resulting from chemotherapy. However, information on changes to lifestyle such as weight management, nutrition and exercise only began to appear in medical journals around 2008–2011. So, women who had completed their treatment did the best they could to look after themselves.

Having done postgraduate degrees, I was fortunate that I was able to do my own research into breast cancer ‘survivorship’, which was then a new term being used to identify women or any other person who’d had a cancer.

The main areas of interest then for most women who’d had breast cancer were what foods could you eat that were full of antioxidants and making sure you had good movement in your shoulder on the affected side where your breast cancer was treated. Women were also interested about the ingredients in cosmetics and if that could have contributed to them getting breast cancer.

In 2000, I had become interested in making my own cosmetics, soaps and lotions using pure essential oils. I used natural preservatives instead of parabens, which are endocrine disruptors that affect and can mimic oestrogens in your body. It was this early interest in more natural cosmetics that encouraged me to look in more detail at the overall increase in our exposure to everyday chemicals and pesticides, especially in agricultural areas.

Through my work, I met many women who wanted to know what they could do to ensure they had a healthy lifestyle after a breast cancer diagnosis. One woman asked me to write a book about how to look after yourself once you’d had breast cancer, so that request, together with encouragement from my family, prompted me to do so.

Every medical article on breast cancer survival always starts with statistics on breast cancer and risk factors, so I will do the same.

Statistics

In 2021 it was estimated that 20,030 Australians, 19,866 women and 164 men, would be diagnosed with breast cancer in 2021.(*) Breast cancer is the most common cancer in Australian women, with on average 53 people being diagnosed every day. The risk of being diagnosed with breast cancer by age 85 is 1 in 8 for women and 1 in 829 for men.

_______________

* Even though men can also develop breast cancer, I only refer to women in this book as the vast majority of people who get breast cancer are women.

The number of women with breast cancer is increasing. In 1982, when I was appointed the first Medical Director of The Wesley Breast Clinic in Brisbane, the risk of developing breast cancer was 1 in 14; now this risk has increased to 1 in 8. With the introduction of breast screening in Australia in the 1990s, breast cancer detection rates have increased.

Australian breast cancer survival is one of the best in the world. Five-year survival rates have improved from 76% in 1988–1992 to 92% in 2013–2017. It is thought that the increase in breast cancer survival is due to earlier diagnosis and improvements in treatment.

At the end of 2016, more than 77,236 women were alive who had been diagnosed with breast cancer in the 5-year period 2012–2016.(¹)(²)

Survival is influenced by many factors: the type of breast cancer and the size, whether any lymph nodes are involved, are oestrogen, progesterone or Herceptin receptors positive or negative, as well as the age at which the woman developed breast cancer. These factors are well documented, and they soon become part of your language once you are diagnosed with breast cancer.

Some tumours like ductal carcinoma in situ (DCIS) have a better prognosis than an invasive breast cancer, mainly because this type of early cancer has not invaded surrounding breast tissue. If the lymph nodes are not involved, again this usually means a better prognosis. And oestrogen and progesterone positive tumours behave differently to oestrogen and progesterone negative tumours and so treatment is different. If the HER2 (human epidermal growth factor receptor 2) is negative, the tumour does not need treatment with Herceptin, whereas if the HER2 is positive, it does.

Age is an important risk factor, with younger women sometimes having a more aggressive tumour which can be more challenging to treat, whereas older women may have other medical conditions which complicate treatment options.(¹)

Unfortunately, you may have been included as part of these breast cancer statistics, but these statistics also show that today your likelihood of survival is much higher than it has ever been. However, your survival is influenced by many factors, including the type and size of your cancer, your treatment, your age, other medical conditions, your health, your diet and your lifestyle. We will explore these things further in the following chapters.

Survivorship

Once a woman has completed her treatment, she is often left wondering to whom she can turn, for ongoing care and support. The word ‘survivor’ is often used to identify these women. Even though I use the medical word survivor (which I don’t like), I think of each woman as having a ‘specific outcome’ which is particular to her. Medical papers compare 5-year survival rates for different types of treatment, which is necessary for scientific research to establish the best forms of treatment. Medically, the word survivor has been used to collectively describe a group of people who have had similar treatments, but we all know that each person is an individual who has a specific outcome dependent on how their body responds. For some women, being a survivor begins when they start cancer treatment but for others, it begins after treatment, when they start seeing their family doctor as part of their follow-up.(³)

Another common definition for surviving is the process of living with, through and beyond cancer.(⁴) This is why I decided to call my book Beyond Breast Cancer as I feel we need to look to the future after our treatment is completed.

