Hormonal Therapy After Breast Cancer

If Cancer Comes Back Or Has Spread

AIs, tamoxifen, and fulvestrant can be used to treat more advanced hormone-positive breast cancers, especially in post-menopausal women. They are often continued for as long as they are helpful. Pre-menopausal women might be offered tamoxifen alone or an AI in combination with an LHRH agonist for advanced disease.

Having Hormonal Therapy For Breast Cancer

Hormonal therapy drugs reduce the risk of breast cancer coming back. It is important to take it for as long as you have been prescribed it for. Try to make taking it part of your daily routine so it becomes a habit.

Most women cope well with the side effects of hormonal therapy. They may be more of a problem in the first few months, but usually get better over time. If the side effects do not improve or are difficult to cope with, talk to your specialist nurse or cancer doctor. They can prescribe drugs to help and suggest ways of coping.

If you are still having problems after this, then your cancer doctor may suggest changing to a different type of hormonal therapy.

Should A Person Take Hrt

The benefits of taking HRT can vary from person to person. Some people decide that the benefits outweigh the risks.

HRT can help relieve the symptoms of menopause. It can also help reduce the risk of developing osteoporosis.

A person should discuss the benefits and risks with a healthcare professional before deciding whether HRT is right for them.

If a person decides to take HRT, they should attend all their breast cancer screening appointments.

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What Type Of Breast Cancer Is Treated With Hormones

Adjuvant therapy for early-stage breast cancer: Tamoxifen is FDA approved for adjuvant hormone treatment of premenopausal and postmenopausal women with ER-positive early-stage breast cancer, and the aromatase inhibitors anastrozole, letrozole, and exemestane are approved for this use in postmenopausal women.

Drugs That Block Estrogen

Some drugs work by blocking estrogen from causing cancer cells to grow.

Tamoxifen is a drug that prevents estrogen from telling cancer cells to grow. It has a number of benefits:

• Taking Tamoxifen for 5 years after breast cancer surgery cuts the chance of cancer coming back by half. Some studies show that taking it for 10 years may work even better.
• It reduces the risk that cancer will grow in the other breast.
• It slows the growth and shrinks cancer that has spread.
• It reduces the risk of getting cancer in women who are at high risk.

Other drugs that work in a similar way are used to treat advanced cancer that has spread:

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Assessment Of Risk For Breast Cancer

Various methods are available to identif y women at increased risk for breast cancer, including formal clinical risk assessment tools or assessing breast cancer risk factors without using a formal tool.

Numerous risk assessment tools, such as the National Cancer Institute Breast Cancer Risk Assessment Tool,5 estimate a womans risk of developing breast cancer over the next 5 years. There is no single cutoff for defining increased risk for all women. Women at greater risk, such as those with at least a 3% risk for breast cancer in the next 5 years, are likely to derive more benefit than harm from risk-reducing medications6 and should be offered these medications if their risk of harms is low. Some women at lower risk for breast cancer have also been included in trials documenting reduced risk for breast cancer when taking tamoxifen, raloxifene, or aromatase inhibitors.3,4 However, when balancing the harms associated with these medications, the net benefit will be lower among women at lower risk.

Women not at increased risk for breast cancer, such as women younger than 60 years with no additional risk factors for breast cancer, or women with a low 5-year risk of breast cancer should not be routinely offered medications to reduce risk of breast cancer because the risk of harms from these medications likely outweighs their potential benefit.

Tamoxifen And Breast Cancer Prevention

A large study by the National Cancer Institute looked at whether tamoxifen lowered cases of breast cancer in healthy women who were known to be likely to get the disease. The results of the trial showed a 50% reduction in breast cancer in the women who took the drug.

Studies have also shown that tamoxifen lessens the risk of breast cancer returning in women who have had the earliest form of the disease, ductal carcinoma in situ .

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Treatment Tailoring In Hormone

RT-PCR, reverse transcriptase-PCR. Modified from Sotiriou & Pusztai .

