Hair loss Treatment Center

PARTICIPANTS Stephen E. Jones, MD Baylor-Sammons Cancer Center, Dallas, Texas Debu Tripathy, MD Professor of Medicine, University of Texas Southwestern Medical Center EDITORIAL CONSULTANT Maura N. Dickler, MD Assistant Attending Physician, Memorial Sloan-Kettering

ANNOUNCER: Many women with early stage disease have a type of breast cancer that grows in response to estrogen. Those women may be good candidates for hormonal treatment, which either blocks estrogen from binding to the cancer cells or decreases the level of estrogen in the body.

STEVEN JONES, MD: What we've learned in the last 25 years is that those women are candidates for hormone treatment. The gold standard up to this time has been five years of a drug called tamoxifen.

There is now another option and that's one of the drugs called an anti-aromatase agent. The one drug that is approved for this is a drug called anastrozole or Arimidex.

ANNOUNCER: While these medications can be quite effective, there also may be side effects associated with their use.

DEBU TRIPATHY, MD: Side effects from hormonal therapies are fairly common. They don't happen to everybody. I'd say about a third of patients on hormonal therapy will develop side effects.

ANNOUNCER: Some of the side effects of both tamoxifen and aromatase inhibitors, although not considered serious, can affect a woman's quality of life. Fortunately, they can often be treated.

STEVEN JONES, MD: The most common side effects by far and away are hot flashes. They tend to peak at about six months and then slowly subside. Vitamin E in low doses has proven to be effective. Sometimes you'll have some mood disorders. Moodiness, a little bit of depression, problems sleeping. And it's important to recognize that because that's pretty readily treated with some of the available antidepressants. Just very low doses will really correct that. And particularly, if the woman is going to be on this for a long period of time.

Certainly more serious would be vaginal bleeding; that needs to be investigated to make sure it's not uterine cancer.

ANNOUNCER: Vaginal dryness and pain with intercourse might also occur with hormonal treatment.

DEBU TRIPATHY, MD: We sometimes recommend lubricants, if this is a problem. Even topical estrogens are sometimes tried, although we are not 100% sure that those might be safe. Many times these side effects simply get better over time, so we may not need to manage them or the things we use to manage them may only be used temporarily.

ANNOUNCER: More serious side effects from hormonal treatment can also occur, although the likelihood is low.

DEBU TRIPATHY, MD: Serious side effects of tamoxifen are not that common, but these do include an increased risk of blood clots and this might seen in maybe 1 in 500, 1 in 400 patients.

ANNOUNCER: These clots may occur in the leg or lung, or in the brain, causing a stroke.

STEVEN JONES, MD: I think if a patient has a blood clot or end up with a stroke or something of that sort, we're going to stop the tamoxifen. That's generally what's done.

There are alternatives now because I think anastrozole or Arimidex is an alternative that has less risk of those things involved.

ANNOUNCER: Also with tamoxifen, there is a slightly increased risk of developing uterine cancer.

STEVEN JONES, MD: Almost always when the uterine cancer is found, it's treatable so that would not be a reason not to take tamoxifen.

ANNOUNCER: The risk of blood clots and uterine cancer may be more common with tamoxifen than Arimidex, but Arimidex can also produce problems that need to be watched.

DEBU TRIPATHY, MD: Some of the more serious side effects of aromatase inhibitors are an increase in the risk of osteoporosis, which is thinning of the bones, and might predispose some women to fractures.

Managing bone loss from aromatase inhibitors, at this point, encompasses the standard recommendations we would use for any postmenopausal woman. And that is that she should periodically have her bone mineral density tested; there is a simple test called a bone mineral density test that one can do.

STEVEN JONES, MD: If there is not bone loss or there is a little bit of bone loss, it's important to follow that woman with repeat testing, and then to begin to intervene early, if she starts to lose bone mass. It doesn't change that rapidly so it's not an emergency, but it's something that needs to be dealt with.

So all these women actually should take extra calcium. They should all take vitamin D. And then they should be monitored with bone mineral density testing.

DEBU TRIPATHY, MD: If the bone mineral density is low, we recommend for all women, whether they are taking aromatase inhibitors or not, that they take a drug called a bisphosphonate, which can help lower the risk of osteoporosis and the risk of fractures associated with it.

Another side effect is what's called the musculoskeletal syndrome and what that is are pains in the joints and in the bone. And we don't know exactly what causes them, but about 1 in 20 women will have those side effects.

ANNOUNCER: While patients and doctors may both understand the implications of the more serious side effects of hormonal treatment, there may be a gap in perception about the kind of impact the less serious side effects may have on a patient's quality of life.

DEBU TRIPATHY, MD: Sometimes patients themselves don't want to bring these things up, because they feel that the more serious side effects or the risk of cancer coming back is more important and that's what they need to spend their time discussing. So it's important for physicians, at the very beginning, to tell patients to talk about any side effects. That sometimes there are treatments and approaches that might help.

STEVEN JONES, MD: These women are going to be on these hormonal treatments for a long period of time. And there really is no reason anymore to have someone very uncomfortable for months or years on these agents when there are things that could alleviate the symptoms.