April 2004: Hormonal Therapy Updates

Estrogen vaginal creams safe?

Question from Dermnurse: How safe are estrogen vaginal creams for breast cancer patients? I am 4 years post-diagnosis of breast cancer. I had a wide-excision lumpectomy, radiation, and am in my fourth year of tamoxifen. I had a hysterectomy 1 year ago.

Answers —Sandra Schnall, M.D.: Most estrogen vaginal creams are relatively safe. They have minimal absorption of the estrogen so there's not much absorption into the bloodstream. Something like Vagifem (chemical name: estradiol) can be used for 2 weeks straight and then just twice a week. That can be very helpful to decrease the vaginal dryness, etc. So I think it's safe to use, and I recommend this if deemed necessary.

Marisa Weiss, M.D., president and founder: You can also use the Vagifem estrogen tablet, inserted in the vagina, as an alternative to the estrogen creams.

Another product to check out is the Estring, which is a small plastic ring that's got estrogen in it. It is placed inside the vagina for 3 months at a time. Slowly, the estrogen comes out of the ring and "feeds" the vaginal walls. Some doctors may prefer this over the creams because the amount of estrogen that gets into the blood might be less. Also, it helps avoid the messiness that creams can cause in terms of dripping out of the vagina.

If you need wetness in the vagina, try lubricants before you go to any type of estrogen product. My patients' favorites are Slippery Stuff and Astroglide. Good old K-Y Jelly or the new gels are also popular.

Sandra Schnall, M.D.: People also like Replens.

Marisa Weiss, M.D., president and founder: Replens is described by its maker as a vaginal moisturizer, providing moisture that supposedly holds on to the walls of the vagina, so it's different from other lubricants. Replens tends to be more expensive that the other lubricants, so if what you need it just a lubricant, you might want to try a cheaper product, like those I mentioned before.

Sandra Schnall, M.D.: One possible downside to the ring is that some women may notice some difficulties with the ring and may therefore prefer the creams.

Marisa Weiss, M.D., president and founder: You might need to make sure that the ring is in the proper position before intercourse, just like a woman who uses a diaphragm. If it's not in the right spot, it can be uncomfortable.

Hormonal therapies for pre-menopausal?

Question from Nance: Besides tamoxifen, are there any other hormonal therapies for pre-menopausal ER/PR-positive node-negative cancers?

Answers —Sandra Schnall, M.D.: Tamoxifen is probably the most commonly used agent. Perhaps you can combine it using some other agent such as Zoladex (chemical name: goserelin) to have more complete ovarian shutdown. The newer agents called the aromatase inhibitors are not effective in the pre-menopausal setting.

Marisa Weiss, M.D., president and founder: It's important to remember that if you're pre-menopausal and you take tamoxifen, you can keep menstruating. Or, if you're close to menopause, tamoxifen may push you over the edge and stop your periods. Some ovarian function might still persist in this case, but not enough for you to have periods. For complete ovarian shutdown in a pre-menopausal woman, Zoladex is usually needed to make the ovaries stop working. Depending on the situation, your doctor may recommend only tamoxifen without full ovarian shutdown. Or your doctor might recommend both tamoxifen and Zoladex. In post-menopausal women, the ovaries are already shut down, so tamoxifen alone is enough. Or your doctor might prescribe an aromatase inhibitor instead of tamoxifen.

Stay tuned for new advances in the field of hormonal therapy for young women. There may be some early study results presented at the American Society for Clinical Oncology meeting this June.

Femara more effective than Arimidex?

Question from JennyP: Following chemotherapy and radiation, my doctor prescribed Arimidex. Now we are hearing more about Femara and I am wondering if that might be even more effective. My doctor feels more comfortable with Arimidex because it has been studied longer.

Answer —Sandra Schnall, M.D.: There's probably not that much difference between the two drugs. They are both in the same category of drugs, called aromatase inhibitors. Arimidex is the original agent to be used in that category and is usually first-line therapy. Femara has usually been used after the patient has been treated with tamoxifen for 5 years.

