Management of Gynecologicl Issues in Women with Breast Cancer

Question 1

What are some types of Breast Cancer treatments?

Answer 1

1. surgery
2. radiation therapy
3. chemotherapy
4. hormonal therapies

Question 2

Carriers of BRCA gene have a hereditary predisposition for what types of cancer:

Answer 2

breast cancer and ovarian cancer

Question 3

are there any effective screening methods for ovarian cancer?

Answer 3

no. risk reducing salpingooophrectomy is typically recommended by age 40 years or when childbearing is complete.

Question 4

some high-risk women undergoing breast cancer surgery may need, or choose, to have associated gynecologic surgery, including bilateral salpingo-oophrectomy or hysterectomy or both, to decrease their risk of other types of cancer Carriers of the BRCA gene have a hereditary predisposition for not only ___ cancer but also ___ cancer

Answer 4

breast and ovarian

Question 5

what is the primary disadvantage of salpingo-oophrectomy?

Answer 5

loss of natural ovarian hormone secretion. the reproductive hormone profile observed with surgical menopause in a premenopausal woman is quite similar to that of a postmenopausal woman, wiht mean reductions in serum testosterone and estradiol concetrations of 50% and 80% respectively. systemic hormone therapy is not generally recommended in breast cancer survivors.

Question 6

how are menopausal symptoms managed with nonhormonal therapy?

Answer 6

1. Selective serotonin reuptake inhibitors (SSRIs) ex. citalopram or fluoxetine
2. serotonin-norepinephrine reuptake inhibitors (SNRIs) ex. venlafaxine

have been shown to be safe and to reduce the severity of hot flushes in patients with breast cancer, although caution must be used when these agents are used in conjunction with tamoxifen.

SNRI is preferable to SSRI when used in conjunction with tamoxifen (less potent inhibition of cytochrome p450 required for tamoxifen metabolism.

Other options for management of vasomotor symptoms in breast CA survivors who cannot use estrogens or progesterones include gabapentin and clonidine

Question 7

nonhormonal options that are safe and effective in breast cancer survivors for atrophic vaginitis are:

Answer 7

1. vaginal moisturizers

2vaginal pH-balanced gel

use of vaginal estrogen in which the above two fail may be considered. Small studies show safety of topical estrogen products in breast ca pts.

Low dose 10microgram estradil-17beta vaginal tablets or the low-dose vaginal estradiol ring ,compared with oral estradiol or estradiol vaginal cream results in lowest systemic absorption.

Question 8

what classes of drugs are used for the prevention of breast cancer and for the treatment of hormone-responsive breast cancer?

Answer 8

estrogen agonists and estrogen antagonists. - selectively stimulate or inhibit the estrogen receptors of different target tissues.

they have been shown to be very effective treatments for hormone-receptor-positive breast cancer. ex: tamoxifen, raloxifene, and toremifene

Question 9

Tamoxifen

Answer 9

is approved by FDA for treatment of breast cancer and reduction of breast cancer risk in healthy women at high risk of developing the disease. studies show that 5 years of treatment decreases the annual risk of breast cancer recurrence by 40% and annual mortality risk by 34%

Question 10

raloxifene

Answer 10

approved by FDA for prevention of invasive breast cancer in postmenopausal women who are at high risk for developing the disease. trial show that after 5 years of raloxifene use, risk of invasive breast cancer was reduced by 38% versus 49% among tamoxifen users, and risk of noninvasive breast cancer was decreased by 39% vs 50% for tamoxifen group. Raloxifene also approved for prevention and treatment of osteoporosis in postmenopausal women

Question 11

Toremifene

Answer 11

approved by FDA for treatment of metastic breast cancer. results show similar benefits to tamoxifen in postmenopausal women with hormone receptor-positive breast cancer

Question 12

what are some adverse effects of estrogen agonists and estrogen antagonists?

Answer 12

their effects in some tissues can have a deleterious physiologic effect. including an increased risk of thromboembolic events, endometrial and vulvovaginal abnormalities, and vasomotor problems

Question 13

Raloxifene causes less toxicity compared with ____ , including reduced thromboembolic events following nearly 7 years of follow-up.