Survivorship is a time of transition when concerns related to long-term follow-up care, management of late effects, rehabilitation and future health welfare are most important. This survivorship period is now recognised as a specific phase along the cancer trajectory.(⁵)

In 2005, the US Institute of Medicine in its report ‘From Cancer Patient to Cancer Survivor: Lost in Transition’, recommended that as part of optimal survivorship care, a ‘Survivorship Care Plan (SCP) should be provided to every patient upon completion of treatment’ or a ‘comprehensive care summary and follow-up plan’ be provided as a means of improving patient-reported and health-related outcomes such as distress, confidence and quality of life.(⁶)(⁷)

This report was ground-breaking research which identified that there were gaps in the ongoing care of people diagnosed with cancer. The title says it all – Lost in Transition.

The SCP can include summaries of the patient’s cancer type and treatment history, future screening recommendations, any potential post-treatment issues, signs of recurrence, guidelines for lifestyle modifications and important community resources.(⁷) Sometimes, there is a lack of coordination in this transition from active treatment to the GP. The SCP can offer direction and assist with communication, so that you can be supported to receive the appropriate follow-up care in a timely manner.(⁷)

Your needs as a breast cancer survivor are varied depending on the outcome of your treatment. Currently, this care is provided by surgeons, oncologists, GPs and breast care nurses depending on the cancer care setting. Follow-up care for breast cancer survivors is currently a clinical breast examination, a yearly mammogram and ultrasound with a possible MRI (magnetic resonance imaging), if indicated, to exclude a recurrence. Oncologists and surgeons monitor adjuvant therapy, radiotherapy and chemotherapy treatments, usually over a 5-year period, after which you are discharged back to the care of your GP.

Lifestyle changes have been shown to reduce the risk of recurrence in breast cancer survivors, especially physical activity, improved nutrition, weight management, smoking cessation and adhering to recommended alcohol consumption. Once I became aware of these lifestyle changes, I began further research and have now identified how other bodily systems are involved in a breast cancer diagnosis. These specific lifestyle changes that we will look at in the following chapters can also reduce your risk of breast cancer recurrence.

Hallmarks of cancer

My research led me to two important papers by Douglas Hanahan and Robert Weinberg published in 2000 and 2011 discussing ‘The Hallmarks of Cancer’(¹³) and ‘Hallmarks of Cancer: The Next Generation’(¹⁴). Their papers discussed how ‘normal cells evolve progressively to a neoplastic state’,(¹⁴) i.e., become cancerous.

They identified that cancer cells:

stimulate their own growth,

are resistant to processes that might stop their growth,

avoid their own death, which normally occurs as cells become old or damaged and self-destruct – a process called ‘apoptosis’,

can multiply indefinitely,

stimulate the growth of blood vessels to obtain nutrients (angiogenesis),

invade surrounding non-cancerous tissue to spread within the body (metastasise).

In the more recent paper, the authors identified four new hallmarks (or distinctive features) of cancer cells. Cancer cells can:

appear invisible to the immune system, which normally destroys invaders,

use chronic inflammation produced by the cancer itself, to increase its growth,

use glucose (sugar) as its preferred nutrient to grow instead of oxygen, known as the Warburg effect or ‘aerobic glycolysis’,(¹⁵)

make the genome (DNA) more unstable in the cancer cell and therefore more aggressive.

After reading about the new hallmarks in the second paper, I questioned if these topics would be relevant to breast cancer survivors. Further detailed research about these four hallmarks is becoming more prevalent in medical journals, so I have included information discussing DNA, the immune system, the role of sugar, the effect of inflammation and the contribution of the environment to provide you with additional knowledge to help you achieve a healthy body.

If you hope to avoid a recurrence of breast cancer, it is important for you to understand how cancer cells work and for you to be proactive about your overall health.(⁸)

Survivorship Care Plans (SCPs)

Below is a brief overview of some SCPs in use today.

The National Cancer Survivorship Initiative (NCSI) of the United Kingdom in August 2014 announced the start of a new ‘Living With and Beyond Cancer Programme’.(⁹) The vision of the NCSI is that those living with and beyond cancer are supported to live as healthy and active a life as possible. Part of this programme, ‘The Recovery Package’, focuses on providing access to a holistic needs assessment clinic, where a treatment summary is developed, which includes cancer care review, patient education and support in the form of a ‘Health and Wellbeing Clinic’. This Wellbeing Clinic promotes physical activity, healthy weight management, and nutrition, and addresses the management of the consequences of treatment.

