Breast Cancer And Tamoxifen
Tamoxifen is a pill that doctors have prescribed for more than 30 years to treat breast cancer. It works by keeping estrogen from attaching to the cancer cells.
Doctors first used tamoxifen to treat women whose breast cancer had spread in their bodies because it slowed or stopped the growth of the disease. The drug also lowers the chance that some early stage breast cancers will come back. And it can lower the risk that a woman will get cancer in the other breast later on.
Women who are at high risk for breast cancer can take tamoxifen to try to lower their chances of getting the disease. Itâs an alternative to watchful waiting or having surgery to remove a breast, called a mastectomy, before they get the disease.
Tamoxifen is an option for:
- Treatment of the earliest form of breast cancer, ductal carcinoma in situ , along with surgery
- Treatment of abnormal cells in the glands that make milk, called lobular carcinoma in situ , to lessen the chance that theyâll become more advanced breast cancer
- Treatment of breast cancer in men and women whose cancers use estrogen
- Treatment of breast cancer that has spread to other parts of the body or that comes back after treatment
- To prevent breast cancer in women at high risk for the disease
Some people should not use tamoxifen:
Talk to your doctor to see if tamoxifen is right for you.
Possible Side Effects Of Ais
The most common side effects of AIs are:
- Hot flashes
- Bone and joint pain
- Muscle pain
AIs tend to have side effects different from tamoxifen. They don’t cause uterine cancers and very rarely cause blood clots. They can, however, cause muscle pain and joint stiffness and/or pain. The joint pain may be similar to a feeling of having arthritis in many different joints at one time. Options for treating this side effect include, stopping the AI and then switching to a different AI, taking a medicine called duloxetine , or routine exercise with nonsteroidal anti-inflammatory drugs . But the muscle and joint pain has led some women to stop treatment. If this happens, most doctors recommend using tamoxifen to complete 5 to 10 years of hormone treatment.
Because AIs drastically lower the estrogen level in women after menopause, they can also cause bone thinning, sometimes leading to osteoporosis and even fractures. If you are taking an AI, your bone density may be tested regularly and you may also be given bisphosphonates or denosumab , to strengthen your bones.
What Is Antiestrogen Used For
Antiestrogen is a form of hormonal therapy that aims to slow or stop the growth of hormone-sensitive tumors.
The therapy works in several ways. It can block the bodys ability to produce cancer-causing hormones or it can change the way hormones affect breast cancer cells.
It can also be used on more advanced breast cancers to make them smaller in size or slow their growth.
Antiestrogen therapy is generally used alongside surgery that removes the tumor. Antiestrogen therapy will ideally prevent the cancerous tumor from coming back.
Its typically taken as a daily oral pill, though sometimes it is taken as an injection instead.
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Joint Discomfort And Pain
Joint symptoms related to hormone therapy for breast cancer do not tend to improve with the use of medications that you might take for typical arthritis, like acetaminophen or ibuprofen, Mayer says.
What helps: Acupuncture and activity both show promise. âWe do have evidence that acupuncture can be helpful for joint pain,â Mayer says. âRegular exercise can also help reduce joint pain as well as helping you sleep better at night.â
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.
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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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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.
Blocking The Effects Of Estrogen
Different kinds of drugs are used to block the effects of estrogen.
Selective estrogen receptor modulators block the effects of estrogen in breast tissue. SERMs mimic estrogen and attach to the estrogen receptors, preventing estrogen from binding to receptors.
Examples of SERMs include:
Another drug that blocks the effects of estrogen is Faslodex . The difference is that, unlike SERMs, Faslodex doesnt mimic estrogen.
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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.
What Is Estrogen Suppressing Therapy
Estrogen suppressing therapy is a form of antiestrogen therapy that slows or reduces the amount of estrogen in a females body.
A group of estrogen suppressants called aromatase inhibitors, for example, block the enzyme aromatase, which turns the hormone androgen into small amounts of estrogen in the body.
This results in less estrogen being available elsewhere to contribute to the growth of breast cancer cells that are sensitive to hormones.
While estrogen suppressing therapies cant stop ovaries from making estrogen, they can reduce the bodys production of estrogen.
Generally taken as a pill, estrogen suppressants are best for treating early stage breast cancer thats sensitive to hormones. Joint stiffness and joint pain are two common side effects of the medication.
However, like all medications, estrogen suppressants may also have serious side effects. Heart complications and increased bone loss are rare but possible.
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What Are The Side Effects Of Hormone Therapy
The side effects of hormone therapy depend largely on the specific drug or the type of treatment . The benefits and harms of taking hormone therapy should be carefully weighed for each person. A common switching strategy used for adjuvant therapy, in which patients take tamoxifen for 2 or 3 years, followed by an aromatase inhibitor for 2 or 3 years, may yield the best balance of benefits and harms of these two types of hormone therapy .
Less common but serious side effects of hormone therapy drugs are listed below.
- breathing problems, including painful breathing, shortness of breath, and cough
- loss of appetite
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
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Problems Getting An Erection
Hormone therapy lowers the amount of testosterone in the body and this affects your ability to have and maintain an erection. This may get better within 3 to 12 months after the treatment ends.
For some men, erection problems are permanent. It depends on the drug you are having and how long you have been taking it.
Your doctor or clinical nurse specialist will be able to offer you advice.