In general, there's probably not that much difference between the two. There are some side-effect differences between Femara and Arimidex. On Arimidex, patients seem to have more difficulties with achiness and muscle pain. Both are associated with increased risk of osteoporosis. Usually the achiness would be a reason to switch agents, but otherwise I wouldn't recommend switching from one to the other.

Recurrence while taking Femara?

Question from Cheryl: What form of treatment is used if you get a recurrence while you are still taking Femara?

Answers —Sandra Schnall, M.D.: Where the recurrence is may reflect what kind of treatment would be recommended. There are salvage hormone therapies if hormone treatment is what's recommended. If you haven't been treated with tamoxifen, that may be an easy one to start with. Alternative hormones may be something like Faslodex, which is an injectable hormone treatment given once monthly.

Marisa Weiss, M.D., president and founder: I guess once all the various hormone therapies have been tried, if the disease continues to progress, it's time to talk to your doctor about other forms of systemic treatment. Those include chemotherapy or immune therapy like Herceptin (chemical name: trastuzumab), if the cancer is HER2-positive.

Long-term prevention of recurrence?

Question from Mary: Are there any definitive studies regarding the long-term effectiveness of hormone therapy in preventing recurrence of breast cancer?

Answers —Sandra Schnall, M.D.: There are several studies that show the advantage of hormone therapy in decreasing the risk of new breast cancers from developing.

Marisa Weiss, M.D., president and founder: There is the completed tamoxifen prevention study. There is the ongoing STAR study. And there are some new studies officially looking at the value of aromatase inhibitors in preventing new cancers. In prior studies of aromatase inhibitors, we saw that they seemed to be very good at reducing the risk of developing a new cancer in the other breast.

Sandra Schnall, M.D.: There's another hormone treatment for osteoporosis prevention that patients may be placed on. It's called Evista, or raloxifene. It's often used for osteoporosis prevention but also causes decreased breast cancer risk.

Marisa Weiss, M.D., president and founder: In post-menopausal women, that is.

Hormonal therapy affected by antidepressants?

Question from Hjshaman: How is hormonal therapy affected, if at all, by the use of antidepressants?

Answer —Marisa Weiss, M.D., president and founder: For women who are experiencing depression or hot flashes while on tamoxifen, studies have found that low doses of antidepressants like Paxil (chemical name: paroxetine) or Effexor (chemical name: venlafaxine) can reduce hot flashes by about one-half to two-thirds.

Recently, there was some concern expressed about whether the antidepressants may interfere with the effectiveness of hormonal therapy. This concern has not been substantiated. At this time, most oncologists—as well as primary care doctors—still feel comfortable giving low doses of these medications to improve the quality of life relative to hot flashes (low doses of these meds) or for depression (higher doses of these meds).

Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take. Some antidepressants -- including Paxil, Wellbutrin (chemical name: bupropion), Prozac (chemical name: fluoxetine), Cymbalta (chemical name: duloxetine), and Zoloft (chemical name: sertraline) -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.

Treating hot flashes?

Question from Fredda: I am taking tamoxifen and unable to take Effexor for hot flashes, and vitamin E didn't work. Is there something else?

Answers —Sandra Schnall, M.D.: There are some herbal therapies one can try. However, many—such as evening primrose oil or black cohosh—carry natural estrogen in them, which makes them a less than optimal therapy.

Other agents, such as some antihypertensive agents, can help to some degree, but they have other side effects. The hypertensive agent may be the clonidine (brand name: Catapres) patch. Although this is often well tolerated, there can be lowering of blood pressure, which can be uncomfortable or symptomatic.

