Breast Cancer Survivorship

Even after treatment ends, your cancer journey continues. Many cancer survivors refer to the time after treatment ends as the “new normal.” It may take you a while to readjust to life after treatment. You may wish to make changes in your nutrition and lifestyle to help prevent recurrence.

Follow-up care after completing breast cancer treatment is very important. Your healthcare team will help you manage long term side effects and watch for any changes such as the cancer occurring in the other breast, spreading, or coming back. Here are some things to remember about follow-up care:

  • Continue your monthly breast self-exams.
    • If you had surgery (mastectomy, lumpectomy, or reconstruction), wait until the area has completely healed from surgery.
    • If you are having radiation, resume your self-exams after completion of treatments.
    • Look at your breasts for differences in your breast tissue or your nipples. Report any changes to your healthcare team.
  • Always go to your follow-up appointments.
    • You will probably have follow up exams following treatment depending on the stage of your cancer. If you have any symptoms or changes, contact your healthcare team immediately. A typical schedule could be:
      • Every 3-6 months until you are 3 years past treatment
      • Every 6-12 months from 4-5 years past treatment
      • Once a year if you are 6 years or more past treatment
    • If you notice any changes in your health, always let your healthcare team know.
  • Follow your recommended breast screening schedule.
    • Your screening schedule will depend on the stage of your cancer and other aspects of your medical history. Your healthcare team will decide what type of screening is best for you: mammogram, mammogram ultrasound, tomosynthesis, breast MRI, or PET scan.
  • Speak to registered dietitian about nutrition.
    • Maintaining good nutrition after breast cancer treatment can be difficult.
    • Especially if your treatment affected your body's hormone production, you may need to watch for weight gain.
  • If you change your primary care physician, make sure your new doctor has all your medical records and history.
  • Tell your doctor about any side effects.
    • Some side effects occur after treatment ends. Let you healthcare team know of any and all changes so they can help you manage them effectively.
  • Keep your health insurance if at all possible.
    • Follow-up care, especially imaging, can be very expensive if you do not have health insurance.

Eat at least 7 servings of fruits and vegetables (preferably fresh) per day.
Fruits and vegetables contain phytochemicals and antioxidants. It is important to introduce a wide variety of colors in to the body. Each color contains different phytochemicals that serve different purposes but they all have cancer fighting properties. Examples of antioxidants are vitamins A. C, and E. These fight against substances in the body called free radicals which may lead to cancer cell production. A serving of vegetables is a whole cup if raw or a ½ cup when cooked. A serving of fruit is about the size of a baseball if whole, ½ cup if canned or frozen.

Keep meat to a minimum.
Move toward a more plant-based diet including non-meat sources of protein such as beans. Limit red meat to no more than 18 ounces per week. For reference, 3 ounces of meat is about the size of a deck of cards. Red meat includes beef, pork, and lamb. Eat lean meats such as organic chicken and fresh fish (not farm raised). Limit processed meats such as hot dogs, bacon, sausage, and lunch meats. Select natural and uncured, nitrite-free versions of processed meats.

Eat beans.
Beans are a healthy, inexpensive alternative to meat. Beans are an excellent source of complex carbohydrates and fiber. They may reduce risk for breast cancer recurrence due to their fiber content. The fiber binds to circulating hormones and the excess hormones are ultimately excreted in the stool. Choose kidney, pinto, navy, cannellini, chick peas, etc. Introduce beans slowly into your diet to give the gastrointestinal tract time to adapt to the increased fiber.

Eat 3-6 servings of whole grains every day.
Select whole grains like oats, wheat, brown rice, and whole grain pasta. Whole grains are digested slowly due to their high fiber content, providing sustained energy. Choose grain products that have whole wheat or a whole grain flour listed as one of the first 3 ingredients. Avoid highly processed and refined grains (white enriched flour, baked goods, snack foods, sweets). A serving of whole grain is one slice of bread, ½ cup of cooked rice or pasta, and ½ cup of whole grain cold cereals and oatmeal.

Eat 1-2 servings of low-fat dairy products every day.
Low-fat dairy products include those made with reduced fat milk such as 1% or skim milk, low fat yogurt, 2% cheese or low fat kefir. Choose yogurt that is lower in sugar, not sweetened with artificial sweeteners, and that has active yogurt cultures listed on the label. Greek yogurt is naturally higher in protein and often contains less sugar than some other regular yogurts.

Limit excess sugar.
Sugar provides the body with excess calories without any nutrients. It also causes the body to produce more insulin. Higher levels of insulin circulating in the blood may increase risk for breast cancer recurrence. Excess sugar can also be problematic when attempting to achieve a healthy body weight. Try to choose a healthy sweet food such as fruit to satisfy cravings for sweets.

