CC#2: Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer

Question 1

Percentage of breast cancers that are ER+, percentage of breast cancers that are PR+

Answer 1

80%, 65%

Question 2

Median age at breast cancer dx

Answer 2

62 y/o

Question 3

Percentage of breast cancers diagnosed in pts <50 y/o, percentage of breast cancers diagnosed in pts <40 y/o

Answer 3

30%, 7%

Question 4

Likelihood of having hormone receptor-neg breast cancer is higher in which age group of pts?

Answer 4

Premenopausal

Question 5

Are majority of breast cancers in premenopausal pts hormone receptor-pos or -neg?

Answer 5

Hormone receptor-pos

Question 6

Common adjuvant med therapy for premenopausal pts w/ breast cancer

Answer 6

Tamoxifen (typically 5+ years)

Question 7

Class of common adjuvant med therapy for postmenopausal pts w/ breast cancer

Answer 7

AI (for up to 10 years)

Question 8

Class of med of tamoxifen, MoA of tamoxifen re breast cancer

Answer 8

SERM, antagonist activity in breast (blocking E2 at receptor level)

Question 9

MoA of AIs

Answer 9

Block peripheral E2 conversion from androstenedione and testosterone

Question 10

Between tamoxifen and AIs, which meds are associated w/ GUSM

Answer 10

Both (2/2 low E2 levels), though sxs from tamoxifen ten to be more pronounced 2/2 pt age when used

Question 11

How would exogenous estrogen affect breast tissue in pts taking tamoxifen, in pts taking AIs?

Answer 11

Effects would be blocked in pts taking tamoxifen, effects would not be blocked in pts taking AIs

Question 12

Common indications for PO/transdermal estrogen (4)

Answer 12

Vasomotor sxs, night sweats, adjunct tx of GUSM, prevention of postmenopausal osteoporosis

Question 13

First-line tx of GUSM alone

Answer 13

Vaginal estrogen

Question 14

Therapy that is contraindicated in pts w/ a hx of hormone receptor-pos breast cancer, and why

Answer 14

Systemic estrogen, 2/2 potential for systemic estrogen to increase risk of recurrence

Question 15

Hormonal tx options for GUSM (6)

Answer 15

CEE vaginal cream, 17β-estradiol vaginal cream, 17β-estradiol vaginal ring, estradiol hemihydrate vaginal tablet/insert, prasterone vaginal insert, testosterone vaginal cream

Question 16

Dosing for CEE vaginal cream (and alternative dosing)

Answer 16

0.5g 2x/week (1g qHS x2 weeks > 0.5-1g 2x/week thereafter)

Question 17

Dosing for 17β-estradiol vaginal cream

Answer 17

1-4g daily x1-2 weeks > reduced to half initial dosage x1-2 weeks > maintenance dose of 1g 1-3x/week

Question 18

Dosing for 17β-estradiol vaginal ring

Answer 18

7.5mcg/day x90 days

Question 19

Dosing for estradiol hemihydrate vaginal tablet/insert (and alternative dosing)

Answer 19

10mcg/day x2 weeks > 10mcg/day 2x/week (4mcg/day dosing also available)

Question 20

Dosing for prasterone vaginal insert

Answer 20

6.5mg daily

Question 21

For which pts should caution be exercised when using prasterone vaginal insert for GUSM, and why?

Answer 21

Pts w/ current/past hx of breast cancer, because E2 is active metabolite of prasterone

Question 22

Dosing for testosterone vaginal cream (and alternative dosing)

Answer 22

300mcg/150mcg daily x28 weeks (300mcg/150mcg daily x2 weeks > 3x/week thereafter)

Question 23

Nonhormonal tx categories for GUSM (4)

Answer 23

Lubricants, moisturizers, vaginal suppositories, aqueous lidocaine

Question 24

Common composition options for lubricant products (3)

Answer 24

Water-based, silicone-based, polycarbophil-based

Question 25

Common composition options for moisturizer products (3)

Answer 25

Hyaluronic acid, polyacrylic acid, polycarbophil-based

Question 26

Dosing for hyaluronic acid vaginal moisturizer

Answer 26

5mg daily x2 weeks > 3-5x/week thereafter

Question 27

Dosing for polyacrylic acid vaginal moisturizer

Answer 27

3g daily

Question 28

Dosing for polycarbophil-based vaginal moisturizer

Answer 28

2.5g 3x/week

Question 29

Common composition options for vaginal suppositories (2)

Answer 29

Vit E, vit D

Question 30

Dosing for vit E vaginal suppository

Answer 30

30-200IU

Question 31

Dosing for vit D vaginal suppository

Answer 31

1000IU

Question 32

Application instructions for aqueous lidocaine

Answer 32

4% aqueous lidocaine applied via fully saturated cotton ball applied to vulvar vestibule x3 mins before intercourse

Question 33

Average age of dx of breast cancer in Black pts compared to white pts

Answer 33

Slightly younger at 56 y/o compared to 59 y/o

Question 34

Sequelae of Black pts having younger age at dx of breast cancer

Answer 34

Potential to experience more severe sxs 2/2 endocrine therapy

Question 35

Which demographics were found to have lower initiation and adherence rates to endocrine therapy?