Marisa Weiss, M.D., president and founder: Some women may have a good response to another low-dose antidepressant even if they couldn't tolerate the first one. Other medications you might try besides Effexor can include the antidepressants Paxil (chemical name: paroxetine) and Prozac (chemical name: fluoxetine), and the mood-stabilizer medication Neurontin (chemical name: gabapentin).

Before going to medications, of course, it's helpful to look at your lifestyle. Stress reduction can be quite helpful, as can exercise, meditation, weight loss, and dressing in layers of natural fiber clothing. Get a thermal cup with ice water in it and bring it with you wherever you go. Put nearly full water bottles into the freezer and take those with you and drink them as they melt during the day.

Portable fans and avoiding caffeine and spicy foods can make a difference. Try to get to meetings on time when possible and do your best to prepare before the meeting to avoid avoidable stresses. Check out other ideas at Breastcancer.org You have to be resourceful and patient because it does take a lot of trial-and-error to find the 1-2-3 combination of things that might help you.

Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take to manage hot flashes. Some antidepressants -- including Paxil, Wellbutrin (chemical name: bupropion), Prozac, Cymbalta (chemical name: duloxetine), and Zoloft (chemical name: sertraline) -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.

Sandra Schnall, M.D.: Oftentimes, the hot flashes do dissipate without medical intervention, or the patient may become more tolerant of them so they seem less bothersome.

Length of hormonal treatment for metastatic?

Question from Grannylor: I have metastatic breast cancer to the bone and am being treated with Femara daily and monthly Zometa. How long will this treatment be necessary?

Answer —Sandra Schnall, M.D.: More than likely, treatment will be indefinite. Unfortunately, once there's metastatic disease, it's less likely curable. So as long as the Femara in combination with the Zometa is controlling the disease, I would likely recommend continuance until evidence of progression.

Hormonal therapy for ER-negative, PR-positive?

Question from Katie: Which hormonal therapies are effective with estrogen-negative, progesterone-positive breast cancer?

Answers —Sandra Schnall, M.D.: Most of them are as effective in either situation. I don't tend to recommend one hormonal therapy vs. another based on that alone.

Marisa Weiss, M.D., president and founder: Most oncologists consider a patient's cancer to be hormone-receptor-positive if either or both the estrogen and progesterone receptors are positive (meaning present).

Sandra Schnall, M.D.: We do quantify the percentage of them being present, so that less than 5% to 10% may not be strongly positive. If just the progesterone was 5% positive with the estrogen receptor being negative, it may not equate to a strong hormone response, but the treatment would be the same.

Testosterone cream for women?

Question from Flyby: How does testosterone cream affect women? I was hoping to use something that could help libido.

Answers —Marisa Weiss, M.D., president and founder: If your libido is sagging, your doctor may evaluate your hormone levels and find a very low testosterone level. Under the circumstances, your doctor, usually a gynecologist, might try giving you a little bit of testosterone to see if it increases your sex drive and ability to enjoy sex.

A little bit of testosterone can go a long way. We still don't know if it's safe to give testosterone, but most people feel comfortable with a little bit. Before going ahead with this, make sure your gynecologist talks to your oncologist about this treatment recommendation.

There are a lot of other reasons why your libido might be lower than it used to be, including all of the post-menopausal symptoms like vaginal dryness, vaginal shortening, hot flashes, weight gain, body image changes, and sleep deprivation. Stay tuned to next month's conference on dealing with these tough issues, featuring a gynecologist who specializes in this area.

Sandra Schnall, M.D.: From an oncology viewpoint, depending on how severe and debilitating one's symptoms are, I often have no objection to a trial of testosterone.

Marisa Weiss, M.D., president and founder: If it works, it works!

Sandra Schnall, M.D.: When patients are going through breast cancer treatment, sometimes a little testosterone treatment makes them feel better about themselves.

Aromatase inhibitors for prevention?

Question from Jean: Do you recommend aromatase inhibitors for breast cancer prevention in high-risk patients with no previous cancer?

