Dealing With the Challenges of Breast Cancer Treatment with Tiffany Onger, MD

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

When you fight breast cancer, it's not just a battle against the disease; it's an ongoing struggle to feel like yourself. Treatment for breast cancer can be followed by fatigue, sleepless nights, brain fog and other quality-of-life issues. Coping with these matters can be a critical part of the healing process. In fact, some patients report that dealing with these symptoms can be as difficult as dealing with the cancer itself. So what can you do to get through it? That's what we're going to find out today from oncologist Tiffany Onger. Dr. Onger is one of the many experts at Cleveland Clinic who pop into our weekly podcast to talk about how we can better take care of ourselves. Now, let's take some time to learn how you can navigate through some tough parts of your breast cancer recovery. Dr. Onger, so glad to have you with us. Thanks for fitting us into your busy schedule.

Dr. Tiffany Onger:

Well, thanks for having me.

John Horton:

In doing my homework ahead of your visit, I was surprised to read that people with breast cancer often consider side issues related to the treatment to be as difficult as fighting the cancer. I'm guessing it's something you frequently talk about with your patients.

Dr. Tiffany Onger:

It most certainly is. It's one of the most important topics that I talk to my patients about. A lot of the time, our treatments are curative-intent, and so we want to make sure that you have a good quality of life while going through treatment.

John Horton:

Absolutely. So let's start looking at some of the more common ones. And I know the one that came up for 90% of patients … they report feeling fatigued. So let's start there. What can they do to address that?

Dr. Tiffany Onger:

So John, unfortunately, fatigue is really common. I mean, 90, some studies say even up to 100%, of patients will experience some aspect of fatigue while they're going through treatment. The fatigue can really be due to a number of different causes, anything from just recovering from surgery to radiation, to the chemotherapies, to mood changes due to your changing body. All of that can contribute to fatigue. One of the important things that I try to talk to my patients about is knowing that this can happen, knowing that it's normal and really listening to their bodies as they're going through cancer treatment. It's a big stress on the body, and so allowing yourself to have some grace and take a little extra time, if it takes more time to do things, can be really helpful.

John Horton:

Is there anything you can do to give yourself a little more energy? I mean, there's some little tips that you might have because, obviously, you're going through a lot, but is there something you can do?

Dr. Tiffany Onger:

Most certainly, and it's one of the most challenging things to do, but exercise — exercise, even if it's just walking, walking even 30 minutes a day. Sometimes, that can sound like not very much when you're in a state of health, but when you're going through cancer treatment, walking can really be beneficial to your energy. Not only are you getting some sunlight, you're getting fresh air, but just that activity of moving the body helps to give your body the strength and energy it needs to take care of the rest of activities for the rest of the day, even the rest of the week.

And so I really encourage my patients, as we're moving into treatment and during treatment, to try to move their bodies in gentle ways. My hope and expectation would not be lying in bed 18 hours a day. If that's going on, I definitely need to know about it because that is not the goal during treatment.

John Horton:

Well, I imagine it also brings a sense of normalcy back to you, too, because you're out, you're moving around, which is what most of us do every day.

Dr. Tiffany Onger:

It most certainly is. And not only is it good for the body and that mind and that sense of normalcy, but it can also be encouraging to family members to see that you're able to do some of the normal activities of your life. Even if this is not an opportunity to vacuum the living room or mop the floors — certainly take time off from those types of responsibilities — but even just gentle movements, it could be yoga, it could even be chair yoga. At the Cleveland Clinic, we've got some resources for even chair yoga for our patients. I don't expect you to do a lot of “downward dog” and that kind of thing, but yoga in the chair is certainly something many people can participate in.

John Horton:

Well, the next issue, sleeplessness seems, just sadly, ironic, given that it often accompanies fatigue. What causes this insomnia and how might people be able to put that concern to bed?

