Physicians Urged to Listen to Tamoxifen Users' Concerns

An expert panel of 10 international cancer researchers and practicingoncologists met in Boston to discuss the past, present, and future usesof antiestrogens in the treatment of breast cancer. The first four articlesin this series, based on the symposium presentations, appeared in OncologyNews International in Oct 1996 , Nov 1996, Dec 1996 , and Jan 1997 . Thesymposium was sponsored by Zeneca Pharmaceuticals.

BOSTON--Breast cancer patients taking tamoxifen (Nolvadex) as adjuvanttherapy may speak more freely of their concerns about the drug when theirphysician is female, Bonnie S. Reichman, MD, said in her presentation atthe symposium. "All of my knowledge is gathered from experience withpatients as a female physician who, I think, is tuned in to a lot of whatgoes on in my patient's lives."

Dr. Reichman, of Cornell University Medical College and New York Hospital,believes strongly in educating patients about the risks and benefits oftamoxifen, and in listening to the complaints of women on the drug andtrying to treat any tamoxifen-related symptoms.

In addition to talking with patients, Dr. Reichman provides an educationalhandout and refers women to support groups. "When patients are wellinformed, then tend to take the drug, and if they are aware of the possibleside effects, they know what to expect, know their side effects are real,and they do better."

One common side effect women complain of is weight gain, which physiciansdon't always take seriously. "Women who have just been through relativelydeforming surgery, whether conservation or mastectomy and whether reconstructedor not, can be particularly sensitive about their body image," shesaid.

She offered patient quotes reflecting physician insensitivity on thisissue: "I'm sick and tired of my doctor acting as if weight loss wereeasy." "I've gained 20 lb and my doc says just eat less."

Effects on Quality of Life

Women on tamoxifen often report severe menopausal symptoms, and yet,she pointed out, the NSABP B14 trial found no difference in quality oflife between patients taking tamoxifen and controls. "I think thisindicates there was a problem with the assessment tools they used, becauseit doesn't make sense in terms of our own clinical experience."

For hot flashes, she suggested using a divided tamoxifen dosing scheduleor taking it at different times of the day. Over-the-counter remedies thatmay provide relief include vitamin B6 and selenium; prescription drugsinclude Bellergal, clonidine, and progestational agents.

"There is a 'hot' line on the Internet for women having hot flashes,"she said. Some women add soy products to the diet several times a weekor use a variety of Chinese herbs and so-called natural remedies such asprimrose oil. "We don't know why or if they really help, but theyare very popular."

Finally, uterine cancer and osteo-porosis are major concerns of thesewomen. "We are now afraid not to investigate these patients more closely,"she said, "but beyond annual Pap smear and pelvic exam with evaluationof bleeding, there doesn't seem to be any greater indication for testingin these women."

She noted that previously, physicians at her center had been doing pelvicultrasounds, "but this resulted in a lot of biopsies for benign findingsand a lot of angst among patients."

Dr. Reichman said that she has been ordering more bone density scansof late and has been shocked to find how many women have osteoporosis whodo not appear to be at high risk. She emphasized that oncologists shouldfind out if their postmenopausal patients are taking adequate calcium supplementationwith vitamin D and exercising regularly.