Answers —Sandra Schnall, M.D.: To date there has been no definitive trial to support that class of medications for chemoprevention for breast cancer. There have been studies that show the chemoprevention with tamoxifen and with raloxifene.

Marisa Weiss, M.D., president and founder: See the question answered above for other ideas on risk reduction with hormone therapies.

To continue tamoxifen or try new medication?

Question from Evelyn: I am 50 years old, had a hysterectomy with BSO and 0.9 cm breast cancer treated with lumpectomy and radiation. I am on tamoxifen for 2½ years. How do I decide whether to continue with tamoxifen or use some of the new aromatase inhibitors?

Answers —Marisa Weiss, M.D., president and founder: In other words, you have had your uterus, ovaries, and fallopian tubes removed, and you also were diagnosed with a 0.9 cm (about a half-inch) breast cancer.

Sandra Schnall, M.D.: The recommendation would be to continue with the tamoxifen to complete the 5-year course, and, based on present data, to then initiate a course of the aromatase inhibitors for another 5 years of that agent.

Marisa Weiss, M.D., president and founder: You are probably aware of two studies in the last 6 months that looked at switching from tamoxifen after 2 or 3 years over to Arimidex or to Aromasin recently reviewed at Breastcancer.org. There are more options today than there were when you were first presented with the recommendation to take tamoxifen. 

During the 5 years of taking any medication, it's good when new advances come along that make you reconsider what you're doing. One of the reasons why you go back and see your doctor several times a year is to discuss what you're doing and how you might decide to improve upon it. Last month's Research News presents all the options that you can print out and take into your doctor's office to stimulate this discussion.

Sandra Schnall, M.D.: Any time there are toxicities or side effects from one agent, it's good to discuss with your doctor options to switch to other hormonal therapies to alleviate those side effects.

Arimidex for more than 5 years?

Question from lizzy: I'm ER+ and currently taking Arimidex (since January). Is this medication prescribed for 5 years or longer? After that timeframe, is there any other hormonal treatment available?

Answer —Sandra Schnall, M.D.: Currently, we would recommend the 5 years of Arimidex. There is a study coming out that looks at Arimidex for the 5 years followed by tamoxifen. This is a flip from the study that recently came out looking at tamoxifen first, followed by one of the aromatase inhibitors. Therefore, an option to discuss with your doctor at completion or near completion of 5 years of Arimidex may be what other hormones there are to use. Options to participate in a study may also be available.

Natural products instead of tamoxifen?

Question from Meg: Have there been any published studies on the use of natural foods and products like flaxseed or progesterone cream as alternatives to tamoxifen?

Answers —Marisa Weiss, M.D., president and founder: No. There are no "head-to-head" studies that compare pharmaceutical hormonal therapies to plant hormone-like therapies. There are studies that look at hormonal drugs and, separately, there are small, non-scientific studies that have looked at plant sources of estrogen-like molecules.

It's natural for people to want to pursue natural remedies because there's a strong belief that they are going to be more gentle, with fewer side effects. Despite this strong belief, we are without solid data to support taking these natural substances and giving up the proven powerful benefits of hormonal therapies from the pharmacy.

Sandra Schnall, M.D.: Do not be misled by some organizations or professionals who have strong beliefs in the natural modalities. Also, in taking them and buying them over the counter, patients should ask to take them in conjunction with the prescription hormone therapies. Before doing so, I would discuss that with your physician.

Marisa Weiss, M.D., president and founder: Products that come from food and plants are not regulated by the Food and Drug Administration. In general, the producers of these products can make these claims without substantiating them. In contrast, any drug that comes out of the pharmacy is rigorously regulated and controlled by the FDA.

The only way the drug company is allowed to make a claim about its drug's potential benefit is if there are studies to back up those claims. So, it's important to be careful when you hear claims that are enticing, at a time when you are looking for just those types of treatments.

Delaying hormonal therapy?

