Hormonal Therapy (Part 1)

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Estrogen has many different roles in a woman's body, including keeping her bones strong and cholesterol low, as well as improving her sense of well-being. Before menopause, most of the estrogen in a woman's body is made by the ovaries. After menopause, the ovaries stop producing estrogen, but smaller amounts of estrogen are still made in the body; a steroid produced by the adrenal glands is made into estrogen in fat tissue.

Unfortunately, however, estrogen can also stimulate the growth of estrogen-receptor-positive (ER+) breast cancer, about 80% of all breast cancers. For this type of cancer, the estrogen receptor is like the ignition and estrogen is the key; when estrogen in the body attaches to the receptors, the breast cancer cells respond to signals from the hormones that tell the cells to grow and multiply. The more estrogen, the more cancer.

Hormonal or endocrine therapy medicines are a systemic treatment for ER+ breast cancers. They treat these breast cancers by lowering the amount and by blocking the action of estrogen in the body. Hormonal therapy medicines can be used to:

  • lower the risk of early-stage breast cancer coming back
  • lower the risk of breast cancer in women who are at high risk but haven't been diagnosed with breast cancer
  • help shrink or slow the growth of advanced-stage or metastatic breast cancers 

There are two main types of hormonal therapy medicines: AIs (aromatase inhibitors) and SERMs (selective estrogen receptor modulators). SERMs work by blocking estrogen from getting into cancer cells. AIs work by stopping other hormones from changing into estrogen. Because the ovaries are the main source of estrogen before menopause, AIs are only effective in premenopausal patients when coupled with ovarian function shutdown (OFS), either temporarily using medication or permanently by surgically removing the ovaries.

In the past, premenopausal women were routinely treated with five to ten years of tamoxifen, a SERM, while postmenopausal women were treated with five years of AIs. However, last year the results of the SOFT and TEXT trials were released showing that the AI drug Aromasin (exemestane) combined with OFS worked better than tamoxifen at preventing a recurrence of breast cancer in certain premenopausal women. Almost 93 percent of women on Aromasin remained free of recurrence after five years, compared to about 89 percent of the women on tamoxifen, a 34% relative difference. The benefit was particularly pronounced in "very young" women (under 35), where the rate of recurrence went from one in three on tamoxifen alone to one in six with AI/OFS. Based on these results, Dr. Hurvitz told me last Thursday that now that I have completed surgery I should immediately start Lupron, an ovarian suppression drug administered in a monthly injection, and as soon as my estrogen levels are low enough, start taking Aromasin - and continue both for the next five years.

Information from breastcancer.org, onclive.com, and webmd.com.

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