Avoid artificial sweeteners.
Artificial sweeteners are chemically based sweeteners including sucralose, acesulfame potassium, aspartame, and saccharin. Due the lack of research on these chemicals and their relationship to cancer, it is better to avoid them completely. A good alternative is a natural, plant-based sweetener called Stevia.

Drink water and green tea.
The human body is about 60% water. Every organ and organ system needs water to function optimally. Water is needed to transport nutrients to cells and to get rid of toxins from the organs. Water also helps to keep the environment of ears, nose, and throat moist. An easy starting point is to strive to drink eight 8 ounce glasses of fluid per day. Green tea and white tea are other good choices for beverages. Drink unsweetened green tea and limit calories from other beverages. Save calories for good whole foods especially when striving to reach a healthy body weight.

Incorporate omega-3 fatty acids into your diet.
Omega-3 fatty acids are found in fatty fish including salmon, albacore tuna, halibut, mackerel, lake trout, sardines, and herring. They are also found in walnuts, flaxseed, tofu, and soybeans. Omega-3 fatty acids have anti-inflammatory qualities. Reducing inflammation in the body reduces risk for cancer recurrence as well as improves cardiovascular health. A fish oil supplement is recommended if food sources of omega-3 fatty acids are not regularly consumed. Consult a registered dietitian for the recommendation of a fish oil supplement.

Have your vitamin D level checked.
It is possible to be vitamin D deficient and not know. A simple blood test can determine the level of vitamin in your bloodstream. Although the research is inconclusive about the relationship between breast cancer and vitamin D level, it is still a good idea to make sure that your body has adequate vitamin D. Vitamin D helps to reduce inflammation, aids in the absorption of calcium, improves muscle strength, and boosts the immune system.

Reduce or eliminate alcohol.
Alcohol intake is a known risk factor for several types of cancer including breast cancer. If alcohol is consumed at all, it is best to limit it to no more than one drink per day for women and 2 drinks for men.

Achieve and maintain a healthy body weight.
Carrying extra weight is a risk factor for breast cancer recurrence. Excess body fat plays a role in hormone production which can lead to tumor growth. Lose weight by eating modest portions of healthy food combined with regular exercise. Begin keeping a food and exercise journal. Consult a registered dietitian for a specific calorie range.

A good reference can be found at www.aicr.org. It is called “The New American Plate” and is designed specifically for eating for cancer prevention.

Move toward an active lifestyle.
Exercise is vital to a healthy lifestyle. For breast cancer survivors it is the key to losing and maintaining weight. During treatment it is not uncommon to become more sedentary and as a result lose lean body mass (muscle). Hormonal changes also contribute to increased body fat and decreased muscle. Begin slowly and incorporate a combination of strength training, cardiovascular exercise, and flexibility/stretching. Sometimes there are support groups for survivors that make a point to exercise as a group. Having a friend, instructor, or trainer as an extra motivator is often helpful.

Learn to relax.
Stress increases inflammation in the body. Learning to manage stress effectively can greatly reduce this inflammation. For some people, exercise may be relaxing and for others a good deep tissue massage is relaxing. The key is finding what is relaxing to you. If you are finding it difficult to relax you may try progressive muscle relaxation, prayer, meditation, or imagery. Some support groups may focus on these as a group.

Many believe that once treatment ends, the cancer journey is over, but that's not the case. Many cancer survivors struggle with the fear of recurrence. What if my cancer comes back? What if my cancer spreads? For some, these fears can become overwhelming even years into remission. These fears are completely normal, but there are things you can do to try to manage them.

Take charge of what you can.
You may feel afraid because of the lack of control you have over the situation. To take back some control in your life, try making positive changes.

  • Talk to a registered dietitian about developing a survivorship nutrition plan. Good nutrition can reduce your chance of recurrence and make you healthier all around.
  • Start an exercise program. Exercising is not only good for your body; it is also good for your mind. Exercising releases endorphins, natural chemicals that make you feel happier. Many people also say exercising helps clear their minds and lower stress. Always talk to your doctor before starting any exercise program.
  • Stay on top of your screenings and checkups. At the end of your treatment, work out a screening and checkup plan with your oncologist. What kind of scans or tests to do you need? How often do you need them?

Take a deep breath.
If you feel yourself starting to get worked up, close your eyes, take a deep breath, and count to ten. This may seem like silly or old advice, but taking a second to gather your thoughts can make you feel a lot better.

Try meditation or visualization. Find a quiet, comfortable spot in your home. Take a few moments to yourself to breathe deeply and reflect on the positive things in your life. Think about some of your goals, even simple ones, and imagine yourself reaching them. In the rush of everyday activities, we sometimes forget to just breathe.

Find a hobby.
Hobbies can be a great source of entertainment and can also take your mind off of negative things. Try one of the hobbies listed below or make up one of your own. Find something that you enjoy and are passionate about.