One of such tools, the Oncotype DX, merits to be addressed in more details . This test was developed to answer the following question Is it possible to identify a woman with hormone receptor-positive, lymph node-negative breast cancer, for whom it may be necessary something more than just tamoxifen alone? Among the 16 genes that the Oncotype DX analyzes, some are related to the ER , other related to cell proliferation , and other, like HER2, which are not functionally related. The relative expression of these genes compared with that of five reference genes whose expression does not correlate with tumor aggressiveness is combined by a mathematical formula that results in a continuous score ) that is directly proportional to the risk of metastatic relapse. The RS has been into divided into three risk categories by cutoffs that were established studying the clinical outcome of women enrolled in the tamoxifen arm of the NSABP B-20 clinical trial . The low-risk group has been defined by a RS< 18, the intermediate by a RS between 18 and 30, and the high risk by a RS> 30.

RS, recurrence score NSABP, national surgical adjuvant breast and bowel project ECOG, eastern cooperative oncology group SWOG, south western oncology group.

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It Will Also Be Important In The Future To Differentiate Prior To Treatment Patients Who Are At High Risk Of Relapse From Those At Lower Risk In Order To Tailor Hormone Treatment This May Be Done To Avoid Escalation Of Anti

The CANTO cohort comprises 12,000 women with breast cancer treated in 26 French centres. It is sponsored by Unicancer and directed by Professor Fabrice André, specialist breast cancer oncologist at Gustave Roussy, Inserm research director and responsible of the lab Predictive Biomarkers and Novel Therapeutic Strategies in Oncology . Its objective is to describe adverse effects associated with treatment, to identify the populations at risk of developing them and to adjust therapy accordingly, so as to afford a better quality of life following cancer.

Watch the video on YouTube :

J Clin Oncol. 2019 Feb 10 37:423-438 : https://doi.org/10.1200/JCO.18.01160

TO CITE THIS POST :

1INSERM Unit 981, Gustave Roussy, Cancer Campus, Villejuif, France

2Breast Unit, Champalimaud Clinical Center, Champalimaud Foundation, Lisbon, Portugal

3Medical Oncology, Gustave Roussy, Cancer Campus, Villejuif

4Department of Supportive Care, Gustave Roussy, Cancer Campus, Villejuif

5Medical Oncology, Centre François Baclesse Caen, Caen

6Unicancer, Paris, France

7Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova

8Department of Internal Medicine and Medical Specialties , School of Medicine, University of Genova, Genova, Italy

9Surgical Oncology, Centre Georges-François Leclerc, Dijon

10Medical Oncology, Institut Curie, Paris

14Surgical Oncology, C.R.L.C Val dAurelle, Montpellier

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Exercise Relaxation Techniques And Behavioral Therapies

Some women find these types of approaches help them with menopausal symptoms. Although there is only limited research showing these techniques might be helpful, theres likely to be little harm in trying them. Before starting any exercise program after being diagnosed with breast cancer, its important to speak with your doctor or someone on your health care team.

Some research has suggested that acupuncture might be helpful in treating hot flashes, although not all studies have found this. This might be another option to discuss with your doctor.

Menopausal Hormone Therapy After Breast Cancer

Taking post-menopausal hormone therapy , also called hormone replacement therapy , to help with menopause symptoms may not be safe for women who have had breast cancer. If you are bothered by menopause symptoms, talk to your doctor about ways to get relief.

Many women have menopause symptoms such as hot flashes after treatment for breast cancer. This can happen naturally as women get older, but it can also be caused by some breast cancer treatments. Some pre-menopausal women have menopause symptoms as a result of chemotherapy or from hormone therapy drugs used to treat breast cancer . Women who are past menopause might also get symptoms if they had to stop taking PHT when they were diagnosed with breast cancer.

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Less Common Types Of Hormone Therapy

Some other types of hormone therapy that were used more often in the past, but are rarely given now include:

• Megestrol acetate , a progesterone-like drug
• Androgens , like testosterone

These might be options if other forms of hormone therapy are no longer working, but they can often cause side effects.

Role Of Hormones In The Body

Our bodies naturally make hormones, including estrogen and progesterone.

Estrogen has multiple roles. It helps sex organs develop, makes pregnancy possible, strengthens bones, and more.

As you get older, the level of estrogen in your body changes.

