Doc, Should I Take This Pill or Not?
Doc, Should I Take This Pill or Not?
Dr. Schapira: If our 60-year-old affluent, otherwise healthy American or Canadian woman who has a long life expectancy says, "Look, I will do everything to reduce my risk for breast cancer." What medication should she receive and for how long?
Dr. Goss: Fortunately there are a number of effective options. Tamoxifen and raloxifene are the most well known, but there are other SERMs, such as lasofoxifene, that are also effective. The aromatase inhibitors, used extensively for breast cancer treatment, are another class of drugs that are highly effective at reducing risk.
Importantly, risk/benefit, quality of life, and other factors (such as cost) need discussion, but fortunately with the aromatase inhibitors -- although side effects are common and can be troublesome -- there have not been any life-threatening side effects identified, making them an attractive choice. A trial of treatment for 3 months usually allows the woman and her physician the opportunity to determine how well the medication will be tolerated, and therefore makes it easier to decide about long-term use for up to 5 years. Side effects that are predominantly menopausal in nature are reversible, and lasting damage is not caused by use of these drugs. The greatest challenge is that we still are unable to accurately select the women at most risk, and this is the focus of much research. Identifying personal risk factors, hopefully in a noninvasive manner through mammography and saliva, breast, or blood samples, would be ideal; considerable effort is going toward such a future.
Dr. Schapira: Let me push this argument a little further. Your neighbor comes to your door. She is 58, a cyclist, and is lean. She doesn't smoke. She drinks fewer than 3 glasses of wine a week. She had her children young. She never took hormone replacement. She says, "Dr. Goss, you are the world expert. I get an annual exam and mammogram. I have no family history of breast cancer, but I'm worried. Should I take exemestane for 5 years or not?" What would you tell her?
Dr. Goss: I would discuss the risks and benefits of taking a medication for up to 5 years and I would favor a trial of an aromatase inhibitor over a SERM. Tamoxifen is associated with very rare risk for blood clot and uterine cancer, but with the aromatase inhibitors, only very mild accelerated bone loss has been identified as a long-term side effect, and this is very easy to monitor (and if necessary, to overcome with intervention).
In my view, chemoprevention is something that women should discuss with their physicians and consider.
Why Not Suggest a 3-Month Trial?
Dr. Schapira: If our 60-year-old affluent, otherwise healthy American or Canadian woman who has a long life expectancy says, "Look, I will do everything to reduce my risk for breast cancer." What medication should she receive and for how long?
Dr. Goss: Fortunately there are a number of effective options. Tamoxifen and raloxifene are the most well known, but there are other SERMs, such as lasofoxifene, that are also effective. The aromatase inhibitors, used extensively for breast cancer treatment, are another class of drugs that are highly effective at reducing risk.
Importantly, risk/benefit, quality of life, and other factors (such as cost) need discussion, but fortunately with the aromatase inhibitors -- although side effects are common and can be troublesome -- there have not been any life-threatening side effects identified, making them an attractive choice. A trial of treatment for 3 months usually allows the woman and her physician the opportunity to determine how well the medication will be tolerated, and therefore makes it easier to decide about long-term use for up to 5 years. Side effects that are predominantly menopausal in nature are reversible, and lasting damage is not caused by use of these drugs. The greatest challenge is that we still are unable to accurately select the women at most risk, and this is the focus of much research. Identifying personal risk factors, hopefully in a noninvasive manner through mammography and saliva, breast, or blood samples, would be ideal; considerable effort is going toward such a future.
Dr. Schapira: Let me push this argument a little further. Your neighbor comes to your door. She is 58, a cyclist, and is lean. She doesn't smoke. She drinks fewer than 3 glasses of wine a week. She had her children young. She never took hormone replacement. She says, "Dr. Goss, you are the world expert. I get an annual exam and mammogram. I have no family history of breast cancer, but I'm worried. Should I take exemestane for 5 years or not?" What would you tell her?
Dr. Goss: I would discuss the risks and benefits of taking a medication for up to 5 years and I would favor a trial of an aromatase inhibitor over a SERM. Tamoxifen is associated with very rare risk for blood clot and uterine cancer, but with the aromatase inhibitors, only very mild accelerated bone loss has been identified as a long-term side effect, and this is very easy to monitor (and if necessary, to overcome with intervention).
In my view, chemoprevention is something that women should discuss with their physicians and consider.
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