Hormones. Hormones? Hormones!

Rebecca Bechhold, MD

It used to be so easy. Patients with ER-positive breast cancer got 5 years of tamoxifen. You could anticipate most of the side effects, explain it, patients were happy not to be on chemotherapy. No one showed up with an armload of internet downloads ready to debate the utility of hormone therapy, the risks, and metabolism or drug interactions.

No more. Now we have (thankfully) aromatase inhibitors for postmenopausal patients. We currently use 5 years, but I know there are doctors who just leave high-risk women on them “for life.” The extension trial data is not out yet, but the recent ATLAS trial tells us to leave tamoxifen patients on that drug for 10 years.

What are you doing with the T1a N0, strongly ER-positive patient who just finished 5 years of tamoxifen? I know I am having a lot of long talks with my patients about what is right for them. I honestly do not have strong confidence I know what the best practice for every scenario is. Much of it is dictated by the way the patient has tolerated tamoxifen and how committed they are to continuing it for another 5 years.

Thankfully, many patients who ask about it are barely into their first 5 years so we can forgo that decision for a bit as the data shakes out. Some changes I jump into, others not so much. You?

CYP2D6. Somebody please answer that question decisively and permanently! Do we need to test all patients for genetic alterations? Matthew Goetz, MD, of the Mayo Clinic, would say yes. Do we have to change their antidepressants? Does it make a difference in survival? If you are an extensive metabolizer, can you just take tamoxifen for 5 years (or maybe 10) and not switch to an aromatase inhibitor? We need to know. I cannot get a consensus among my own partners, one of whom did estrogen receptor research before going into clinical practice. We need the Ten Commandments of hormonal therapy. What gives the best outcome for our patients? What are premenopausal women supposed to do if they are poor metabolizers?

Hormone therapy is apparently a new gold mine. You must have the same TV ads in your area. We have multiple “natural hormone” replacement practices and the ads are all the same theme. The woman sits with her husband behind her and talks about how her life has changed with natural hormone therapy. She openly declares and her husband confirms that she is now hot all the time, but not from hot flashes. She also predicts that she is going to lose that extra weight she has been carrying for the last 40 years, plus she is going to get her college degree and land her dream job! The fact that she is 55 to 65 years old and had plenty of estrogen coursing through her veins all those premenopausal years, and yet never lost her postpartum pounds and never exhibited a passing interest in furthering her education should not detract from the message that hormone therapy will make your life amazing.

I have yet to see any small print disclaimer at the bottom of the screen about the risks of hormone therapy. If that were a pharma company making such claims you know they would be required to have a host of small print and fast talking actors to “balance” the message. Why are the hormone palaces allowed such unbridled freedom? New breast cancer patients still come in and say they have been on hormone therapy for 10, 15, 20 years and when asked what it was originally started for it is sometimes for severe hot flashes, but one woman told me last week that her doctor told her if she didn’t take it she would “look like an old woman” in a few years. Oh, well in that case.

We now have low T clinics here. If Victoria’s Secret didn’t have so many catalogs, maybe there wouldn’t be such so many feelings of inadequacy. But, again, how are they allowed to manipulate consumers to seek prescriptions for drugs with such unrestrained, unregulated messages.

We all want our patients to be healthy and happy. If I prescribe a medication, I want to feel confident that I am offering a necessary treatment and that I have educated the patient about the risks and benefits. That is why we all want the best information on how to proceed with hormonal manipulation for breast cancer patients.

I look forward to your comments and advice.