The holistic needs assessment clinic focuses on all a person’s concerns, which might include medical, psychological, social, spiritual, financial and informational needs, which are discussed with the patient’s doctor. This results in a care plan being developed to transition the patient to supported self-management.(⁹)

This care plan includes issues related to diagnosis and prioritises the individual’s concerns with specific actions and approaches to address them, thereby providing a cultural shift away from a focus on cancer as an acute illness, to a greater focus on recovery, health and wellbeing and return to work.(¹⁰)

The American Society of Clinical Oncology (ASCO) has developed cancer treatment summaries and SCPs for breast cancer patients, which can be found on Cancer Net (https://www.cancer.net). The ASCO answers ‘cancer survivorship’ questions and gives detailed information on the full range of issues identified by breast cancer patients during and after breast cancer treatment.(⁴)

Closer to home, the Australian Cancer Survivorship Centre (ACSC), based at Peter MacCallum Cancer Centre Melbourne, was established in 2009 to help improve outcomes for Australian cancer survivors.(³) A survivorship care plan for GPs was implemented in 2011 and assessed, showing that the SCPs were useful. Even though the GPs endorsed the concept of the SCP, longer consultations for the patients resulted. The patients found the SCP especially useful, with over 80% finding information about resuming or initiating healthy lifestyle behaviours following cancer treatment to be particularly helpful.(¹¹)

Research is ongoing about the effectiveness of SCPs for survivors. However, the SCP has assisted with the assessment and symptom management of survivors in the longer term and could assist with surveillance and communication between all involved, to transition from a medical model to a ‘wellness model’.(¹²)

Your own plan for wellness

Finally, with the information in this book, you will know how to improve your own health to reduce your risk of a possible recurrence; be able to document your own breast cancer history; know what, why, and when, medical checks are needed; and be aware of any consequences of your treatment which may occur in the future.

Surviving breast cancer involves you developing your own total health care strategy, because even though you had breast cancer, being healthy means you have a better chance of survival than do unhealthy women.(⁸)

You will become vigilant, empowered and more confident in managing your own breast health.

References

1. Breast cancer in Australia: an overview. Cancer series no 71. Australian Institute of Health and Welfare, Canberra. http://www.aihw.gov.au/. https://breast-cancer.canceraustralia.gov.au/statistics

2. Breast Cancer Network Australia. https://www.bcna.org.au

3. Australian Cancer Survivorship Centre (ACSC). (2013) http://www.petermac.org/cancersurvivorship

4. American Society of Clinical Oncologists. (2021) Cancer survivorship: practical and trusted information to manage life after cancer from the American Society of Clinical Oncology. Cancer.Net. https://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf

5. Grunfeld E, Earle CC. (2010) The interface between primary and oncology speciality care: treatment through survivorship. Jn Nat Can Inst Mono, 40.

6. Hewitt M, Greenfield S, Stoval E (Eds), (2005) From cancer patient to cancer survivor: lost in transition. Washington, DC: National Academies Press.

7. Daudt HM, van Mossel C, Dennis DL, et al. (2014) Survivorship care plans: a work in progress. Curr Oncol 21(3), e466–79.

8. Bodai BI. (2015) Breast cancer survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations. Perm J 19(2), 48–79.

9. Department of Health, Macmillan Cancer Support, NHS Improvement. (2013) Living with and beyond cancer: taking action to improve outcomes (National Cancer Survivorship Initiative). https://www.gov.uk/government/publications/living-with-and-beyond-cancer-taking-action-to-improve-outcomes

10. Jefford M, Rowland J, Grunfeld E. (2013) Implementing improved post-treatment care for cancer survivors in England, with reflections from Australia, Canada and the USA. Br J Cancer 108, 14–20.

11. Australian Cancer Survivorship Centre (ACSC) (2014) Evaluation of the implementation of survivorship care plans at Peter MacCallum Cancer Centre. http://www.petermac.org/cancersurvivorship.

12. Kessing S, McNamara B, Rosenwax L. (2014) Cancer survivors’ experiences of using survivorship care plans: a systematic review of qualitative studies. J Cancer Surviv 9(2), 260–8. https://doi.org/10.1007/s11764-014-0407-x.

13. Hanahan D, Weinberg RA. (2000) The hallmarks of cancer. Cell 100, 57–70.

14. Hanahan D, Weinberg RA. (2011) Hallmarks of cancer: the next generation. Cell 144, 646–74.

15. Warburg O. (1956) On respiratory impairment in cancer cells. Science 124, 269–70.

PART 1

YOUR BODY AND

BREAST CANCER

Chapter 1

How is your weight related

to the likelihood of

breast cancer recurrence?

‘It always seems impossible until it’s done.’

– Nelson Mandela

After a diagnosis of breast cancer, it is important to maintain good health. This requires a change in lifestyle to one that helps fight breast cancer and improves future long-term health. We’ll start with lifestyle factors as they have been linked to improved survival and a decreased risk of recurrence of breast cancer.

The first three chapters on Weight Management, Nutrition and Exercise are all interconnected. These chapters discuss lifestyle factors that may be modified to achieve a much better outcome for breast cancer survivors. Each subject will be dealt with individually, but there is more research showing how changing one factor influences the other two.

The number of people worldwide who are overweight or obese has increased rapidly over the last two to three decades. Australia is no exception, with nearly 60% of Australian women being overweight or obese. Unfortunately, some women with breast cancer are also overweight, which is a risk factor that can contribute to your long-term survival.

It is important for everyone to maintain a healthy weight,

but after breast cancer even more so,

as studies show a link