Question from Maribeth: I had a lumpectomy and radiation therapy just a year ago. I declined hormonal therapy. Is there any research on beginning at a delayed time?

Answers —Sandra Schnall, M.D.: Assuming that the hormone receptors were positive, there is probably no downside to starting the hormonal therapy at this time, not only to prevent the recent cancer from coming back but as a measure for preventing future cancers from developing.

Marisa Weiss, M.D., president and founder: Making decisions on hormonal therapy is not easy. It takes a lot of discussion between you and your doctor, family members, and friends that you trust before you are ready to commit to a therapy that's supposed to be taken on a daily basis over 5 years. Dr. Schnall and I share in the care of many women who might take many months, or even a year, to come to the point when they feel comfortable enough and sufficiently confident to jump in and start a hormonal therapy.

In contrast, we take care of people who may be ready to make the decision in 5 minutes to take it or not to take it. Each one of you is unique and different from each other. No one can force you to do something or take something if you don't want it or if you're not ready.

But if you are not ready and you're trying to figure out what to do, it's helpful to write down what's getting in your way. You have more questions that haven't been answered? Are there concerns you want to express? Get them on the table so that you can move through them and move beyond this decision.

Sandra Schnall, M.D.: As part of the discussion, even though we as physicians can recommend the medication if helpful, we can always have you discuss this with other women who have started the hormonal therapy, or who have stopped, so you can discuss with them their reasons for starting or stopping. If you make the decision to proceed, you can always stop for side-effect reasons or for psychological reasons.

Arimidex during radiation?

Question from Kandi: Because I am in a clinical trial, I have started Arimidex while still receiving radiation therapy. I understand there might be some controversy about the synergy of the two treatments. Would you comment on that?

Answer —Marisa Weiss, M.D., president and founder: There is a concern that taking hormonal therapy during radiation might make any cancer cells—if they were there—become less vulnerable to the effect of radiation. This is a theoretical concern. Whether or not it's OK to give a hormonal therapy during radiation has not been studied in a clinical trial.

Recently, two centers looked at whether it's OK to give tamoxifen during radiation or if it's best to push it off until after radiation is done. One study showed it's OK to give it together; the other study showed that radiation MIGHT not work as well if given together. Still, we're left without a clear answer.

Be reassured that large clinical trials such as the NSABP (National Surgical Adjuvant Breast and Bowel Project) studies did use tamoxifen together with radiation, and that radiation worked very well in those studies. So I'd stick to your protocol and expect the best.

Menopausal status blood tests accurate?

Question from Jan: Are blood tests to determine if someone has gone through menopause accurate? I am on tamoxifen and would like to have a blood test to see if I can be switched to Arimidex, but I do not want to take the chance unless they are very accurate.

Answers —Sandra Schnall, M.D.: If you are on tamoxifen, I would question why you wish to switch at this time. Is there a medical or psychological reason for the switch? However, there are blood tests to determine one's menopausal status which are relatively accurate at the time they are taken.

Marisa Weiss, M.D., president and founder: Meaning that if they show that you are post-menopausal at the time the blood is tested, then you are most likely post-menopausal at that time. Your menopausal status, however, could change if your ovaries decide to "wake up" again at some later time.

Sandra Schnall, M.D.: Tamoxifen may be the cause of the development of menopause and oftentimes after stopping it, the ovaries may resume functioning again. My recommendation would be to complete the planned course of tamoxifen, then determine if you're in menopause, and then proceed with alternative hormone treatment.

Marisa Weiss, M.D., president and founder: It can be very confusing to know what your menopausal status is. Perhaps, for example, you were pre-menopausal at diagnosis, then your period stopped during chemotherapy and you haven't gotten the period back. Dr. Schnall and I have had patients who had a "post-menopausal blood test" during the time when the periods had stopped, but who later on, even 2 years later, somehow got their period back. Their blood tests shifted from post-menopausal to pre-menopausal.