• In premenopausal women who have periods, the ovaries make most of the bodys estrogen. Estrogen levels in premenopausal women are usually high.
• In perimenopause, the ovaries slow down and make less estrogen. But it is still possible to have menstrual periods, even when the ovaries are working more slowly. Periods may sometimes be irregular. This in-between time happens several years before menopause.
• In menopause, the ovaries gradually stop making estrogen. Periods become irregular and then stop altogether.
• Post-menopausal means a woman has not had any menstrual periods for 12 months in a row and blood work demonstrates hormonal levels are in post-menopausal range.

After menopause, the ovaries no longer make estradiol, the most active form of estrogen. But a womans body still makes estrone, another form of estrogen, after menopause. Estrone is made when an enzyme called aromatase converts the male sex hormone androstenedione made in the adrenal glands, ovaries, and fat cells into estrogen. In men, androstenedione is made in the testes.

Treatments for hormone receptor-positive breast cancer may include hormonal therapy, radiation therapy, chemotherapy, or targeted therapy.

Depending on the type, hormonal therapy works by:

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Can Other Drugs Interfere With Hormone Therapy

Certain drugs, including several commonly prescribed antidepressants , inhibit an enzyme called CYP2D6. This enzyme plays a critical role in the body’s use of tamoxifen because CYP2D6 metabolizes, or breaks down, tamoxifen into molecules, or metabolites, that are much more active than tamoxifen itself.

The possibility that SSRIs might, by inhibiting CYP2D6, slow the metabolism of tamoxifen and reduce its effectiveness is a concern given that as many as one-fourth of breast cancer patients experience clinical depression and may be treated with SSRIs. In addition, SSRIs are sometimes used to treat hot flashes caused by hormone therapy.

Many experts suggest that patients who are taking antidepressants along with tamoxifen should discuss treatment options with their doctors, such as switching from an SSRI that is a potent inhibitor of CYP2D6, such as paroxetine hydrochloride , to one that is a weaker inhibitor, such as sertraline or citalopram , or to an antidepressant that does not inhibit CYP2D6, such as venlafaxine . Or doctors may suggest that their postmenopausal patients take an aromatase inhibitor instead of tamoxifen.

Other medications that inhibit CYP2D6 include the following:

• quinidine, which is used to treat abnormal heart rhythms

What Are Hormones And Hormone Receptors

Hormones are substances that function as chemical messengers in the body. They affect the actions of cells and tissues at various locations in the body, often reaching their targets through the bloodstream.

The hormones estrogen and progesterone are produced by the ovaries in premenopausal women and by some other tissues, including fat and skin, in both premenopausal and postmenopausal women and in men. Estrogen promotes the development and maintenance of female sex characteristics and the growth of long bones. Progesterone plays a role in the menstrual cycle and pregnancy.

Estrogen and progesterone also promote the growth of some breast cancers, which are called hormone-sensitive breast cancers. Hormone-sensitive breast cancer cells contain proteins called hormone receptors that become activated when hormones bind to them. The activated receptors cause changes in the expression of specific genes, which can stimulate cell growth.

Breast cancers that lack ERs are called ER negative, and if they lack both ER and PR they may be called HR negative.

Approximately 67%80% of breast cancers in women are ER positive . Approximately 90% of breast cancers in men are ER positive and approximately 80% are PR positive .

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Breast Cancer Surgery During Pregnancy

Surgery to remove the cancer in the breast and nearby lymph nodes is a major part of treatment for any woman with early breast cancer, and generally is safe in pregnancy.

Options for breast cancer surgery might include:

• Removing the entire breast
• Removing just the part containing the cancer

The type of surgery a woman might have depends on the extent of her cancer and when the cancer is diagnosed during the pregnancy.

Stopping The Ovaries Working

In pre menopausal women, doctors might use a type of hormone treatment to stop the ovaries from producing oestrogen. This type of drug is called a luteinising hormone releasing hormone . For example, goserelin and leuprorelin . You might have this on its own or with other hormone therapy drugs.

LHRH drugs work by blocking a hormone made in the pituitary gland that stimulates your ovaries to make and release oestrogen. This stops your ovaries from working. So you won’t have periods or release eggs while you are having the injections.

