Hormone Treatment After Breast Cancer Surgery

Targeted Therapy For Breast Cancer

Targeted therapy refers to a variety of drugs that enter the bloodstream and treat cancer throughout the body. Targeted therapy drugs aim to attack cancer cells without harming healthy cells, and tend to have fewer side effects than chemotherapy drugs.

Targeted therapies are often used to treat HER2-positive breast cancers. These are cancers that have an excess of a protein called HER2 that promotes the growth of cancer cells.

Common targeted therapy drugs for HER2-positive breast cancers include:

• Monoclonal antibodies like trastuzumab are synthetic antibodies designed to attach to HER2 proteins and stop cells from growing.
• Antibody-drug conjugates like ado-trastuzumab emtansine attach to HER2 proteins on cancer cells and help chemotherapy reach them.
• Kinase inhibitors like Lapatinib block HER2 proteins.

Targeted therapies are also used to treat hormone receptor-positive breast cancer along with hormone therapy.

Common targeted therapy drugs for people with hormone receptor-positive cancers include:

• CDK4/6 inhibitors, which block CDK proteins in cancer cells to stop them from dividing and slow cancer growth.
• mTOR inhibitors, which block mTOR proteins in cancer cells to stop them from dividing and growing. This treatment is believed to help hormone therapy drugs work more efficiently.
• PI3K inhibitors, which block the PI3K proteins in cancer cells and helps prevent them from growing.

Common targeted therapy drugs for people with TNBC include:

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.

Hormone Therapy After Breast Surgery

If the DCIS is hormone receptor-positive , treatment with tamoxifen or an aromatase inhibitor, such as exemestane or anastrozole, for 5 years after surgery can lower the risk of another DCIS or invasive cancer developing in either breast. If you have hormone receptor-positive DCIS, discuss the reasons for and against hormone therapy with your doctor.

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Estrogen Receptor Blockers Estrogen Receptor Blocker Drugs Attach Directly To And Block The Estrogen Receptors On Cancer Cells So That The Cancer Cells Cant Use Estrogen They Do Not Affect The Level Of Estrogen In The Body Estrogen Receptor Blockers Are Also Called Selective Estrogen Receptor Modulators

Tamoxifen

Tamoxifen is the most commonly used anti-estrogen drug. It is used in post-menopausal and premenopausal women. Tamoxifen is given by mouth as a pill.

Tamoxifen is the hormonal therapy drug used most often to lower the risk that DCIS or LCIS will lead to an invasive breast cancer.

Tamoxifen very slightly increases the risk for uterine cancer, deep vein thrombosis and stroke. Doctors will carefully weigh these risks against the benefits of giving this drug before they offer it to women who have a personal or a strong family history of these conditions. Usually the benefits of taking tamoxifen outweigh these risks.

Fulvestrant

Fulvestrant is an anti-estrogen drug that reduces the number of estrogen receptors on breast cancer cells. It is given as an injection into the muscles of the buttocks.

Fulvestrant is used in post-menopausal women if the breast cancer has grown after they were treated with tamoxifen. It is also used in postmenopausal women with locally advanced or metastatic breast cancer that have never been treated with hormonal therapy.

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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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 .

Is Anesthesia Safe During Pregnancy

Surgery for breast cancer generally carries little risk to the baby. But there are certain times in pregnancy when anesthesia may be risky for the baby.

Your surgeon and anesthesiologist, along with a high-risk obstetrician , will need to work together to decide the best time during pregnancy to operate. If the surgery is done later in the pregnancy, your obstetrician may be there just in case there are any problems with the baby during surgery. Together, your doctors will decide which anesthesia drugs and techniques are the safest for both you and the baby.

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What This Means For Patients

Because the results of ER and PR testing can make a difference in a persons treatment and chance of recurrence, its important that these tests are accurate. This guideline was developed to help both doctors and laboratories know how to improve the accuracy of ER and PR testing for those with breast cancer. Understanding the ER/PR status of the primary tumor and any distant or recurrent tumors can help doctors make sure that patients receive the appropriate treatment and avoid side effects of a treatment that may not work. Use this guideline to talk with your doctor about the accuracy of your ER and PR test results and what that means for your treatment.

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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Side Effects Of Hormone Therapy

Like any treatment, hormone therapy can cause side effects. Everyone reacts differently to drugs and some people have more side effects than others.

Side effects can often be managed and those described here will not affect everyone.

Some side effects are common to all hormone therapies, while others are specific to certain drugs. You can read about specific side effects on our individual drug pages .

If youre concerned about any side effects, whether or not they are listed here, talk to your treatment team as soon as possible.

Strengths And Weaknesses Of This Study

Some limitations of this study arise from inevitable shortfalls in completeness and accuracy within any routinely collected dataset. A small proportion of women had missing information on smoking status, alcohol consumption, and BMI, but these were dealt with by multiple imputation. As we did not have reliable data for age at onset of menopause for all women, we estimated onset from the first menopause specific record before the earliest HRT prescription. For women with no such record we assumed onset within the most common age range of 50 to 54 years. We did not investigate the differences between continuous and sequential HRT because these regimens are prescribed at different times after menopause. As our cases and controls were matched by age, they would likely have been prescribed similar regimens, making a comparison infeasible. Our primary focus, anyway, was recent long term exposure.