Dr. Tiffany Onger:

So you're asking some of the most common questions people here have concerns about. And it's a cruel irony that the fatigue and the sleeplessness, a lot of times, go hand-in-hand. And sleeplessness, similar to the fatigue, can be due to what we call multifactorial, or lots of different things can contribute to that.

Think about a woman who has maybe had a mastectomy or bilateral mastectomy. Those patients can sometimes have tubes connected to their bodies as they're going through the healing process. As you might imagine, those tubes are not the most comfortable things to sleep with, and there's some adjustment to sleeping with tubes. You might not be able to sleep on the side of your body that you're used to sleeping on. So there can, certainly, be adjustments related to that.

Surgery presents some challenges for sleeping but certainly, the treatments can as well. A lot of our treatments, especially the chemotherapy treatments, you'll get dexamethasone, which is a steroid, which can really impact your sleep. We try to give it earlier in the day but it just depends on what time your chemo is scheduled for, and so that can also contribute to difficulty sleeping during cancer treatment.

The third part I want to mention is the mental health aspect, anxiety. Anxiety is really common during cancer treatment. When you're going through something that's so stressful and played with a lot of uncertainty, such as going through cancer, there can be a lot of anxiety and that can keep you up at night. Different things can keep you up at night, and not all of these are going to be treated simply with a sleep aid or something like that.

John Horton:

You mentioned sleep aids there, is that something that can be used, or if you're undergoing cancer treatment, do you want to try to stay away from tossing other medications in?

Dr. Tiffany Onger:

That's a very good question. So we know that different medications can have different interactions with the treatments as one is going through treatment for cancers. So sleep aids sometimes do have a role in helping patients work through the side effects of their treatment, but it's not right for everybody. And so I really encourage people to talk with their doctor, importantly, about the impact that sleeplessness has had in their life. What's keeping them awake? Is it ruminating thoughts? Is it worried about … are you going to be here for the next important milestone within your family's life? Is it due to physical changes within the body? All of those different causes can have different treatments associated with them. So certainly, there can be a role for sleep aids but we want to be thoughtful and careful as we're adding more medicines during the cancer journey.

John Horton:

Well, let's move on to another issue that comes up a lot, and that is mental fog. I know the formal term for this is “chemotherapy-induced cognitive impairment,” but most people know it by a much shorter name, which is just called chemo brain. What can you tell us about it?

Dr. Tiffany Onger:

So chemo brain is also very common, and we noticed that many, at least in my clinic, a lot of young women do worry about chemo brain. Many times, these women are in the prime of their lives, they're in the prime of their working years. They might have high-powered jobs, where they're using a lot of mental energy to take care of their homes and take care of their work. And so this is top of mind, so to speak, for many patients. Chemo brain, it is common but there are things that we can do to mitigate it. It's typically defined as a mental fogginess or trouble with concentration or memory during and even after treatment. And unfortunately, this isn't one of those side effects that ends right at the end of treatment.

It can persist for months and sometimes, even years, although it does tend to get significantly better over time. One of the things that is very important during chemo brain is patience with yourself, is — again, as the body is going through an extremely stressful time and emotionally stressful as well — it's important that you give yourself that flexibility to take a little bit more time to do things. You might not be able to, for example, keep your grocery list all in your head. You might find that you need to make more lists. You might find that you need to reduce multitasking and really just give yourself more reminders than you used to.

John Horton:

So it sounds like this is one of those things where you need to understand that it might happen, and then just give yourself some adjustments, like you said, making lists, giving yourself some extra time and just allowing yourself to live with it until maybe it clears.

Dr. Tiffany Onger:

Certainly.

John Horton:

What other issues or symptoms do you frequently hear about and how do you recommend addressing them?