This confusion can lead to uncertainty, not just about what hormonal therapies to choose, but also it brings up issues about fertility. If you were pre-menopausal at diagnosis and your periods have stopped, be sure to use birth control if you want to avoid pregnancy.

Hysterectomy instead of tamoxifen?

Question from Tracey: Would it not be better to have a hysterectomy than have to take tamoxifen?

Answers —Sandra Schnall, M.D.: Actually some people consider tamoxifen a "medical" oophorectomy, which is removal of the ovaries. That's in relationship to the hormone response.

Marisa Weiss, M.D., president and founder: Even though if you're pre-menopausal tamoxifen doesn't necessarily put you into early menopause.

Sandra Schnall, M.D.: In reference to the risk of uterine cancers while on tamoxifen, I have not been routinely recommending hysterectomy to avoid that complication. It occurs in only 1% of women who take it and, hopefully, with good gynecologic screening, we can catch the tumors of the uterus early. The screening mechanisms would include a routine pelvic exam, often in conjunction with a pelvic and vaginal ultrasound.

The ultrasounds are recommended but are not mandatory. However, I do recommend a gynecology exam annually in all women, but most notably those on tamoxifen.

Marisa Weiss, M.D., president and founder: You can read more about medical treatments to shut down the ovaries as well as what the surgical options are for the pre-menopausal woman at Breastcancer.org. And you can read more about all of your hormonal options, including tamoxifen and aromatase inhibitors for women beyond the menopause, at Breastcancer.org as well.

Why get an oophorectomy?

Question from Kimmy Too: If tamoxifen is a "medical" oophorectomy, then why in the world are my medical oncologist and my radiology oncologist insisting that I have my ovaries removed?

Answers —Sandra Schnall, M.D.: In a pre-menopausal woman, oftentimes the tamoxifen does not complete menopause and, therefore, sometimes we need to add other hormones such as Zoladex. In a pre-menopausal woman, the oophorectomy may be simpler to perform than taking combined-modality hormones. If the ovaries can be removed laparoscopically, that makes it more ideal than an incision-associated removal through major surgery.

Marisa Weiss, M.D., president and founder: There may be other reasons why your doctor may suggest removal of your ovaries as well as fallopian tubes. For example, if there is a proven breast cancer gene in your family, and if you also have the gene, and if you are finished childbearing, your doctor might recommend this type of surgery to substantially reduce the risk of ever getting ovarian cancer. Removal of the ovaries in a pre-menopausal woman with a breast cancer gene abnormality also substantially reduces the risk of ever getting breast cancer.

If you are a young woman who has had breast cancer that is hormone-receptor-positive, and if your oncologist is recommending that your ovaries be shut down in order to reduce the risk of breast cancer coming back, I would recommend trying to shut your ovaries down with hormonal therapy rather than removal of the ovaries.

This is because you might want to have children at some point in the future, and, in general, removing the ovaries would take away your ability to bear your own children with your own eggs in the future. We are working hard at figuring out how to freeze eggs and ovaries in special banks to keep alive the hope of having children in the future with your own eggs. But there's a lot more work that has to be done to perfect that.

Can Arimidex cause cognitive problems?

Question from Pat: Can Arimidex cause cognitive problems and are they permanent?

Answers —Sandra Schnall, M.D.: Some women do experience some cognitive changes such as decreased memory. However, most of these problems resolve upon stopping the medication. This can even be a cause of premature stopping of tamoxifen if it is disabling or noticeable to the patient to a degree that is uncomfortable.

Marisa Weiss, M.D., president and founder: There are a lot of different things that can affect your ability to think and speak clearly, remember things, keep organized, and multi-task. Medications like hormonal therapy are only some of the causes of problems with these cognitive functions.

Anxiety and sleep deprivation can really get in the way of feeling and thinking normally. Chemotherapy, growing older, depression, and fatigue are other significant causes of trouble in this area.

