New direction for multidisciplinary care: Menopausal Symptoms After Cancer Service

Author:	Christobel Saunders, Laura Emery and Martha Hickey
Details:	1. School of Surgery, University of Western Australia. 2. Department of Obstetrics and Gynaecology, University of Melbourne; School of Women’s and Infants Health, King Edward Memorial Hospital, University of Western Australia.
Email address:	christobel.saunders@uwa.edu.au

Abstract

Menopausal symptoms are common following treatment for cancer, particularly breast and gynaecological cancers. The nature, severity and causes of menopausal symptoms following hormone-dependent cancer are likely to differ from those seen in women with spontaneous menopause. Management can be further complicated by the history of estrogen dependent cancer. Multidisciplinary management offers many advantages to cancer patients and health care providers. This paper presents information about the establishment of a novel multidisciplinary clinical service for cancer patients with menopausal symptoms. This paper has been developed to describe some of the factors important in developing the Menopausal Symptoms After Cancer service.

Menopausal symptoms are some of the most common and debilitating side-effects of breast cancer treatments, not only in older women, but in women of all ages and may lead to non-compliance with cancer treatments. Across all trials of adjuvant endocrine therapy, vasomotor symptoms such as hot flushes are the most common side-effect.1 Up to 20% of breast cancer patients will consider stopping or actually cease endocrine therapy because of menopausal symptoms,2-3 despite its established role in reducing recurrence. Treatments for other cancers, notably gynaecological malignancies and chemotherapy for cancer in very young women, may also cause significant menopausal symptoms.

Hot flushes, night sweats, sexual dysfunction, poor sleep and tiredness frequently occur following breast cancer treatment.4 Some authors have suggested that vasomotor symptoms, particularly hot flushes, may be more severe than in women who have not had breast cancer treatment,2,5,6however this has not been objectively assessed. Atrophic vaginitis affects many women using endocrine therapy for breast cancer, particularly those using aromatase inhibitors.7 Sexual dysfunction may be related to atrophic vaginitis, but also to changes in body image, libido and self-esteem.8,9

In healthy women, oestrogen containing hormone therapy is the most effective treatment for menopausal symptoms,10 however recent level one evidence has questioned the safety of hormone therapy following breast cancer. The safety of hormone therapy following some gynaecological cancers is also largely unknown. Long-term sequalae of early menopause is an important health issue for young cancer survivors. Safe and effective treatments for severe menopausal symptoms after cancer are urgently required.

The management of menopausal symptoms has traditionally been by general practitioners and specialist gynaecologists and consists of supportive care, hormone replacement therapy and symptomatic treatments. Many women also use unproven ‘complementary’ therapies, which may have considerable cost implications.10 Treatment of cancer patients with menopausal symptoms may be more complex, as GPs and gynaecologists may be less confident about the potential interaction between cancer, its treatment and menopausal therapies.11 Oncologists may have limited expertise in managing menopausal symptoms. As a result, there is a need for more information on how these symptoms affect women with a prior history of cancer and what long-term health consequences ensue, as well as how best to control them and within what setting.

A multidisciplinary research based public clinic has been established to service the entire state of Western Australia to address the needs of these women. It comprises gynaecologists, breast surgeons, endocrinologist, oncologists, psychiatrist, clinical psychologists, physiotherapist, genetic counsellors, clinical nurse specialist, dietitian and research staff.

This report describes some of the factors important in developing such a service. A summary of these is noted in table 1.

View larger version 221.01 KB:
[in this window]
[in a new window]

Table 1

The service

The Menopausal Symptoms After Cancer (MSAC) clinic was established in 2003, after specialists identified women with cancer had menopausal issues that were not being addressed satisfactorily by other health professionals. The MSAC clinic provides menopause advice and management to women with symptoms and a history of prior breast and/or other cancers. To best utilise existing resources, the clinic runs within an existing general menopause service at King Edward Memorial Hospital (WA’s women’s and infants health tertiary centre) one full day per week.

Appointments are made for women after the clinic receives a referral from the patient’s GP or other health care provider. Patients are triaged by the gynaecologist or GP specialising in menopause, with priority given to premenopausal women considering risk reducing salpingo-ophorectomy, to inform women about potential short and long-term implications of surgical menopause and assist with decision making.

A key to this service has been the training and appointment of clinical nurse specialists. This role is varied, with duties including patient consults and support, information dissemination, research and administration. The main role for the clinical nurse specialists during consultations (and subsequent visits) is to discuss menopausal concerns with patients, including:

type, severity and impact of menopausal symptoms
information about lifestyle options
impact of the cancer diagnosis
survivorship issues (ie. fatigue, body image, sexuality, family and relationships)
general mid-life health and lifestyle issues (ie. diet, weight control and exercise).