Dr. Tiffany Onger:

I'm really glad you asked that question. So one symptom that patients frequently experience but don't as often bring to their doctor's attention is the sexual side effects of treatment. Lots of different treatments for cancer, including surgery, radiation and the medicines, which could include chemotherapy, endocrine therapy, and immunotherapy, can all contribute to sexual dysfunction. When I talk to my patients about this, I usually define sexual dysfunction as sometimes reduced interest in sexual activity, sometimes, a difficulty having an orgasm, sometimes, vaginal or personal dryness. That just touches the tip of the iceberg, but it can impact a lot of aspects of the sexual experience during and after cancer treatment. As you can imagine, oncologists are not always the most open to having these conversations. Sometimes, there still is a little bit of taboo around it, but I think that's just an aspect of our Western culture that we don't like to talk about these aspects, but they are so important to patients' quality of life.

And so I am really encouraging folks to bring this up to their doctors if they're noticing an impact in their sexual well-being. Some of the things that can contribute to that include hormone treatments, or we call this “endocrine therapy” in breast cancer. That can certainly impact interest and functioning during sexual activity. But there's also the mental aspect, for example, someone who's had a bilateral mastectomy. If her breasts were an important part of her sexuality, that might really impact how she feels when it's time to be intimate with her partner. So there can be a lot of aspects that contribute to this, but because it's an important part of health, of overall health, please do bring it up to your doctor if you're noticing some challenges when it comes to intimacy.

John Horton:

Dr. Onger, I'm so glad you brought that up. Like you said, that is a very sensitive topic and it's something a lot of people ... you get nervous talking about, but that's why we have this podcast in order to bring those sorts of things up to make the conversation a little natural.

Dr. Tiffany Onger:

Absolutely.

John Horton:

So with all of these issues that we've discussed, do they eventually resolve and fade away?

Dr. Tiffany Onger:

Thankfully, many side effects due to cancer do. It can take time, it can take time, and so it might be a matter of weeks to months before things really are feeling back to normal. And because someone, when they're dealing with cancer, they're really going through one of the most challenging times of their lives, even as those side effects improve, they still might feel like a new person compared to their pre-cancer life, but that's part of change, it's part of continuing to live. And so sometimes, those side effects can persist longer, longer than hoped, but the vast majority of times, they do get better with time. And so even if you're having a tough time going through treatment right now, know that the expectation is that it will get better with time.

John Horton:

Well, we've talked about some tough issues today, Dr. Onger, but I'm a silver-lining sort of guy, so that brings me to this. It seems that there's been a lot of increased focus on dealing with these quality-of-life issues after breast cancer treatment, and that's because so many more people are surviving. In other words, I mean, these are good problems to have to talk about.

Dr. Tiffany Onger:

Absolutely. So not only have our screening rates increased, which has contributed to the increase of diagnosis, and specifically, screening tends to find more early-stage disease where it's most treatable. We have more and more patients who are living each year cancer-free down the line after they've completed their cancer treatment. And so we do know that there can be side effects that persist but part of that is just a manifestation of us having more survivors in the years as science has advanced. So I expect that we'll continue to have these conversations about the side effects from cancer care, but even as the treatments have advanced, the management of those side effects have advanced as well. The way we treat cancer today is not the way that we treated it 10 years ago and even five years ago. There have been a lot of wonderful advances in the field.

John Horton:

You have just provided a load of information for us today, Dr. Onger. So before we say goodbye, do you have any final words of advice or encouragement to share with those with breast cancer?

Dr. Tiffany Onger:

Most certainly. I think one of the important things that you can do is share with your family, share with your loved ones what's going on. I have patients sometimes who tell me that they don't want to tell their family members, they don't want to tell their kids, but your family loves you and they want to support you while you're going through something difficult. And so I really encourage folks to talk with their family and their close friends about what they're going through to allow them to support them through their cancer journey. It's not only helpful for the patient, but it's also helpful for your family to know that there's something that they can do to help you through a difficult time.

John Horton:

Perfectly said, Dr. Onger. Thank you so much for coming in and for such a wonderful conversation.

Dr. Tiffany Onger:

Thank you for having me.

John Horton:

Breast cancer treatment and recovery bring challenges. Give yourself time for self-care and grace as you work through the issues. Will it be easy? No, but you can do it. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.