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Lowering Estrogen Levels From The Ovaries

This type of treatment only works in premenopausal women who have functioning ovaries. It can help some types of hormone therapy work better. It is also used to treat cancer that has spread.

There are three ways to lower estrogen levels from the ovaries:

• Surgery to remove the ovaries
• Radiation to damage the ovaries so they no longer function, which is permanent
• Drugs such as goserelin and leuprolide that temporarily stop the ovaries from making estrogen

Any of these methods will put a woman into menopause. This causes symptoms of menopause:

Hormone Replacement Therapy After Breast Cancer: Yes No Or Maybe

Breast cancer treatment including estrogen depleting therapy and chemotherapy leads to premature menopause.

Many breast cancer survivors suffer from intense and premature menopausal symptoms.

Hormone replacement therapy is avoided in this group due to concerns of increased breast cancer recurrence.

Evidence is not conclusive to demonstrate increased breast cancer recurrence with hormone replacement.

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Hormone Therapy After Surgery For Breast Cancer

After surgery, hormone therapy can be given to reduce the risk of the cancer coming back. Taking an AI, either alone or after tamoxifen, has been shown to work better than taking just tamoxifen for 5 years.

These hormone therapy schedules are known to be helpful for women who are post-menopausal when diagnosed:

• Tamoxifen for 2 to 3 years, followed by an AI for 2 to 3 years
• Tamoxifen for 2 to 3 years, followed by an AI for 5 years
• Tamoxifen for 4½ to 6 years, followed by an AI for 5 years
• Tamoxifen for 5 to 10 years
• An AI for 5 to 10 years
• An AI for 2 to 3 years, followed by tamoxifen for 2 to 3 years
• For women who are unable to take an AI, tamoxifen for 5 to 10 years is an option

For most post-menopausal women whose cancers are hormone receptor-positive, most doctors recommend taking an AI at some point during adjuvant therapy. Standard treatment is to take these drugs for about 5 years, or to take in sequence with tamoxifen for 5 to 10 years. For women at a higher risk of recurrence, hormone treatment for longer than 5 years may be recommended. Tamoxifen is an option for some women who cannot take an AI. Taking tamoxifen for 10 years is considered more effective than taking it for 5 years, but you and your doctor will decide the best schedule of treatment for you.

These therapy schedules are known to be helpful forwomen who are pre-menopausal when diagnosed:

What Are The Side Effects

Hormone therapy is a systemic treatment, which means it can affect cells throughout the body.

As each hormone in the body has a specific function, altering the balance of hormones in the body can cause side effects. Whether or not you experience side effects, and how severe they are, depends on the type of hormone you are taking, the dose, and how long you take the treatment. Talk to your doctor about the risks and benefits of taking hormone therapy.

Common side effects include tiredness, hot flushes, mood changes, weight gain and sweating. Hormone therapy can also affect the fertility of both women and men, bring on menopause, and have an impact on your sexuality.

Hormone therapy may also cause bones to weaken and break more easily . Talk to your doctor about having a bone density test or taking medicine to prevent your bones from becoming weak. Regular exercise, eating calcium-rich foods and getting enough vitamin D will also help keep your bones strong.

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Learn More About How Hormone Therapy Is Used To Target Cancer Cells

Hormone therapy may also be called endocrine therapy or hormone-blocking therapy.

Some cancers grow in response to particular hormones. These cancers are known as hormone-dependent cancers. They include some types of breast, uterine and prostate cancers. The aim of hormone therapy is the slow or stop the growth of hormone receptor positive cells.

Cancers Treated With Hormone Therapy

Hormone therapy is used to treat prostate and breast cancers that use hormones to grow. Hormone therapy is most often used along with other cancer treatments. The types of treatment that you need depend on the type of cancer, if it has spread and how far, if it uses hormones to grow, and if you have other health problems.

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Hormone Replacement Therapy After Breast Cancer

Many women in the UK take hormone replacement therapy to reduce menopausal symptoms. But doctors dont routinely recommend taking HRT after breast cancer.

The concern is that HRT could increase the risk of your breast cancer coming back . The risk for women who have had breast cancer is uncertain because research so far has not drawn any firm conclusions. This might depend on the type of HRT and how long you have it.

The risk is thought to be greater in women:

• whose breast cancer has receptors for the female hormones hormone receptor positive breast cancer
• who take HRT that contains oestrogen and progestogen

Its important that you talk to a health professional if you are finding menopausal symptoms difficult to cope with. Ideally you should speak to your cancer doctor as well as a doctor that specialises in the menopause.

Your doctor might suggest that you try other things first, such as non hormonal medicines. But they may offer HRT if your symptoms are severe. For example, if hot flushes or low mood, or a combination of symptoms are affecting your quality of life. Your doctor should discuss the risks and benefits of HRT with you.

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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Why Are Triple Negative Breast Cancers More Common

Triple-negative breast cancer cells dont have estrogen or progesterone receptors and also dont make any or too much of the protein called HER2. These cancers tend to be more common in women younger than 40 years of age, who are Black, or who have a mutation in the BRCA1 gene. Triple-negative breast cancers grow and spread faster than most other types of breast cancer. Because the cancer cells dont have hormone receptors, hormone therapy is not helpful in treating these cancers. And because they dont have too much HER2, drugs that target HER2 arent helpful, either. Chemotherapy can still be useful. See Triple-negative Breast Cancer to learn more.

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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.

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