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Is Hormone Therapy Necessary After Lumpectomy

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Drugs That Lower Estrogen Levels

Intermittent Hormone Therapy for Prostate Cancer 101 | Ask a Prostate Expert, Mark Scholz, MD

Some drugs, called aromatase inhibitors , stop the body from making estrogen in tissues such as fat and skin. But, these drugs do not work to make the ovaries stop making estrogen. For this reason, they are used mainly to lower estrogen levels in women who have been through menopause . Their ovaries no longer make estrogen.

Premenopausal women can take AIs if they are also taking drugs that stop their ovaries from making estrogen.

Aromatase inhibitors include:

Faqs After Diagnosis: Early Stage Hormone

Amanda Nottke, PhDIndependent Consultant/Writer, formerly Scientist and Product Team Member at Cancer Commons

This post is written by ASK Cancer Commons Scientist and Product Team Member Amanda Nottke, PhD. Dr. Nottke regularly provides guidance to patients through our ASK Cancer Commons service.

After a diagnosis of early stage, hormone-positive breast cancer, you may find yourself facing several daunting decisions, such as choosing between the extensive surgery of mastectomy versus a more minor lumpectomy procedure paired with radiation . And once surgery is complete, what next? Hormone therapy is clearly indicated for many women, but which drug, and how long to take it? And what about chemohow to know if the tough side effects are worth the possible reduction in risk of recurrence?

Fortunately, there are a wealth of quality datasets available to inform these decisions. Below are some of the questions we get most frequently from patients using our ASK Cancer Commons service, answered according to the latest thinking from scientific literature and our expert physician network. If you are facing your own cancer treatment decisions and would like free one-one-one expert support, please submit your case here.

1. If my doctor has said either mastectomy or lumpectomy plus radiation are appropriate for me, how do I choose?

2. What are the rates of recurrence and overall survival rates for mastectomy versus lumpectomy plus radiation?

  • Tumor size larger than 10 mm
  • Hormonal Therapies Slow Or Stop Breast Cancers Growth By Changing The Hormonal Milieu

    For early stage cancer, these treatments include tamoxifen and a class of drugs called aromatase inhibitors . Three aromatase blocking drugs are available clinically. Anastrozole and letrozole work by reversibly blocking this enzyme, while exemestane binds to the enzyme and inactivates it permanently. Studies suggest that all three are equally effective. Women with metastatic breast cancer also have other hormone therapy options, including fulvesrant , megestrol acetate , and tormifene .

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    What Are Hormone Inhibitors And How Do They Work

    Hormone inhibitors also target breast cancer cells with hormone receptors, but unlike hormone blockers, they work by reducing the bodys hormone production. When breast cancer cells are cut off from the food supply the tumor begins to starve and die.Generally, the benefits of using hormone therapy and chemotherapy together have a much greater combined effect than using either alone. If your breast cancer is positive for hormone receptors, your doctor may recommend both therapies.

    Questions To Ask The Health Care Team

    Breast cancer. What are the treatment options?
    • What side effects are common from the hormone therapy treatment you are recommending for me?

    • When is it likely that side effects will occur? How often?

    • How long will side effects last? Could any of them be permanent?

    • Is there anything I can do to prepare for these side effects?

    • What can the health care team do to prevent or relieve side effects?

    • Who should I tell if I begin experiencing side effects from hormone therapy? How soon?

    • What side effects are considered emergencies? What should I do if I experience an urgent side effect?

    • Who do I contact if I have questions about specifci side effects?

    • How can I reach them during regular business hours? After hours?

    • Are there any support groups you can recommend to help cope with the fear of side effects?

    • Are there other ways I can cope with my fears about the effects of treatment?

    • Can you recommend a social worker, counselor, or supportive or palliative care specialist for me to talk with?

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    A Lower Risk For Breast Cancer Recurrence

    Landmark 2004 research, augmented by later studies, helped cancer experts develop guidelines defining which women with early-stage breast cancer could safely omit radiation after lumpectomy.

