Source: Journal of clinical oncology
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What is the recommended treatment for patients with hormone receptor positive breast cancer?
In a nutshell
This paper reviewed and provided recommendations on treatment for breast cancer that is hormone receptor positive (presence of estrogen or progesterone receptor).
Adjuvant endocrine therapy (treatment given after surgery) is highly effective for hormone receptor positive breast cancer. Tamoxifen (Nolvadex) taken for 5 years has long been the standard adjuvant endocrine treatment. Recently, it has been suggested that patients who are postmenopausal (no menstruation for a year) can also take an aromatase inhibitor (Femara, Arimidex).
Methods & findings
A group of experts in the field looked at results from clinical trials and made recommendations.
Women who have not completed menopause should be offered tamoxifen for an initial 5 years. After 5 years, these women should receive tamoxifen for an additional 5 years. However, if they have completed menopause during the inital 5 years of tamoxifen therapy, they should receive either tamoxifen for another 5 years or an aromatase inhibitor for up to 5 years.
There are several options for women who are postmenopausal. The first option is tamoxifen for 10 years. A second option would be an aromatase inhibitor for 5 years as there is currently insufficient data to recomment use of an aromatase inhibitor for longer than this. A third option would be tamoxifen first for 5 years then switching to an aromatase inhibitor for up to 5 years. The fourth option would be tamoxifen for 2 to 3 years and switching to an aromatase inhibitor for up to 5 years.
Overall, endocrine treatment after surgery increases overall survival and reduces risk of cancer returning. However, side effects like hot flashes (feeling of warmth around face) can occur. Risks associated with tamoxifen include blockage of blood vessels, uterine cancer, and endometrial cancer if tamoxifen is continued in the long term. Side effects of aromatase inhibitors include heart disease and osteoporosis (weak and brittle bones).
The bottom line
The authors concluded that tamoxifen is now recommended for a duration of up to 10 years rather than 5 years in hormone receptor positive breast cancer.
The fine print
This study reviewed only evidence on durations of tamoxifen of greater than 5 years.
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Discussion about this item
I have read a few articles that indicate that tamoxifen can cause damage to the Central Nervous System and brain. I am nervous about continuing tamoxifen treatment for the full 10 years. Over the past 5 years my memory, word register, and thought processing have taken a beating! Reply
Yes I understand you. I have what my therapist calls "chemo brain". I suddenly have short term memory loss and struggle with my words at times. It's scary and frustrating..
I've also been referred to a gyno surgeon for a hysterectomy. I have a very thick uterine lining and a polyp (benign ) but they want it out before it becomes cancerous. IV only been on Tamoxifen 4 months. H3 did mention I'd be on it 10 yrs and not 5yr as originally told. He side effects give me pain in my bones and joints . You are never the same. This is our new normal I guess. Reply
There are no gaurantees in medicine. I was on Tamoxifen for almost 8 years. Unfortunately you cannot diffinively say if the mind is not the same due to chemo treatment or tamoxifen. I thought of a Tamoxifen as menopause. You exhibit simmilur even symptoms as menopause while on it, maybe stronger in some women's cases. If you speak to women going through menopause a great concern of theirs is concentration and focus with other memory concerns. Seems as if this is what is happening naturally to many women with the slow down and loss of hormones. I have not seen studies indicating CNS or brain damage. I would be very intereasted as I feel foggy and I am contributing it to hormonal changes and chemo treatment. I would like to know if there is damage and if so it is reversible. Reply
In G B the trend is now for post menopausal women to be prescribed aromatase inhibitors for 5 years. Discussions with my oncologist indicate that evidence suggests that a further 5 years offers increased protection and would therefore be beneficial as I have hormone receptive cancer Reply
My oncologist still is not sure about more than 5 years. However she mentioned this could change. Thanks for the information Reply
I have stopped taking Tamoxifen after 4 years. I could no longer function with the side effects. Reply
what side effects were you experiencing?? Reply
I am on my 6th out of 10 years of Tamoxifen. The most frustrating side effect is my brain doesn't work properly anymore. I can't go back to teaching highschool-- I would make a complete fool of myself. The kids would crucify me! I can't multitask anymore. I can't do banking or paperwork well because I can't remember the first page of info after I've moved onto the next page; I get so mixed up. I can't think of the right words, I lose my train of thought, I say the stupidest illogical things.