Written information supplied to patients includes information sheets developed by the clinic and others on treatments (ie. clonidine, gabapentin, Venlafaxine and vaginal preparations), information developed by national menopause organisations such as the Jean Hailes Institute,15 ENHANCE group16 and the Australasian Menopause Society17 on early menopause, libido, depression and sleep disturbance. Other information and advice developed by the National Breast and Ovarian Cancer Centre on contraception, fertility and familial risk of breast and ovarian cancer are also given to women as required.

Database and protocols

During consultations, information collected is recorded in each patient’s hospital record to assist with clinical management. Once patient consent has been provided, patient information is added to a database.

Assessment protocols are established to ensure patients are managed in a uniform manner, but with the capacity to individualise care. This includes collecting information about the index cancer and treatment, family cancer history, previous gynaecological surgery and current medications, gynaecological history, along with previous use of HRT or complimentary therapies and lifestyle issues. Quality of life assessments are collected for each of the patients, including the nature and severity of menopausal symptoms, using the Greene Climacteric Scale.18

MSAC clinic staff base treatment recommendations on existing clinical guidelines, as well as the recently published international guidelines for breast cancer patients with menopausal symptoms.4

In women with apparent chemotherapy induced ovarian failure, standard protocols have been developed to monitor long-term bone health and ovarian function.19 Advice about safe and effective contraception after breast cancer is also offered.

Outcomes generated at multidisciplinary meetings are noted in patient files and the patient’s GP is sent a letter outlining the recommended treatment pathway. GPs may also be phoned if more in-depth discussion is required. Other health professionals may also be contacted by the clinical nurse specialists or treating doctor to discuss amended treatment plans and feedback from the multidisciplinary discussion.

Multidisciplinary meetings

Multidisciplinary meetings are another key aspect of the clinic. They are held monthly and include both patient discussion and an education component. The current membership includes gynaecologists, gynae-oncologists, breast surgeons, clinical nurse specialist, an endocrinologist, oncologists, psychiatrist, clinical psychologists, physiotherapist, genetic counsellors, dietitian, research staff and medical students.

At each meeting, a number of patients are discussed with a summary of individual patients and their specific clinical problems to be resolved being presented individually. GPs are invited to attend when their patient is being discussed. The discussion points and outcome summary are recorded in patient files under a MSAC stamp and an individualised care plan established.

An outreach of the multidisciplinary meeting is the email provision of relevant publication updates and breaking news from conferences.

Because vast distances sometimes mean patients have difficulty accessing the service, the MSAC clinic attempts to accommodate rural patients by factoring in driving or flying time when making appointments. Where visits to Perth are difficult, telephone consults with the clinical nurse specialists can also be ultilised and rural doctors are also encouraged to phone the clinic and discuss their patients with staff.

Doctors in training in gynaecology, surgery and endocrinology attend the clinics and multidisciplinary meetings. Fifth year medical students assist with consultations and other medical students have had the opportunity to undertake small research projects.

Educational presentations at the meetings include topics ranging from depression, exercise and cancer and bone health, to novel symptom management.

Since 2008, the MSAC clinic has also offered learning opportunities for rural clinicians with an interest in cancer care. The program includes written information on menopause after cancer and guidelines on managing this,4,6,20,21 a supervised clinical placement at the MSAC clinic, attendance at a multidisciplinary meeting and a supervised clinical placement with a multidisciplinary breast service.

Community based education sessions routinely organised by local groups such as Cancer Council WA, Menopause Support Service, breast and gynaecology cancer support groups and the university extension program provide an avenue for clinic staff to promote clinic services while also talking about menopause management.

Patient information and research

The MSAC clinic highlighted the lack of patient focused information in the area of menopause and cancer. In particular, breast cancer patients indicated the lack of information about menopause was a significant unmet need.22

This was addressed by developing a Menopause for breast cancer patients information booklet and web based resource. This resource was originally developed for use in WA, but with the assistance of the National Breast and Ovarian Cancer Centre it was launched as a national resource.14 A similar resource for women experiencing menopause following ovarian cancer has recently been developed.23

While the main focus of the MSAC clinic is the clinical assessment and management of menopause symptoms, patient consent ensures data being collected can also be used to answer research questions posed by clinic staff. Currently, women are being invited to participate in a study observing menopausal symptoms experienced by women with and without a history of cancer.

The clinic also provides a platform to undertake treatment trials, both independent and industry sponsored.

A service such as the MSAC clinic provides for individualised evidence based multidisciplinary management in an important area of cancer survivorship. In addition, it allows for unique educational and research opportunities.