CATHY CONLEY: Hi I'm Cathy Conley. I'm here at the 24th annual San Antonio Breast Cancer Symposium, where the top researchers and clinicians have gathered to discuss the latest advances in the fight against breast cancer.
One of the main issues on the table is hormonal therapy. This treatment has proven to be effective in preventing the spread, growth, and recurrence of breast cancer, but it's also known to have side effects. I met with the experts to assess hormonal therapy.
LODOVICO BALDUCCI, MD: Hormonal treatment is really the mainstay of cancer treatment in postmenopausal woman. That is because the majority of postmenopausal women have a cancer that is rich in hormone receptors, estrogen and/or progesterone receptors. This makes the cancer susceptible to hormonal therapy.
JOANNE E. MORTIMER, MD: In treating spread of breast cancer, there are a number of different hormonal agents that we use. The class of drugs which are used in first line treatment in the spread of breast cancer are aromatase inhibitors, of which there are three generally used. Arimidex or anastrozole, Femara or letrozole, exemestane or Aromasin, are the three used as first line treatment in the spread of breast cancer.
The drug that is used most often in prevention of breast cancer in treating newly diagnosed breast cancer is tamoxifen. The brand name is Nolvadex.
CATHY CONLEY: The main hormonal agents are all beneficial, but they vary in their benefits and side effects.
LODOVICO BALDUCCI, MD: One major benefit of the hormonal therapies, not only that it is so active, but also it is much less toxic than chemotherapy. This SERM, the selective estrogen receptor modulators, include Tamoxifen, which is a time-honored drug, Toremifene, which is practically equivalent with Tamoxifen, may have some minor benefit. The use of Tamoxifen in the adjuvant setting is associated with a decrement of 30% in the mortality rate of breast cancer.
So they were very safe and very effective medications. They have some problems, however. They are associated with increased risk of blood clot, with an increased risk of strokes, with an increased risk of cancer of the endometrium, of the uterus. It's a very small risk.
Now there is this new generation of product called aromatase inhibitors. The way that these compounds work is by depriving completely the tissues of estrogen. That gives them some edge over estrogen antagonists. In that way, they really eliminate the source of fuel that stimulate the growth of the tumor.
How are we going to choose which one is the best? The best way, of course, would be a side-to-side comparison. On the basis of the information that we have, the effectiveness of Aromasin seems to be a little better than the effectiveness of the other drugs. It was shown that it still has about a 25% response rate in people who progress while receiving letrozole or receiving anastrozole. It looks like Aromasin may have a mild androgenic effect. That may be very instrumental in reducing the risk of hot flashes.
CATHY CONLEY: Dr. Mortimer, you presented data on the effects of tamoxifen on sexuality and cognition. Tell us about that.
JOANNE E. MORTIMER, MD: What it does on sexuality is not actually favorable. It seems as though tamoxifen is actually associated with a decrease in libido, a decreased ability to become aroused sexually, and a decreased ability to have orgasm. Most women don't complain about that, but I think that it is an issue that we need to consider as long as we keep women on hormones like tamoxifen for long periods of time.
CATHY CONLEY: Tell us about the implications of these results.
JOANNE E. MORTIMER, MD: As we start to look at using drugs to prevent breast cancer in absolutely normal, healthy women, then effects on sexuality really are an issue.
CATHY CONLEY: Let's talk about the benefits of tamoxifen on bone and lipids in postmenopausal women.
JOANNE E. MORTIMER, MD: Tamoxifen has estrogenic effects on the normal tissue. That translates to a favorable effect by increasing the bone density in women who are at risk for osteoporosis or bone loss. It lowers your cholesterol, although to be fair, it's never been shown to decrease your risk of dying of heart disease or stroke.
CATHY CONLEY: Dr. Balducci, would you like to add to that?
LODOVICO BALDUCCI, MD: There is some change in lipid profiles, but even when you talk about the benefits of estrogen, postmenopausal estrogen in preventing heart attacks, there is a lot of controversy right now. So I really don't think that we can say anything about lipids.
But I think that the bone has a definite benefit. We know that tamoxifen reduces the risk of bone fracture.
CATHY CONLEY: What about the benefits of aromatase inhibitors?
LODOVICO BALDUCCI, MD: That, I think, we will just have to wait and see. As I say, a rose is not a rose when we talk about aromatase inhibitors. We have two families, the steroidal, which is the Aromasin, and then nonsteroidal. Although they may have the same effect in breast cancer, they may have the opposite effect in a situation like that. So it's very important not to translate from one to the other.
CATHY CONLEY: Hot flashes are often a problem associated with hormonal therapy. Is that true with all hormonal treatments?
LODOVICO BALDUCCI, MD: In a randomized controlled study, the Aromasin was found to cause much less hot flashes than tamoxifen. So that was a definite benefit that probably was related, as I said, to the steroidal structure of these compounds.
The other compounds, as far as I can remember, there was no real benefit in hot flashes.
CATHY CONLEY: With all the different patient types and types of breast cancer, what advice do you have for viewers as far as treatment and testing for breast cancer.
LODOVICO BALDUCCI, MD: Postmenopausal women who have breast cancer which is rich in hormone receptor, I always strongly recommend that they receive adjuvant hormonal therapy. I also recommend adjuvant chemotherapy. Their risk of occurrence is high, and if they are having a reasonable good general condition. But the benefits of adjuvant chemotherapy in the postmenopausal women pale in comparison to the benefits of the adjuvant hormonal therapy.
If I had a person with metastatic disease sensitive to hormonal therapy, I definitely would treat the patient with an aromatase inhibitor right now. It's a front line treatment. My personal choice, as I say, is Aromasin, because I think it's more powerful.
CATHY CONLEY: Dr. Mortimer, any final comments?
JOANNE E. MORTIMER, MD: Gathering all your information is incredibly important. Patients who are going to see their medical oncologist should go away knowing what their estrogen receptor is, what their HER-2 risk status is, so that they can actually understand why the treatment decisions are being made.
I think it's also important that women with breast cancer derive their information from the healthcare establishment and not from other women with breast cancer, in many cases. Sometimes there is misinformation that is passed on.
CATHY CONLEY: Dr. Mortimer, thanks so much for your time and expertise.
Dr. Balducci, thank you for joining our webcast.
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