Answer 35

Black, Hispanic, Asian pts

Question 36

General category of first-line txs for pts w/ hx of breast cancer w/ GUSM sxs

Answer 36

Nonhormonal approaches

Question 37

Which was superior in terms of tx of vaginal dryness between polycarbophil-based lubricants and water-based lubricants?

Answer 37

Similar results

Question 38

Which was superior in terms of reducing dyspareunia between polycarbophil-based lubricants and water-based lubricants?

Answer 38

Polycarbophil-based lubricants

Question 39

Which was superior in terms of sx relief between silicone-based lubricants and water-based lubricants?

Answer 39

Silicone-based lubricants

Question 40

Percentage improvement in sexual dysfunction in pts using lubricants containing polyacrylic acid

Answer 40

96% to 24%

Question 41

Percentage improvement in sexual dysfunction in pts using standard lubricants

Answer 41

88.9% to 55.6%

Question 42

Are lubricants that contain hyaluronic acid associated w/ sx relief of sexual dysfunction?

Answer 42

Yes

Question 43

Measures for which both vit D and vit E suppositories have been shown to improve in pts taking tamoxifen experiencing sxs of vaginal atrophy (2)

Answer 43

Improved vulvovaginal sxs, lower vaginal pH

Question 44

Counseling for pts who use oil-based lubricants

Answer 44

Should not be used w/ condoms

Question 45

Can water-based and silicone-based lubricants be used w/ condoms?

Answer 45

Yes, yes

Question 46

Percent reduction in dyspareunia in pts using 4% aqueous lidocaine applied to introitus, percent reduction in dyspareunia in pts using saline placebo

Answer 46

88%, 38%

Question 47

Additional condition that aqueous lidocaine has been shown to be helpful for

Answer 47

Reversing vestibular sensitivity

Question 48

Is use of local vaginal estrogen-based txs safe for pts w/ a hx of hormone receptor-pos breast cancer?

Answer 48

Yes

Question 49

Serum E2 levels in many formulations of local estrogen-based txs

Answer 49

<20pg/mL

Question 50

Are low-dose vaginal estrogens superior to relieving sxs of urogenital atrophy compared to placebo or water-based lubricants?

Answer 50

Yes

Question 51

Improved objective measures of vaginal health associated w/ low-dose vaginal estrogens (4)

Answer 51

Improved vaginal maturation index, pH, vaginal cytology, sexual function (using Female Sexual Functioning Index)

Question 52

Does a sexual partner absorb local estrogen-based products?

Answer 52

Data are lacking

Question 53

Are there increased rates of breast cancer seen in pts using vaginal estrogen products?

Answer 53

No

Question 54

Class of medication of prasterone, and indication for use

Answer 54

Vaginal DHEA, FDA-approved for tx of mod-severe dyspareunia 2/2 menopause

Question 55

Pathway via which dehydroepiandrosterone can be converted to E2

Answer 55

Aromatization (dehydroepiandrosterone > androstenedione > E2)

Question 56

Do pts receiving higher dose (6.5mg) prasterone report better sexual health outcomes compared to the lower dose (3.25mg); differences in adverse effects?

Answer 56

Yes; none

Question 57

Are there increases in serum E2 seen in pts using using prasterone?

Answer 57

Only in pts receiving higher dose (6.5mg) who were not on AI therapy

Question 58

How does testosterone help improve vaginal sxs?

Answer 58

Proliferation of vaginal epithelium

Question 59

Can local testosterone be used in pts on AIs, and why/why not?

Answer 59

Yes, because conversion of testosterone to E2 is blocked in pts using AIs, so testosterone may improve atrophy w/o interfering w/ benefits of AIs

Question 60

Measures that vaginal testosterone has been shown to improve in pts taking AIs (3)

Answer 60

VV atrophy, dyspareunia, sexual dysfunction

Question 61

Class of medication of ospemifene, and indication for use

Answer 61

SERM, tx of postmenopausal VV atrophy

Question 62

Typical duration of use of ospemifene; measures that ospemifene has been shown to improve (3)

Answer 62

12 weeks to 1 year; vaginal pH, vaginal tissue health, pt-reported dyspareunia

Question 63

Ospemifene effect on vaginal tissue, bone, breast tissue

Answer 63

E2-agonist, E2-agonist, E2-antagonist

Question 64

Can pts w/ a hx of breast cancer use ospemifene for postmenopausal VV atrophy?

Answer 64

Despite FDA warning against use in such pts, evidence has not demonstrated increased risk of breast cancer recurrence (but inform pt of theoretical concerns prior to initiation)

Question 65

How does vaginal laser therapy work to improve vaginal sxs?

Answer 65

Fractional beams of light create small wounds in vaginal epithelium and lamina propria that then lead to stimulation of collagen/remodeling/regeneration

Question 66

Improved objective characteristics of vaginal mucosa after vaginal laser therapy use (4)

Answer 66

Vaginal mucosa thickness, vaginal mucosa lubrication, vaginal mucosa elasticity, increased blood flow to targeted area (thereby improving tissue quality)

Question 67

Types of vaginal laser therapy available (2)

Answer 67

CO2, erbium

Question 68

Improved subjective measures associated w/ vaginal laser therapy use (3)

Answer 68

VV sxs (including improved Vaginal Health Index measurements), subjective GUSM sxs, sexual function