How Hormone Therapy Works
Oestrogen and progesterone are hormones which are naturally produced in the human body. Before menopause, oestrogen is mostly produced by the ovaries. After menopause, when the ovaries are no longer active, a small amount continues to be produced in other tissues such as fat, muscle and adrenal glands.
Normal breast cells contain receptors that are able to recognise these hormones and allow them to access the cells, where they release signals encouraging growth and development. All breast cancers are tested for the presence of these oestrogen and progesterone receptors, using tissue taken at the time of biopsy or surgery. Approximately 70% of breast cancers retain these receptors, and rely on these hormones to grow. These hormone-sensitive cancers are described as oestrogen receptor positive and/or progesterone receptor positive .
Hormone therapy is also used to shrink or slow the growth of a breast cancer when surgery is not appropriate, for example in an older person with other major health issues. It is also used to help shrink advanced stage breast cancers or slow their growth.
Hormone therapy for breast cancer is not the same as HRT . HRT raises the level of oestrogen +/- progesterone in the body and is not used in the treatment of breast cancer.
How Can Hormones Affect The Growth Of Breast Cancer
Hormones like estrogen and progesterone are chemicals produced by glands in the body. Normally, these hormones help regulate body cycles, like menstruation. However, sometimes these same hormones can cause cancer to grow.
The pathologist will perform tests on the breast cancer cells to determine if they have receptors that feed on estrogen or progesterone, stimulating their growth. If the cancer cells have these receptors, your doctor may recommend hormone therapy drugs, such as blockers or inhibitors. Both types of drugs help to destroy cancer cells by cutting off their supply of hormones.
How Hormone Therapy Is Given
Hormone therapy may be given in many ways:
- Oral. Hormone therapy comes in pills that you swallow.
- Injection. The hormone therapy is given by a shot in a muscle in your arm, thigh, or hip, or right under the skin in the fatty part of your arm, leg, or belly.
- Surgery. You may have surgery to remove organs that produce hormones. In women, the ovaries are removed. In men, the testicles are removed.
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Managing The Side Effects Of Tamoxifen
Hot flashes are one of the most common and bothersome side effects of tamoxifen, being reported in up to 80% of patients undergoing therapy29. They also occur to a much lesser extent in patients taking ais. Drugs that inhibit the activity of CYP2D6, such as the selective serotonin reuptake inhibitors, reduce the occurrence of tamoxifen-related hot flashes by decreasing the conversion of tamoxifen to its most active metabolite, endoxifen30. However, strong CYP2D6 inhibitors could adversely affect drug efficacy. Therefore, moderate CYP2D6 inhibitors are preferred over strong inhibitors for the treatment of hot flashes.
The relative risk of venous thromboembolism is increased by a factor of 23 in older women receiving tamoxifen31,32. The risk seems to be further pronounced when therapy is extended to 10 years from 5 in the adjuvant setting8. Risk factors for tamoxifen-induced venous thromboembolism include prior surgery, fracture, immobilization, and heterozygous factor v Leiden carrier status33. However, the risk of fatal pulmonary embolism does not seem to increase with tamoxifen use extended to 10 years , especially for women less than 54 years of age6,8.
Tamoxifen-Induced Ocular Pathologies
Tamoxifen-Induced Fatty Liver Disease
How To Tell If Hormone Therapy Is Working
If you are taking hormone therapy for prostate cancer, you will have regular PSA tests. If hormone therapy is working, your PSA levels will stay the same or may even go down. But, if your PSA levels go up, this may be a sign that the treatment is no longer working. If this happens, your doctor will discuss treatment options with you.
If you are taking hormone therapy for breast cancer, you will have regular check-ups. Checkups usually include an exam of the neck, underarm, chest, and breast areas. You will have regular mammograms, though you probably wont need a mammogram of a reconstructed breast. Your doctor may also order other imaging procedures or lab tests.