  • Knitting
  • Cooking
  • Painting
  • Hiking
  • Photography
  • Writing
  • Yoga

Volunteer.
Volunteering can be a worthwhile way to pass your free time and make a difference in your community. Is there a cause you are passionate about? Education, the environment, animals. To find a variety of volunteer opportunities in your neighborhood, visit VolunteerMatch.org, Volunteer.gov, or the American Cancer Society at cancer.org.

A quick word of caution: For some, volunteering for a cancer support organization may hit too close to home. Consider how it may affect you to be in this environment with constant reminders of your experience. You need to do what is best for you. If you are unsure how it may affect you, volunteer once before committing more time.

Talk about it.
You may find it helpful to talk to someone. It can be especially comforting to connect with other survivors. Hearing other survivors' stories can show you what you are feeling is normal, and you are not alone. You may also be able to help someone else by sharing your story. Here are some options for connecting with other survivors:

  • Support Groups
  • Ask your healthcare team about other groups in your area or at your hospital.
  • One-on-One Partnering Organizations
    • These organizations connect you with a fellow survivor. Usually the connections happen via phone.
  • Imerman Angels
  • Cancer Hope Network
  • Survivor Retreats
    • Epic Experience offers outdoor adventure retreats to adults with a past cancer diagnosis. Activities are based on the season.
    • Visit epicexperience.org or call (855) 650-9907.
  • First Descents hosts retreats for young adults (18-39) to learn to rock climb, kayak, or surf.

Educate yourself.
Knowledge is power. Talk to your oncologist about your fear of recurrence. Here are some questions to ask:

  • What are my chances of recurrence?
  • What can I do to lower my risk?
  • What signs do I need to look for to know if my cancer has returned?

Armed with the answers to these questions you can better understand your situation and minimize fear of the unknown.

If you do face a recurrence, remember that every survivor's situation is different. With clinical trials and new medications, there may be many treatment options available. Not all recurrences are equal.

Know what triggers your emotions, and avoid it.
Do movies or TV shows that address cancer upset you? Don't watch them. Does the sight of the sweatshirt you wore on treatment days bother you? Throw it out or donate to a clothing bank. Do you get especially anxious around scan days? Ask a friend to go to lunch with you.

If you can identify the objects or activities that trigger negative feelings, you can make a special effort to avoid them.

Don't dismiss your fear.
It is normal and understandable to fear recurrence. A cancer diagnosis is a scary thing. If you've already been through treatment, you know how difficult it can be. Don't be too hard on yourself. It is okay to be scared. It is okay to be upset. Admitting your feelings can be an important first step to managing your emotions.

Remember what works for other people may not work for you. Try a few different things. Once you find an activity that makes you feel at ease, be sure to include it in your schedule. Take time for yourself.

If your fear of recurrence becomes overwhelming or interferes with your day-to-day activity, talk to your doctor. You may need individual counseling from a medical professional. Your doctor can make a recommendation for you.

What are immunizations?

Immunizations help your body build a resistance to specific diseases. Most immunizations work by introducing a small, safe amount of the disease to your immune system. This way if you are ever exposed to the disease, your body's immune system already knows how to fight it. Most immunizations are vaccines given as a shot or series of shots.

Many people receive one-time immunizations when they are children for diseases such as chickenpox. Some immunizations, such as tetanus shots, need boosters to keep them effective. Other immunizations, such as flu vaccines, need to be received annually.

What are the risks of vaccines?

As with any treatment or medication, vaccines can cause side effects. Each vaccine carries risk for different side effects. Most side effects are minor such as pain where you receive the shot and mild fever. There are risks for serious side effects, but vaccines are carefully tested for safety. In most cases, the great benefits of vaccines outweigh the minor risks. To learn more, visit the Centers for Disease Control and Prevention (CDC) at www.cdc.gov. Talk to your healthcare team about the risks and benefits of vaccines to determine what is best for you.

I'm a cancer survivor; what immunizations do I need?

For cancer survivors, immunizations are especially important because cancer treatments weaken the body's immune system. Below is the immunizations schedule recommended by the CDC for people with weakened immune systems, such as cancer survivors.

Influenza (flu)- Annually

Tetanus, diphtheria, pertussis (Td/Tdap)- One Tdap vaccine with Td booster every 10 years.

Varicella (chickenpox)*Should NOT get vaccine**

HPV vaccine (women and men)* - 3 doses through age 26

Zoster (shingles)- Should NOT get vaccine**

Measles, mumps, rubella (MMR)*- Should NOT get vaccine**

Pneumococcal (PCV13)- 1 dose

Pneumococcal (PPSV23)- 1 or 2 doses

Meningococcal - 1 or more doses

Hepatitis A*- 2 doses

Hepatitis B*- 3 doses

Source: Center for Disease Control

* These vaccines are only for adults who did not get them as children.

