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What Are Risk Factors for Loss of Physical Function After Chemotherapy for Breast Cancer in Older Women?

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After surgery to remove early-stage breast cancer, many women are treated with chemotherapy. Treatments given after surgery are called adjuvant treatments. Chemotherapy can cause a number of side effects, including fatigue, nausea, and neuropathy, which is damage to the nerves of the peripheral nervous system. Your peripheral nervous system is made up of the nerves that bring signals from the brain and spinal cord to the peripheral parts of the body, such as the hands and feet. Damage to these nerves can cause pain, numbness, and other symptoms.

These side effects can affect a woman’s ability to function physically, and she may have difficulty walking, carrying things, and getting in and out of bed or the shower. Research has shown that women who’ve been diagnosed with breast cancer tend to have worse physical function than similar women who haven’t been diagnosed with breast cancer.

A study looked specifically at how chemotherapy affected the physical functioning of women 65 and older and found that certain factors, including fatigue, breathing difficulties, a lack of social support, and poor appetite, increased the risk of an older woman’s functional decline after chemotherapy for breast cancer.

The research was published online on Aug. 26, 2018, by the Journal of the American Geriatrics Society. Read “Functional Decline and Resilience in Older Women Receiving Adjuvant Chemotherapy for Breast Cancer.”

The importance of physical function for older people

As with many other diseases, the risk of breast cancer goes up as you get older. Most breast cancer diagnoses are in women age 65 and older, but information on how breast cancer treatment affects the physical functioning of older women is limited.

How breast cancer treatment affects physical function is important for everyone, but is especially important for older people. Older people diagnosed with cancer whose functional ability declines are less independent and more likely to end up in a nursing home or in the hospital. They also have worse overall survival.

To learn more about how chemotherapy for breast cancer affects women 65 and older, researchers did an additional analysis of data collected in the Cancer and Leukemia Group B (CALGB) study 49907. The main goal of the CALGB 49907 study was to compare the benefits of the standard chemotherapy regimens of Adriamycin (chemical name: doxorubicin) and cyclophosphamide (one brand name: Cytoxan) or cyclophosphamide, methotrexate (brand names: Amethopterin, Mexate, Folex), and fluorouracil (also called 5-fluorouracil or 5-FU; brand name: Adrucil) to Xeloda (chemical name: capecitabine). The study found that the standard regimens offered more benefits than Xeloda.

For this analysis, the researchers looked at information from 256 women age 65 and older when diagnosed with breast cancer in the CALGB 49007 study. All the women had been diagnosed with stage I to stage III breast cancer, and all had been treated with chemotherapy after surgery as per the study plan. Other characteristics of the women:

  • the average age was about 72
  • about 87% of the women were white and 1.2% were Black
  • 69% of the women were not employed
  • 67% of the women lived with one or more people; 33% of the women lived alone
  • 58% were married and 42% were not married
  • 21.5% were treated with cyclophosphamide, methotrexate, fluorouracil
  • 31.2% were treated with Adriamycin and cyclophosphamide
  • 47.3% were treated with Xeloda

The researchers used a standardized questionnaire to assess the women’s physical functioning before chemotherapy started, at the end of chemotherapy, and 12 months after chemotherapy started. The questionnaire rates physical function as a score from zero to 100, with higher scores meaning better functioning. The questionnaire asked questions such as:

  • Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?
  • Do you have any trouble taking a long walk?
  • Do you have any trouble taking a short walk outside of the house?
  • Do you need to stay in bed or a chair during the day?
  • Do you need help with eating, dressing, or washing yourself or using the toilet?

The questionnaire also asked about side effects and conditions such as fatigue, nausea, vomiting, pain, trouble sleeping, appetite loss, and trouble breathing.