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When Is Hormone Therapy Advised For Breast Cancer Patients
Treatment of Breast cancer is now based on the biology of the cancer, hence each patients cancer is different. There can be varying permutations and combinations regarding treatment that is offered. It is a multi-modality treatment with not just Chemotherapy and Radiation but also Hormonal therapy because some breast tumours express receptors that are hormone sensitive. The tumour may be responsive to estrogen receptors or progesterone receptors . Hormones can be responsible in causing these tumours while anti-hormones play a role in treating such tumours. HT can be administered at different time points however, majority of the patients are given HT after surgery. When given after surgery, it is termed Adjuvant therapy. If it is given before surgery, it is called Neoadjuvant and the aim is to shrink the tumour. In conclusion, HT is only given if the tumour has hormone receptors i.e. is ER or PR positive.
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
Recommended Reading: He Breast Cancer Research Foundation
Mood Swings Depression And Sleep Disturbances
These side effects sometimes happen with both tamoxifen and aromatase inhibitors. If they do, tell your doctor.
What helps: If you have depression, there are treatments that can help, including medications and therapy. Other approaches that may help with mood swings, depression, and sleep disturbances include cognitive behavioral therapy , tai chi, and meditation.
Remember, depression is a medical condition. Itâs more than having the âbluesâ or the normal range of emotions we all have. Donât hesitate to tell your doctor or therapist.
What Is Hormone Receptor
Breast cancer tumors that are hormone receptor-positive need the hormones estrogen or progesterone to grow. Approximately 75% of breast cancers are hormone-positive in post-menopausal patients. Your healthcare provider will perform a biopsy and laboratory testing to determine the cancer type and most effective treatment.
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Patient Qt: Can We Contact Doctors Online Now
Yes, at Tata memorial hospital, we have started tele and video consultation facilities for all those patients who are unable to travel due to the COVID pandemic. WE can also help find you an Oncologist in your local area. To schedule an online consult, just go to the website tmc.gov.in and click on the link for the same.
Common Hormonal Therapy Side-effects and tips on how to manage themBy Dr Vani Parmar and Breast Cancer survivors
Younger women who are on Tamoxifen or on ovarian suppression may experience hot flashes, which tend to worsen on consumption of caffeinated drinks especially coffee. Exposure to certain temperatures also makes the hot flashes worse. Maintaining good hydration is prudent to reduce these effects. Mixing peppermint oil and water and spraying that on the back of the neck can provide relief. Stay cool with loose, comfortable cotton clothing and avoid make-up. Majority of hot flashes are spontaneous but transient and usually settle down with time.
- Vaginal Dryness
Application of coconut oil is a very effective remedy. It also helps with rash, itching and flaking skin around the groin area.
- Joint/muscle pains
Unwanted hair growth on the face along with thinning of hair in other areas is often seen.
Speak to a counselor and have these uncomfortable talks with your spouse.
Past Convener, Breast Cancer Working GroupProfessor, Surgical Oncology, Breast ServicesAdvanced Centre for Treatment, Research and Education in Cancer ,
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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Hormone Therapy For Breast Cancer
Some types of breast cancer are affected by hormones, like estrogen and progesterone. The breast cancer cells have receptors that attach to estrogen and progesterone, which helps them grow. Treatments that stop these hormones from attaching to these receptors are called hormone or endocrine therapy.
Hormone therapy can reach cancer cells almost anywhere in the body and not just in the breast. It’s recommended for women with tumors that are hormone receptor-positive. It does not help women whose tumors don’t have hormone receptors .
How Does Hormone Therapy Work
About 2 out of 3 breast cancers are hormone receptor-positive. Their cells have receptors for estrogen and/or progesterone which help the cancer cells grow and spread.
There are several types of hormone therapy for breast cancer. Most types of hormone therapy either lower estrogen levels in the body or stop estrogen from helping breast cancer cells grow.
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The Impact Of Medication Side Effects On Adherence And Persistence To Hormone Therapy In Breast Cancer Survivors: A Qualitative Systematic Review And Thematic Synthesis
HT reduces risk of recurrence, yet many cancer survivors do not take HT as prescribed.
Adherence to HT is negatively impacted by the presence and severity of side effects.
16 studies were synthesised to explore how side effects impacted adherence and persistence.
HT side effects significantly impact breast cancer survivor’s quality of life.
Healthcare professionals play an important role in encouraging adherence and persistence.