Looking After Your Bones While Taking An Aromatase Inhibitor
Aromatase inhibitors can reduce bone density. This may increase the risk of breaks in the bones. To keep your bones healthy while you are taking this medication, your doctor may recommend that you:
- have a bone density test before and during treatment
- do regular weight-bearing exercise
- maintain a healthy intake of calcium
- ensure a healthy intake of vitamin D
- take other prescription medications to build up your bones if your bone density is already low
If you do show signs of bone thinning or weakening you may need to see your GP or specialist for special treatment for your bones.
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Surgical Removal Of The Ovaries
The operation to remove the ovaries is called oophorectomy. Surgical removal of the ovaries is a permanent way to reduce the levels of oestrogen.
It is a very effective treatment to stop early breast cancer returning or to slow the progress of metastatic cancer. This can also reduce the risk of developing ovarian cancer.
Surgery to remove the ovaries can be done with keyhole surgery or with an open operation .
Your surgeon will discuss with you the pros and cons of these different techniques. Oophorectomy is done under a general anaesthetic .
Usually the fallopian tubes are also removed but the uterus is left intact. After oophorectomy, the symptoms of menopause may come on suddenly. This is different to turning off the ovaries with medication which brings menopausal symptoms on gradually
Breast Cancer Survivors Lived Experience Of Adjuvant Hormone Therapy: A Thematic Analysis Of Medication Side Effects And Their Impact On Adherence
- 1School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom
- 2School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom
Objectives: Side effects from Hormone Therapy impact medication adherence in breast cancer survivors. Understanding the most distressing HT side effects and their impacts may inform the development and implementation of interventions to alleviate these side effects and maximise HT adherence. This study aimed to explore the lived experience of adjuvant HT and understand the impact of HT side effects on adherence in a sample of breast cancer survivors.
Methods: Twenty-five female breast cancer survivors who were currently taking adjuvant HT participated in the study. One-to-one, online, semi-structured interviews were conducted to explore specific side effects from HT and the impact of these side effects on HT adherence. Data were analysed using Thematic Analysis.
Results: The most commonly reported side effects were sleep disturbance, hot flashes, anxiety, and joint pain. Data exploring the impacts of these side effects on HT adherence were thematically synthesised into four analytical themes: A bitter pill to swallow,Seeking relief,Taking control, and The only way out is through. These themes encompass 14 sub-themes that encapsulate participants daily struggle with HT side effects and the coping strategies developed to manage these.
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What Is Hormone Therapy
Hormone therapy slows or stops the growth of hormone-sensitive tumors by blocking the bodys ability to produce hormones or by interfering with effects of hormones on breast cancer cells. Tumors that are hormone insensitive do not have hormone receptors and do not respond to hormone therapy.
Hormone therapy for breast cancer should not be confused with menopausal hormone therapy treatment with estrogen alone or in combination with progesterone to help relieve symptoms of menopause. These two types of therapy produce opposite effects: hormone therapy for breast cancer blocks the growth of HR-positive breast cancer, whereas MHT can stimulate the growth of HR-positive breast cancer. For this reason, when a woman taking MHT is diagnosed with HR-positive breast cancer she is usually asked to stop that therapy.
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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What Are Alternatives To Hormone Replacement Therapy
What are the alternatives to HRT?
- Herbal medicine a practice based on the use of plants or plant extracts to relieve symptoms, e.g. evening primrose oil or St Johns Wort.
- Alternative medicine a range of therapies used instead of conventional medicine, such as acupressure, acupuncture and homeopathy.
When Is Hormone Therapy Used
Hormone therapy is used when tumors are hormone receptor positive. It can be done at any cancer stage, but is typically done after surgery to reduce the risk of the cancer returning. This makes it adjuvant treatment.
Although sometimes it can be used before surgery to help shrink the tumor, its generally prescribed post-surgery.
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Hot Flashes And Night Sweats
Hot flashes and night sweats happen to a lot of women during menopause. Theyâre also side effects of both tamoxifen and aromatase inhibitors.
âFor tamoxifen, younger premenopausal women whose ovaries are still working tend not to have symptoms that are as severe,â says Patricia Ganz, MD, director of the Center for Cancer Prevention & Control Research at UCLAâs Jonsson Comprehensive Cancer Center. âAs you get nearer to the age of natural menopause, in your 40s and 50s, these symptoms can get worse.â
What helps: To manage hot flashes and night sweats, Mayer recommends starting with environmental approaches, like keeping your bedroom cool at night, dressing in layers, and keeping a fan on.
You can also keep a bottle of cold water by your bed or keep an ice pack under your pillow. Acupuncture may also help with many side effects linked to aromatase inhibitors, including hot flashes, Mayer says.
But if these approaches donât help and hot flashes and night sweats are interfering with your daily life, medication might be helpful.
What helps: âCertain medicines that are used to treat anxiety or depression also actually can treat hot flashes,â says Jessica Jones, MD. Sheâs an assistant professor in the oncology division of The University of Texas Health Science Center McGovern Medical School in Houston.
Jones is talking about medications such as selective serotonin reuptake inhibitors , serotonin-norepinephrine reuptake inhibitors , and gabapentin.
Joint And Muscle Pain
Joint pain and muscle pain are common side effects of aromatase inhibitors . The pain may be in the hands and wrists, feet and ankles, knees, back or other parts of the body. Joint and muscle pain are most common after youve been sleeping or inactive.
Almost half of women taking aromatase inhibitors have joint pain and about 15 percent have muscle pain .
Joint and muscle pain can mimic carpal tunnel syndrome. In rare cases, aromatase inhibitors can cause carpal tunnel syndrome .
Although aromatase inhibitors can cause joint and muscle pain, they dont cause permanent joint or muscle damage.