Answer 13

tamoxifen

Question 14

premenopausal women taking tamoxifen have menstrual irregularities and have been reports of

Answer 14

1. ovarian cysts,
2. endometrial polyps,
3. and increased leiomyoma growth

Question 15

postmenopausal women taking tamoxifen havebeen reported to develop…

Answer 15

endometrial pathology including

1. endometrial proliferation
2. polyps
3. hyperplasia
4. carcinoma which typically presents as abnormal vaginal bleeding

also an increased risk of bening ovarian cysts and uterine leiomyomas. Uterine cancer, especially endometrial cancer, is a rare but serious adverse effect of tamoxifen.

Question 16

Tamoxifen associated with an increased risk of

Answer 16

endometrial cancer and a slightly increased risk of uterine sarcoma

incidence of endometrial cancer is reported to be approximately 2 per 1,000 women taking tamoxifen

Question 17

raloxifene is not believed to have as significan estrogenic effect on the uterus and has not been associated with an increased risk of endometrial cancer. Raloxifene significantly less likely to be associated with

Answer 17

endometrial cancer and endometrial hyperplasia.

Uterine effects of toremifene are thought to be similar or slightly less than tamoxifen

Question 18

Bothersome adverse effects of hormonal therapies such as tamoxifen:

Answer 18

hot flushes (1/2 of woemn taking tamoxifen)

sx of menopause are often more severe in premenopausal patients with breast cancer because of acute onset of chemotherapy-induced amenorrhea in women with previously normal ovarian function.

Question 19

when tamoxifen is contraindicated, what is used in the treatment of hormone sensitive breast cancer?

Answer 19

aromatase inhibitors -

1. they help block growth of estrogen-sensitive tumors by lowering the amount of estrogen in the body.
2. prevent conversion of androstenedione and testosterone into estrogen and decrease peripheral circulating estrogen

Question 20

what are the 3aromatase inhibitors approved for use by FDA?

Answer 20

1. anastrozole
2. exemestane
3. letrozole

they are used for postmenopausal women.

anastrozole and letrozole are approved as first-line therapy in postmenopausal women with early stage breast cancer. Exemestane approved for adjuvant treatment (after tamoxifen use) as well as for prevention of recurrent cancer.

not as useful as breast cancer treatment drug in premenopausal women with functioning ovaries because blocking aromatase in ovaries results in lower estradiol levels, which reduces negative feedback and increases pituitary gonadotropin output, thereby increasing ovarian function.

Question 21

in premneopausal women taking aromatase inhibitors for breast cancer treatment, concurrent _____ is required for drugs to be effective

Answer 21

ovarian suppression

Question 22

what are short-term and long-term adverse effects of aromatse inhibitors in postmenopausal women?

Answer 22

related to a lack of estrogen. the adverse effects include 1. decreased bone mineral density (BMD)

2. increased bone fracture rate
3. arthralgias
4. vasomotor symptoms
5. vaginal dryness
6. possible increased risk of cardiovascular effects.

Question 23

compared to tamoxifen, aromatase inhibitors associated with..?

Answer 23

1. no significant increased risk of thrombosis
2. endometrial cancer
3. reduction in vaginal bleeding

Question 24

What are musculoskeletal effects of aromatase inhibitors? why?

Answer 24

a decrease in peripheral estrogen which is associated with increased bone loss and fracture.

comparing the 5 year use of anastrozole with tamoxifen for treatment of early-stage breast cancer, anastrozole group had significantly more fractures during the treatment period.

Women taking aromatase inhibitors also reported more musculoskeletal problems. up to 45% of women reported joint pain and 10-20% of women discontinued drug treatment for this reason

Question 25

what are vasomotor and gynecologic effects caused by aromatase inhibitors?

Answer 25

effects of aromatase inhibitors < tamoxifen.

1. less vaginal discharge and vaginal bleeding
2. decreased risk of endometrial cancer

One gynecologic adverse effect that is more commonly reported among aromatase inhibitor users compared with women taking tamoxifen is vaginal dryness and dyspareunia

Question 26

effects of aromatase inhibitors on cardiovascular disease

Answer 26

increased risk of cardiovascular disease. Likely related to marked hypoestrogenism having negative effect on serum lipid levels

Question 27

How should risk of osteoporosis be evaluated in breast CA survivors, and what treatments are useful for those found to be at increased risk?

Answer 27

first line pharmacologic options approved by FDA for prevention and treatment of osteoporosis include bisphosphonates and raloxifene.