** If you received these vaccines before your cancer diagnosis, there is no harm done. In fact, it is good that you are protected from these diseases. If you have not received these vaccines, it is not safe to receive them with a weakened immune system.

If you are planning to travel outside of the United States, check the recommended vaccines for where you are going. You may need additional immunizations.

Always consult with your oncologist before receiving any vaccine.

Cancer and Flu Shots

If you are a cancer survivor, the CDC recommends getting the annual flu vaccine. However, only get the flu shot; do NOT get the nasal spray version. The nasal spray version contains live viruses so it is not safe for people with a compromised immune system.

Caregivers or anyone living with a cancer survivor should also receive the flu vaccine to lower the risk of infection.

Pneumococcal

There are two pneumococcal vaccines: PVV13 and PPSV23. For cancer survivors, doses of each may be needed. Ask your healthcare team about the best pneumococcal schedule for you.

Meningococcal, Hepatitis A and B

These vaccines are recommended for adults with certain jobs, lifestyles, or other health factors that increase their risk of these diseases. Your healthcare team can tell you if you are at a higher risk.

Varicella, Zoster, and MMR

As shown in the chart above, people with a compromised immune system, such as cancer survivors currently or recently out of treatment, should NOT receive these vaccines.

Why is smoking bad?

Smoking increases your risk for heart disease, stroke, and emphysema. Smoking also increases your risk for a number of cancers, including:

  • Lung
  • Oral
  • Nasal and Paranasal
  • Throat
  • Esophageal
  • Bladder
  • Kidney
  • Pancreatic
  • Ovarian
  • Cervical
  • Colorectal
  • Stomach

If you already have a cancer diagnosis, smoking can increase your risk of recurrence.

Why should I quit smoking?

Quitting smoking has almost immediate benefits. Here are some of the benefits of quitting smoking:

20 minutes - Blood pressure and heart rate drop

12 hours - CO2 levels in blood stream return to normal*

3 months – 9 months - Circulation and lung function improve

1 year - Risk of heart disease cut in half

5 years - Risk of mouth, throat, esophageal, and bladder cancer cut in half

10 years - One-half as likely to die from lung cancer, and risk of laryngeal and pancreatic cancer decreases

15 years - Risk of heart disease is the same as a non-smoker's

Source: smokefree.gov

*If the CO2 (carbon dioxide) levels in your bloodstream are high, your lungs have to work harder to return these levels to normal. When you exhale, CO2 leaves your body.

How can I quit smoking?

The first step is to talk to your healthcare team about the best quitting strategies for you.

With smoking, your body builds up a dependency on nicotine, a chemical found in tobacco. As you quit smoking, your body will go through withdrawals from nicotine. Some common symptoms and side effects of withdrawal include:

  • Cravings
  • Feelings of sadness
  • Stress and anxiety
  • Difficulty sleeping
  • Restlessness
  • Weight gain

Here are some tips to help you manage the side effects of withdrawal:

  • With your doctor's permission, you may wish to use nicotine replacement therapies (NRT).
    • NRTs give you a small, decreasing dose of nicotine without smoking to help you wean yourself off nicotine and minimize withdrawal symptoms.
    • NRTs come in many forms such as gum, lozenges, inhalers, and patches.
    • Some NRTs are available without a prescription, but always talk to your healthcare team first.
    • Other prescription medications are also available to help you quit. Ask your doctor if these may be right for you.
  • Tell your friends and family that you are trying to quit.
    • They can support you and hold you accountable.
    • Ask a friend or family member you trust to be your “sponsor.” If you feel the urge to smoke, you can call them to talk until the craving passes.
    • If your friends or family members smoke, ask them not to smoke around you and not to offer you cigarettes. This will only make achieving your goal harder.
  • Join a support group or online support group to connect with other people trying to quit.
  • Change your routine.
    • For example, if you always have a cigarette with your coffee, find a new morning routine. Try watching the news with your coffee, or replace your cigarette with a healthy snack.
  • Know your triggers and have a plan.
    • What triggers your cravings—stress, food, other people smoking?
    • Avoid triggers if at all possible.
    • If you encounter a trigger, have a plan to keep yourself from smoking such as chewing gum, counting to 10, or calling a friend.
  • If you have a setback, don't be too hard on yourself. Get back on track as soon as possible. However, do not use a slip as an excuse to start smoking regularly again.
  • Do not use other tobacco products or e-cigarettes as a replacement for smoking.
    • Other tobacco products can also increase your risk for cancer and diseases.
    • E-cigarettes have not been studied enough to know their safety. The chemicals inhaled with e-cigarette use may have their own risks.

Resources for Quitting Smoking

Smokefree.gov

Call (800) Quit-Now to connect with your state's helpline.