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Practice bulletins > #126 Management of Gynecologic Issues in Women with Breast Cancer > Flashcards

#126 Management of Gynecologic Issues in Women with Breast Cancer Flashcards

1
Q

One is the lifetime risk of breast cancer in American women?

A

1 in 8

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2
Q

What is the overall incidence of chemotherapy-induced amenorrhea in women with breast cancer treated w/ chemo?

A

53-89%

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3
Q

What are risk factors for post-chemotherapy amenorrhea for breast cancer patients?

A

Age > 40yo. Alkylating agents like cyclophosphamide

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4
Q

What are long-term effects of chemotherapy on women with breast cancer in regards to menses and ovarian function?

A

Menstrual irregularities common (intermittent anovulation), persistently poor ovarian reserve, infertility, higher risk of premature ovarian failure

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5
Q

What hormone-related therapies are used to treat premenopausal women with ER and/or PR positive breast cancer?

A

Ovarian suppression with GnRH agonist or antagonist. Risk reducing salpingo-oophorectomy. Aromatase inhibitors. Estrogen agonists and estrogen antagonists (SERMs).

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6
Q

At what age should a women with BRCA mutation undergo risk-reducing BSO?

A

By age 40 (35-40yo) or when childbearing is complete

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7
Q

What is the mean reductions in serum testosterone and estradiol in a patient with surgical menopause?

A

testosterone decreases by 50%

Estradiol decreases by 80%

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8
Q

Is systemic hormone therapy recommended in breast cancer survivors?

A

Not generally recommended

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9
Q

What are management options of menopausal hot flashes in breast cancer patients?

A

SSRI, SNRI. Gabapentin, clonidine.

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10
Q

For a patient on tamoxifen for breast cancer, what medication is first line for menopausal symptoms? Why

A

SNRI. Less potent inhibition of cytochrome P450 2D6 isozyme pathway required for tamoxifen metabolism (compared to SSRI).

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11
Q

What is appropriate management for atrophic vaginitis in breast cancer survivors?

A

Vaginal moisturizers, vaginal pH-balanced gel. Use of vaginal estrogen in patients who failed these therapies may be considered

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12
Q

What are low dose vaginal estrogen options for atrophic vaginitis in breast cancer survivors?

A

Lower systemic absorption with low-dose 10mcg estradiol-17b vaginal tablets or low-dose vaginal estradiol ring (compared with oral estradiol or estradiol vaginal cream)

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13
Q

What is the most consistent predictor of satisfying sexual experiences in women with breast cancer?

A

Quality of their relationships

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14
Q

Does chemotherapy for patients with breast cancer increase risk of sexual dysfunction?

A

Yes.
64% absence of sexual desire
38% dyspareunia
42% lubrication problems

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15
Q

What estrogen agonists and estrogen antagonists (SERM) are approved for use in US for hormone receptor-positive breast cancer?

A

Tamoxifen, raloxifene, toremifene

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16
Q

For how long should tamoxifen be used for breast cancer treatment?

A

Studies support 5 years. Little benefit for treatment beyond 5 years

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17
Q

How much does 5 years of tamoxifen decrease risk of breast cancer recurrence?

A

40%

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18
Q

How much does 5 years of tamoxifen decrease annual mortality risk in breast cancer?

A

34%

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19
Q

Do the recurrence rate and mortality benefits of tamoxifen in breast cancer depend on age, menopausal status, lymph node status, or chemotherapy use?

A

No, improvement independent of these factors.

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20
Q

Is tamoxifen used for pre and/or postmenopausal breast cancer patients?

A

Pre and post

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21
Q

What is the FDA approval of raloxifene for in regards to breast cancer?

A

Prevention of invasive breast cancer in postmenopausal women who are at high risk of developing the disease

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22
Q

Is tamoxifen or raloxifene more effective at preventing breast cancer in high-risk women?

A

Safe efficacy

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23
Q

What is the change in risk of invasive breast cancer after 5 years of raloxifene vs tamoxifen use (in high risk patient)

A

Reduced by 38% vs 49%

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24
Q

What is the change in risk of noninvasive breast cancer after 5 years of raloxifene vs tamoxifen use (in high risk patient)

A

39% vs 50%

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25
Q

What is Toremifene FDA approved for in regards to breast cancer?

A

Treatment of metastatic breast cancer.

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26
Q

What is toremifene?

A

Antiestrogen (binds to receptor), used to treat metastatic breast cancer

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27
Q

What are side effects of estrogen agonists and estrogen antagonists (SERM)?

A

Increased risk of thromboembolic events, endometrial and vulvovaginal abnormalities, vasomotor problems

28
Q

Which SERM, raloxifene or tamoxifen, causes fewer thromboembolic events?

A

Raloxifene

29
Q

What uterine/ovarian pathologies have been reported for premenopausal women on tamoxifen?

A

ovarian cysts, endometrial polyps, increasing leiomyoma growth

30
Q

What uterine/ovarian pathologies have been reported for postmenopausal women on tamoxifen?

A

endometrial proliferation, polyps, hyperplasia, and carcinoma. Increased risk of benign ovarian cysts and uterine leiomyomas

31
Q

What is the relative risk of endometrial cancer with tamoxifen use?

A

Relative risk of 2.13 compared to placebo. Slight increased risk of uterine sarcoma.

32
Q

What is the incidence of endometrial cancer in women taking tamoxifen?

A

2 per 1000. (Compared to 0.27 per 1000 for total population)

33
Q

Does raloxifene use increase risk of endometrial cancer?