Physical function was high before chemotherapy

Before chemotherapy started, the researchers found the women were highly functional, with an average functioning score of 86.4:

  • only 1.6% needed help eating, dressing, bathing, or using the toilet
  • 44% said they had no trouble doing strenuous activities
  • 51% had no trouble taking a long walk
  • 86% had no trouble taking a short walk
  • fatigue (82%) and pain (65%) were the two most common side effects the women were experiencing before chemotherapy
  • the women had high levels of emotional support
  • 60% had arthritis or other connective tissue disorder
  • 54% had high blood pressure
  • 24% had osteoporosis

The time from before chemotherapy started to the end of chemotherapy ranged from 2.2 to 6.4 months. At the end of chemotherapy:

  • 42% (108 women) had a decline in physical function; the decline ranged from 11.7 to 73.3 points

The only factor linked to a decline in function from before chemotherapy to the end of chemotherapy was fatigue. Women with some fatigue before chemotherapy started had a higher risk of a decline in physical function at the end of chemotherapy than women who had no fatigue before chemotherapy.

Why were some women more likely to recover?

Of the 108 women who had a decline in physical function from before chemotherapy to the end of chemotherapy, 47% (51 women) recovered to within 10 points of their original function score by 12 months after chemotherapy started. The researchers said that these women were resilient compared to the 53% (57 women) who did not recover physical function by 12 months after chemotherapy started.

Women who were married, had no appetite loss before treatment, and had fewer than four positive lymph nodes were more likely to be resilient and regain physical function 12 months after chemotherapy started.

The researchers then looked to see how many women had a decline in physical function from before chemotherapy started to 12 months after chemotherapy started, whether or not they had a function decline from before chemotherapy started to the end of chemotherapy.

Of the 256 women, 30% (78 women) had a decline in physical function 12 months after chemotherapy started. Women who were unmarried and had some trouble breathing before chemotherapy started had a higher risk of function decline from before chemotherapy to 12 months after chemotherapy started.

About half the women -- 49.6% -- had little or no decline in function. Women who had no fatigue and no trouble breathing before chemotherapy started were more likely to maintain physical function.

"In our study, about half of the patients who experienced functional decline were able to 'bounce back' to their former function, and we considered them to be physically resilient," the researchers wrote. "We also learned that half of the patients were resistant to decline, and maintained their functional status throughout treatment."

What are the risk factors for functional decline?

Overall, risk factors for functional decline 12 months after chemotherapy ended were:

  • fatigue
  • trouble breathing
  • being unmarried or lacking social support, such as assistance from family and friends
  • poor appetite, which could indicate poor nutrition and/or depression

While this study didn’t look specifically at things that can help women be more resilient or resistant to physical functioning decline, the researchers did point out that other studies have found that diet and exercise programs can help women maintain and/or recover physical function after chemotherapy. One study they cited found that starting a diet and exercise program within 18 months of breast cancer diagnosis is linked to an improvement in physical function.

If you’ve been diagnosed with breast cancer, are 65 or older, and will be treated with chemotherapy, you may want to talk to your doctor about this study. If you’re experiencing any of the risk factors for function decline, such as fatigue, loss of appetite, and trouble breathing, ask your doctor about ways to manage these conditions. If you feel you lack social and emotional support, you may want to ask your doctor, nurse, or social worker about support groups for people with breast cancer. You also can find support online, including in the Community, which features more than 210,000 members in 82 forums discussing more than 150,000 topics.

And if you’re busy with work, household chores, and family matters, finding time to start an exercise program can be hard. Exercising also can be extremely difficult if you’re recovering from breast cancer treatment or having painful neuropathy symptoms.

It can help to break up your exercise into 20- or 30-minute sessions that add up to about 5 or more hours per week. Walking is a great way to start. Maybe you walk 30 minutes in the morning and 30 minutes after lunch. You can add a few more minutes by parking farther away from stores when you shop or taking mass transit. Or you can make plans to walk with a friend -- you’re more likely to stick with exercise if someone else is counting on you. Plus, you can socialize at the same time.

Visit the Exercise section for tips on exercising safely and how to stick to an exercise routine.

To talk with others about the importance of exercise after breast cancer treatment or to meet others who can help support your exercise goals, join the Discussion Board forum Fitness and Getting Back in Shape.

Editor’s Note: This article was updated on March 23, 2019, with clarifications about the study participants’ chemotherapy regimens.

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