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 4Â½ 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 diagnosedï»¿:
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How Often And For How Long Will I Need Hormone Therapy
How often you have hormone therapy will depend on the type of drug you are receiving and the type of cancer treated. Some medications need to be administered monthly, while others dont have to be administered quite as frequently.
In regards to how long hormone therapy will last, this will vary based upon the type of cancer you have and how well you are responding to treatment. For some people, it could continue for a few months. However, it is normal to need to continue with hormone therapy for several years. A common example is women undergoing hormone therapy for breast cancer it is normal to continue with treatment for five to seven years.
Possible Side Effects Of Hormone Therapy
Some side effects are common to all methods of hormone therapy and are due to the reduced levels of oestrogen.
Tamoxifen and aromatase inhibitors also produce some different side effects. You may experience some of the side effects listed, but are unlikely to experience them all.
For most people who are recommended to take hormone therapy for breast cancer, the risks of treatment are outweighed by the benefits.
Here is a list of possible side effects that might be experienced on tamoxifen and aromatase inhibitors:
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Why Is This Study Important
Most invasive breast cancers are hormone receptor-positive . Hormone therapy, also called endocrine therapy, can be an important part of treatment for patients with hormone receptor-positive breast cancer. Hormone therapy reduces the risk of cancer returning and may improve overall survival. However, many patients who are prescribed hormone therapy do not begin or complete treatment. This study looked at the reasons behind these decisions.
Adjuvant Endocrine Therapy For Bca
Adjuvant therapy is often decided by the oncologist based on clinical, pathologic, and genetic scoring parameters. Several meta-analyses have demonstrated a consistent benefit for a patients survival with the addition of endocrine therapy in hormone receptorpositive nonmetastatic bca. The three classes of agents used are the selective estrogen receptor modulators , the aromatase inhibitors , and ovarian suppression. Figure 1 summarizes the sequencing strategies for those agents, and notes key definitions .
Algorithm for choice of endocrine therapy in the adjuvant setting. aMenopause: Defined as any patient less than 60 years of age who previously underwent bilateral oophorectomy or who has not had any menstrual periods for 12 months or more in the absence of tamoxifen, chemotherapy, or ovarian suppression, and whose serum estradiol is in the postmenopausal range or who is amenorrheic on tamoxifen, with follicle-stimulating hormone and serum estradiol in the postmenopausal range. bAny patient 60 years of age or older. cAny patient less than 35 years of age or any premenopausal patient who has received chemotherapy in the adjuvant setting. dAdditional treatments to be decided in conjunction with an oncologist, on a case-by-case basis. OS = ovarian suppression Tam = tamoxifen AI = aromatase inhibitor .
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Are There Ways To Minimise These Effects
The younger women who are on Tamoxifen or on ovarian suppression may experience hot flashes, which tend to worsen on consumption of caffeinated drinks especially coffee. Exposure to certain temperatures also makes the hot flashes worse. Maintaining good hydration is prudent to reduce these effects. Majority of hot flashes are spontaneous but transient and usually settle down with time. The side-effects of Aromatase Inhibitors are not stimulated physiologically, so supplements are the best way to manage them.
How Much Hormone Therapy Costs
The cost of hormone therapy depends on
- the types of hormone therapy you receive
- how long and how often you receive hormone therapy
- the part of the country where you live
Talk with your health insurance company about what services it will pay for. Most insurance plans pay for hormone therapy for their members. To learn more, talk with the business office where you go for treatment. You can also go to the National Cancer Institute database, Organizations that Offer Support Services and search “financial assistance.” Or call toll-free 1-800-4-CANCER to ask for help.
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When Is Hormone Therapy Used For Breast Cancer
Hormone therapy is often used after surgery to help reduce the risk of the cancer coming back. Sometimes it is started before surgery .
It is usually taken for at least 5 years. Treatment longer than 5 years might be offered to women whose cancers have a higher chance of coming back. A test called the Breast Cancer Index might be used to help decide if a woman will benefit from more than 5 years of hormone therapy.
Hormone therapy can also be used to treat cancer that has come back after treatment or that has spread to other parts of the body.