When you stop taking the drug, your ovaries should start working again. But, if you’re close to the age at which your menopause would naturally start, your periods might not start again.

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Benefits Of Hormone Therapies In Early And Locally Advanced Breast Cancer Treatment

Treatment with the hormone therapies tamoxifen and/or an aromatase inhibitor lowers the risk of :

• Breast cancer recurrence
• Breast cancer in the opposite breast
• Death from breast cancer

Premenopausal women who get ovarian suppression plus tamoxifen or an aromatase inhibitor may lower these risks more than premenopausal women who get tamoxifen or an aromatase inhibitor alone .

Learn more about tamoxifen.

How To Tell If Hormone Therapy Is Working

If you are taking hormone therapy for prostate cancer, you will have regular PSA tests. If hormone therapy is working, your PSA levels will stay the same or may even go down. But, if your PSA levels go up, this may be a sign that the treatment is no longer working. If this happens, your doctor will discuss treatment options with you.

If you are taking hormone therapy for breast cancer, you will have regular check-ups. Checkups usually include an exam of the neck, underarm, chest, and breast areas. You will have regular mammograms, though you probably wont need a mammogram of a reconstructed breast. Your doctor may also order otherimaging procedures or lab tests.

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Treatments For Vaginal Dryness

Vaginal dryness and discomfort can be bothersome menopausal symptoms for some women.

Devices that use lasers or other forms of energy to ‘rejuvenate’ vaginal tissue are now being studied as well, although it’s not yet clear how helpful they might be. It’s important to discuss the possible risks and benefits of these treatments with your doctor before deciding if one is right for you.

How Hormone Therapy Is Given

Hormone therapy may be given in many ways:

• Oral. Hormone therapy comes in pills that you swallow.
• Injection. The hormone therapy is given by a shot in a muscle in your arm, thigh, or hip, or right under the skin in the fatty part of your arm, leg, or belly.
• Surgery. You may have surgery to remove organs that produce hormones. In women, the ovaries are removed. In men, the testicles are removed.

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For The Population Studied As A Whole There Was An Overall Deterioration In The Quality Of Life At Two Years From Diagnosis This Deterioration Was Greater In Patients Who Had Received Hormone Therapy Especially After The Menopause By Contrast Chemotherapy Had A Bigger Effect On Quality Of Life In Non

It is important in the future that we are able to predict which women are going to develop severe symptoms with anti-hormonal treatment so that we can support them, added Dr Vaz-Luis. While it has been shown that hormone therapy provides a real benefit in reducing the relapse rate of hormone-dependent cancers which represent 75% of all breast cancers, the deterioration in quality of life may also have a negative effect on patient adherence to treatment. It is, therefore, important to offer them symptomatic treatment, in particular for menopausal symptoms, musculoskeletal pain, depression, severe fatigue and cognitive dysfunction and to combine this with supportive measures such as physical exercise and cognitive behaviour therapy.

Combined Hrt And Breast Cancer

Combined estrogen and progesterone may have the highest risk factor of any type of HRT. According to BreastCancer.org, the risk of developing breast cancer increases by 75% for those taking combined HRT.

The organization also noted that combined HRT increases the chance that a healthcare professional may diagnose a persons breast cancer at a more advanced stage, which increases the likelihood of mortality.

According to the , the risk of breast cancer increases the longer a person takes HRT. However, it also decreases significantly after a person discontinues HRT.

The American Cancer Society states that the risk of breast cancer returns to average 3 years after a person discontinues combined HRT.

However, the researchers for the 2020 study found that risk reduced after 5 years for medroxyprogesterone, and 10 years for levonorgestrel, which are types of progesterone.

Combined HRT is also linked to breast density, which can make it harder to locate cancer on a mammogram. Breast density is a term to describe the amount of dense tissue compared to fatty tissue in a persons breast. Dense tissue is more fibrous than fatty tissue.

HRT containing estrogen alone can also increase the risk of a person developing breast cancer. However, it may only increase the risk after 10 years of continued use.

A person who has had or has breast cancer should not take HRT. Instead, they should speak with a doctor about alternative options.

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