    Generally, this option is offered to women 65 or older who have small tumors with nonaggressive cells that havent spread to the lymph nodes. Medically, this is described as a T1N0, grade 1-2 tumor. The tumors must be estrogen receptor-positive, meaning that the hormone estrogen helps fuel their growth. They also must have an adequate margin of normal tissue surrounding the tumor cut away to ensure all the cancer has been removed. Women who decide to omit radiation instead receive medication known as endocrine therapy for five years. This stops cancer cells from using hormones like estrogen to grow and spread.

    “This has been the standard of care for a long time in women 65 or older. Now the debate is whether we can also omit radiation for a larger group of patients with breast cancer. For example, can we take this approach in patients younger than age 65, if patients are chosen carefully?” says Dr. Nadine Tung, director of the Cancer Risk and Prevention Program and Breast Medical Oncology at Beth Israel Deaconess Medical Center.

    Side Effects Of Tamoxifen And Toremifene

    The most common side effects of tamoxifen and toremifene are:

    • Vaginal dryness or discharge
    • Changes in the menstrual cycle

    When tamoxifen treatment starts, a small number of women with cancer that has spread to the bones might have a tumor flare which can cause bone pain. This usually decreases quickly, but in some rare cases a woman may also develop a high calcium level in the blood that is hard to control. If this happens, the treatment may need to be stopped for a time.

    Rare, but more serious side effects are also possible:

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    Emerging Research May Allow More Women With Early

    Women diagnosed with early-stage breast cancer often can choose to have a lumpectomy, which removes only cancerous tissue and a thin margin of surrounding healthy cells instead of the entire breast. Current cancer guidelines for most women under 65 recommend following lumpectomy with radiation therapy, which targets stray cancer cells that might otherwise cause breast cancer to recur or spread to other parts of the body.

    A new study presented at the 2022 annual meeting of the American Society of Clinical Oncology could eventually expand an option for skipping radiation to some women as young as 55. However, limitations in necessary testing could hinder the approach from becoming widespread, according to a Harvard expert.

    Managing The Side Effects Of Hormone Therapy

    Doctor Explains Radiation After Lumpectomy for Breast Cancer

    Before hormone therapy begins, talk with your doctor about what side effects could happen and how they can be managed. Ask questions about anything that is unclear to you. This will help you feel more prepared if you start experiencing those side effects. Let your health care team know about any new or worsening medical problems you have as soon as possible. This is important to do even if you do not think your symptoms are serious or related to your hormone therapy. Tracking your side effects can make getting the relief you need easier. One way to track side effects is using the free Cancer.Net Mobile app. You can securely record when side effects occur and their severity, and you can easily share these details with your health care team to describe your experience.

    Some people may need to take hormone therapy for a long time. Working with your health care team to manage side effects can help maintain quality of life while on this kind of extended cancer treatment.

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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.

    The Types Of Radiotherapy

    The type of radiotherapy you have will depend on the type of breast cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.

    Types of radiotherapy include:

    • breast radiotherapy after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue
    • chest-wall radiotherapy after a mastectomy, radiotherapy is applied to the chest wall
    • breast boost some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed however, this may affect the appearance of your breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of breast tissue
    • radiotherapy to the lymph nodes where radiotherapy is aimed at the armpit and the surrounding area to kill any cancer that may be in the lymph nodes

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    Why Am I So Tired After A Lumpectomy

    You may feel tired after surgery. This can be due to the stress on your body, any pain after surgery and the time it takes to heal. Having a general anaesthetic can also affect your energy levels. If you had treatment before surgery such as chemotherapy or targeted therapies you may still be feeling tired from this.