A

No

34
Q

What are the uterine effects of toremifene?

A

Not well studied, thought to be similar or slightly less than tamoxifen

35
Q

What percentage of women taking tamoxifen experience hot flashes?

A

About 50%

36
Q

Are hot flashes associated with raloxifene use?

A

Yes

37
Q

Are hot flashes associated with toremifene use?

A

Yes

38
Q

How do aromatase inhibitors work?

A

Prevent conversion of androstenedione and testosterone into estrogen, decrease peripheral circulating estrogen

39
Q

Which aromatase inhibitors are FDA approved?

A

Anastrozole, exemestane, and letrozole

40
Q

Which aromatase inhibitor(s) is approved as first-line therapy in postmenopausal women with early-stage breast cancer?

A

Anastrozole and letrozole

41
Q

Which aromatase inhibitor(s) is approved for adjuvant treatment (after tamoxifen use) in postmenopausal women with advanced breast cancer?

A

Exemestane

42
Q

What is the role of aromatase inhibitors in premenopausal women with breast cancer?

A

Need to use concurrent ovarian suppression (otherwise negative feedback will stimulate ovaries to produce more hormone, not helpful in women with functioning ovaries)

43
Q

How efficacious are aromatase inhibitors in breast cancer compared to tamoxifen.

A

very efficacious. More effective than tamoxifen as adjuvant hormonal therapy in postmenopausal women with early-stage HR pos breast ca. Survival benefit compared to tamoxifen users. Also reduces occurrence of contralateral breast ca in several studies.

44
Q

What are adverse effects and risks of aromatase inhibitor therapy for breast cancer?

A

Decreased bone mineral density, increase bone fracture rate, arthralgias, vasomotor symptoms, vaginal dryness, and a possible increased risk of cardiovascular effects.

*compared to tamoxifen, decreased risk of thrombosis, endometrial ca, and reduction in vaginal bleeding

45
Q

What percentage of people on aromatase inhibitors report joint pain?

A

45%. 10-20% of women discontinued drug treatment for this reason

46
Q

What is the risk of endometrial cancer in aromatase inhibitors vs tamoxifen use?

A

Decreased risk of cancer with aromatase OR 0.25. Suggests that these drugs may prevent endometrial cancer

47
Q

What percentage of women taking aromatase inhibitors experience vasomotors symptoms?

A

36%. Fewer than tamoxifen (41%)

48
Q

Which adverse gynecologic effects are more prevalent with aromatase inhibitor use compared to tamoxifen?

A

Vaginal dryness and dyspareunia

49
Q

What percentage of fractures occur in women with normal bone mineral density or osteopenia?

A

80%

50
Q

What are the FDA first-pharmacologic options for the prevention and treatment of osteoporosis?

A

Bisphosphonates and raloxifene

51
Q

What medication can be administered with aromatase inhibitors to decrease the risk of osteoporosis?

A

Bisphosphonates

52
Q

How often should patients with breast cancer whose bone loss risks significantly change or who undertake a major therapeutic intervention be monitored for osteoporosis.

A

Annually

53
Q

How often should patients with breast cancer with elevated fracture risks be monitored?

A

Every 2 years

54
Q

What lifestyle changes should be encouraged for women with or at risk of osteoporosis?

A

weight-bearing and muscle-strengthening exercises to reduce risk of fractures and falls, increased vitamin D and calcium intake, cessation of smoking, reducing alcohol intake, fall-prevention strategies

55
Q

What nonpharmacologic therapy was shown to beneficial for the management of vasomotor symptoms (per cochrane review)

A

Relaxation therapy

56
Q

Are routine endometrial biopsies recommended for postmenopausal women taking tamoxifen?

A

No

57
Q

Are premenopausal women taking tamoxifen at increased risk of endometrial cancer?

A

No

58
Q

Is routine ultrasound surveillance to monitor endometrial thickness recommended for patients on tamoxifen?

A

No

59
Q

What contraceptive options are safe and effective in breast cancer survivors?

A

Condoms, diaphragms, copper IUD, sterilization

60
Q

What proportion of breast cancer diagnoses are hormone-receptor positive?

A

2/3

61
Q

What effect does tamoxifen have on reproduction?

A

Can induce ovulation. High risk to fetus.

62
Q

What is important to counsel premenopausal women on tamoxifen about?

A

Contraception! Needs effective non hormonal contraception during therapy and 2 months after.

63
Q

Can women with breast cancer that is hormone-receptor negative use hormonal birth control?

A

Relatively contraindicated (US MEC Cat 4), although there is a lack of data that demonstrates harm

64
Q

Does pregnancy after breast cancer increase risk of recurrence?

A

No, no significant increase in the risk of breast cancer recurrence or morality

65
Q

Which chemotherapy agent used for breast cancer has the most ovary toxic effect?

A

Cyclophosphamide

66
Q

Is there a method to attempt to preserve ovarian function for fertility purposes during breast cancer treatment?

A

GnRH agonsit. Thought to put ovaries in premenarchal state. Higher rates of spontaneous resumptions of menses and ovulation, but no improvement in pregnancy rates

67
Q

Can breast cancer patients undergo fertility preservation?

A

Yes. No convincing data that ovulation induction or IVF increases the risk of breast cancer. It is not know if the high estrogen level negatively effects existing breast cancer. Some oncologists prefer natural cycle, unstimulated IVF. Letrozole + gonadotropins w/ no increase in cancer recurrence at 2 years follow up. Other considerations are ovarian tissue cryopreservation and oocyte cryopreservation.

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