I am so exhausted and often have insomnia. My hair is sparse. My eyes are dry. I have bad breath. I have an extended stomach so look like I'm pregnant, but don't feel bloated. My ear has been plugged since chemo. I am tired and lethargic. Who knows how much of this is chemo related, or tamoxifen or some other health issue?--hard to say. Reply
I had several myalgias in my legs and arms. Joint pain, memory loss, lack of concentration, fatigue. I couldn't work. I chose to quit taking the Tamoxifen so that I could go back to work. I was fired from my job for missing work, I lost my vehicle and sold my house. I had to go back to work so the Tamoxifen had to go. Reply
Thats rough. Im sorry you didn't have an understanding boss.
Do you notice a difference now that you aren't taking Tamoxifen? Reply
Absolutely it was almost overnight. No more bone and muscle pain so I was able to stop taking all narcotic pain medication. That helped my stomach and bathroom issues. Plus I have less brain fog but still have issues with memory and concentration and finding the right words to use. The physical pain is gone and that's made it possible for me to work again. Reply
I'm 2.5 years into taking an aromatase inhibitor; started with Anastrazole (Arimidex generic) switched to Letrozole (Femara) after severe insomnia with Anastrazole, then experienced increasing nausea and dizziness with vertigo on Letrozole, now I'm back on Anastrazole but have developed chronic joint pain, fatigue and depression. My MO keeps saying 'most women have no side effects' which I think is completely false. He is offering me a switch to Tamoxifen but with my family history of cardiovascular disease - no thanks. I really don't think the side effects for these drugs have been thoroughly researched and although I'm sufficiently frightened by the prospect of recurrence, I wonder if I'm doing other, possibly permanent damage to other areas by this drug. Reply
I share the worry and frustration about side effects. I started on Letrozol and felt so very unwell that I was prescribed exemestane. I suffer now from insomnia but have been prescribed sleeping pills which I take occasionally when I feel desperate. My hair is also very thin. I too worry about the impact of the drugs but fear the reoccurrence of cancer far more so stick with it. We call cancer the disease that keeps taking! Reply
I have just started Anastrozole in the past month. I am 62 and was diagnosed with breast cancer a year ago. Finished left breast madtectomy, 8 rounds of chemo and 8 weeks of radiation. Memory and cognitive problems but they started after chemo. No other side effects yet from Anastrozole so far. My main side effect from this all is neuropathy in hands, fingers, feet, and toes. Fingers the worst. Drop it's all the time. But as others have said. Cancer is in remission at this time. No HER2 found. So glad for that. Reply
I recently started taking Gabapentin for neuropathy but don't think it's working like I had hoped. Reply
What dosage are you on? I take Gabapentin also and had to mess around with the dosage for a while until I felt that it was working. Reply
I take 300 mg at night Reply
Ai side effects hard are to cope with, but after two years,here are my discoveries that have worked for me. ( I've pre checked the research , and done bloods to back up) acknowledging though that each must find our own pathways, and all of us are physiologically different.
vit D3 50, 000. units every fifteen days to keep vit D levels up, and mostly keep fatigue at bay. it also improved arthrelgia. I know this dosage is high, but blood tests validated it. letrozole seemed to prevent d3 metabolism in the liver.
Magnesium, for foggy slowed thinking, thought blocking, word finding.about 300mgs daily.
Tumeric, and Ginger, about 1 inch square pieces raw,grated and a couple of grinds of black pepper, added to two cups of water and boiled down , to roughly one cup and a glug of olive oil. Add to soup, or grape,black current, concentrate pomegranate molasses (To treat swollen joints, as I'm intolerant of aspirin, and non steroidal anti inflammatories)
Melatonin for sleeping ( started with 1/2 mg)
Europe seems prescribe about ten years of AI s, if the tumours are of a higher grade, and or more extensive . There is now interesting research I think after five years on AIs of having a three month drug holiday a year apparently to prevent tumour resistance occurring.( I think called the solo experiment, I would be grateful for advisor comment re this. Reply
I had blood work and was not vit D deficient. My doc did not recommend a vitamin since there was no need. Reply
I stopped taking Letrazole...horrible. I won't take anything that damages me and makes me feel ill. at 74 my quality of life important. I start Herceptin next week. Reply
I took Tamoxifen for less than a year and developed two very large endometrial polyps. I also got so depressed that I planned my suicide twice. I DO NOT want to die. I will never take this drug again, nor would I ever recommend anyone to take this drug. Reply