    Is Radiation Therapy Necessary If The Margins Of The Removed Tissue Are Clear

    MEDizzy

    Many studies have reviewed this approach for patients with invasive cancers. Nearly all show that the risk of relapse in the breast is much higher when radiation is not used than when it is . When breast cancer re-occurs locally after breast conservation surgery, patients may then need to have a mastectomy to be cured. Because having breast cancer reappear in this way is a very traumatic psychological event, and because not everyone who has a recurrence in the breast can be cured, radiation therapy after lumpectomy has become a standard part of breast-conserving therapy.

    There are several recent studies in which older patients with small, favorable invasive cancers have had a low risk of local relapse when treated with lumpectomy and hormonal therapy without radiation therapy. There is still uncertainty about the long-term results with this approach or about which individuals will do best without radiation therapy. This issue should be discussed in detail with your doctor.

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    Possible Side Effects Of Ais

    The most common side effects of AIs are:

    • Bone and joint 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 Hormonal Therapy

    Hormones help control how cells grow and what they do in the body. The hormones oestrogen and progesterone, particularly oestrogen, can encourage some breast cancers to grow.

    Hormonal therapies reduce the amount of oestrogen in the body or stop it attaching to the cancer cells. They only work for women with oestrogen-receptor positive cancers.

    Your cancer doctor will advise you to take hormonal therapy to reduce the risk of the breast cancer coming back. It also helps reduce the risk of getting a new breast cancer in your other breast. Sometimes hormonal therapy drugs are given before surgery to shrink a cancer and avoid a mastectomy.

    You usually take hormonal therapy drugs for a number of years. For some women, this could be up to 10 years. You usually start taking them after surgery or chemotherapy.

    The type of hormonal therapy you have depends on:

    • whether you have been through the menopause or not
    • the risk of the cancer coming back
    • how the side effects are likely to affect you.

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    Hormone Therapy Has A Bigger Impact Than Chemotherapy On Womens Quality Of Life

    Cellules cancéreuses. Expression de la protéine PML en rouge et du gène ZNF703 en vert dans des cellules de la lignée de cancer du sein MCF7. ©Inserm/Ginestier, Christophe

    Analysis of the CANTO cohort published in the journal Annals of Oncology will upset received wisdom on the effects that hormone therapy and chemotherapy have on the quality of life in women with breast cancer. Contrary to the commonly held view, 2 years after diagnosis, hormone therapy, a highly effective breast cancer treatment worsens quality of life to a greater extent and for a longer time, especially in menopausal patients. The deleterious effects of chemotherapy are more transient. Given that current international guidelines recommend the prescription of hormone therapy for 5 to 10 years, it is important to offer treatment to women who develop severe symptoms due to hormone antagonist medication and to identify those who might benefit from less prolonged or intensive treatment strategies.

    This work was directed by Dr Inès Vaz-Luis, specialist breast cancer oncologist and researcher at Gustave Roussy in the lab Predictive Biomarkers and Novel Therapeutic Strategies in Oncology .

    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

    Do Lumpectomy Patients Always Undergo Radiation Therapy?

    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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    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.

    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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    Selective Estrogen Receptor Modulators

    Selective estrogen receptor modulators including tamoxifen , raloxifene and toremifene selectively block estrogen from certain tissues, namely the breast, while increasing its availability in other areas such as the bones.

    When and why theyre used: Doctors may recommend SERMs after surgery for early ER-positive breast cancer in men or women, to reduce the chances that it recurs. Theyre also approved to treat advanced breast cancer, and may be used to prevent breast cancer in high-risk individuals. Toremifene is only approved for advanced stage breast cancer that has spread.

    Risks: In addition to more common side effects of hormone therapy such as hot flashes, tamoxifen risks may include blood clots, stroke, bone loss, mood changes, depression and loss of sex drive. Men who take tamoxifen may experience headaches, nausea, vomiting, rashes, impotence and loss of sex drive. Raloxifene may increase a patients chances of having a stroke or developing potentially fatal blood clots in the lungs or legs. Fortunately, these side effects are considered relatively rare. Have your doctor explain the potential side effects associated with each SERM when discussing the pros and cons of these medications with you.

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