Also keep in mind that during 5 years of taking any drug, you will be growing older during those 5 years. A lot can happen in your life during those 5 years that can also have an effect on how you function. Sort these different causes out with your doctor and see which of these causes can be changed and improved upon.

Factoring other diseases into decisions?

Question from Nellie: Are there any protocols or have any studies been done re: making more complicated treatment decisions for individuals with other diseases, such as MS, systemic sclerosis, etc., that may be negatively impacted by hormonal therapies?

Answers —Sandra Schnall, M.D.: I don't know of any studies that are looking at those. I think there are probably a limited number of individuals who can qualify for those types of studies. I'd probably discuss the interaction of the medications that may be recommended for the second problem (i.e., not the breast cancer) with the specialist treating the other process to try to sort out any interactions that may develop.

Marisa Weiss, M.D., president and founder: One example of a medical issue that commonly comes up is osteoporosis, thinning of the bones. If a woman has osteoporosis, she is going to need treatment for the osteoporosis, like calcium, vitamin D, exercise, smoking cessation, and perhaps a medication like Fosamax or Actonel.

This condition can be first discovered when your oncologist is putting you on a hormonal therapy and gets a baseline DEXA scan, which measures bone strength. In this situation, you may be dealing with decisions on two different conditions, breast cancer and osteoporosis, at the same time.

The issue mostly comes up with aromatase inhibitors, which can cause slight bone loss over the first 2 years that they are given. The only other condition that I can think of right now is a history of endometrial cancer. If you have a history of this type of cancer, most doctors would avoid giving you a drug like tamoxifen.

Blood clots and hormonal therapy?

Question from Kathy: I am diabetic, which means I have a higher risk of stroke. I am about to start hormonal therapy. I am concerned when I read about the side effect of blood clots. Please discuss this side effect.

Answer —Sandra Schnall, M.D.: The risk of blood clot is much more common with tamoxifen than with the aromatase inhibitors, but it's still rare. Having diabetes, or a history of peripheral vascular disease but not blood clots, such as atherosclerosis, wouldn't preclude me from recommending tamoxifen. However, if one has had a blood clot, such as a phlebitis, I would probably start with an aromatase inhibitor as opposed to tamoxifen.

Also, many patients take aspirin to decrease the risk of blood clots, and I have no objection to using that in conjunction with hormone therapy if recommended by their other physicians.

Why stop tamoxifen after 5 years?

Question from Kandi: Why must a hormone medication like tamoxifen be discontinued after 5 years if it is preventing recurrence?

Answers —Sandra Schnall, M.D.: There have been studies looking at using tamoxifen or hormone therapy for longer than 5 years, but there has been no benefit shown. In fact, some studies have shown that it may increase the risk of recurrence. So the benefit does not seem to last more than the 5 years. Hence, the recommendation for the 5-year length of therapy.

Marisa Weiss, M.D., president and founder: As it turns out, if you take tamoxifen for 5 years and stop, the benefit of those 5 years can last longer than the 5 years itself. This is called a carry-over effect. If you are hoping to get the longest protection plan possible, after 5 years of tamoxifen, you might consider taking 5 years of an aromatase inhibitor if you are post-menopausal.

Femara for metastatic disease?

Question from Valerie: What is the current research on the effectiveness of Femara on women who have been diagnosed with inoperable stage IV breast tumors?

Answers —Sandra Schnall, M.D.: Interestingly, Femara was initially FDA-approved for metastatic cancer in the post-menopausal woman, so Femara has a good track record and efficacy in that population.

Marisa Weiss, M.D., president and founder: In addition, for women who have stage III breast cancer because of a large mass in the breast or because of significant lymph node involvement, they may get significant shrinkage of the cancer using Femara prior to surgery. In this situation, the cancer may not have been operable or easily removed up-front, but with a good response to Femara or another hormonal therapy, the cancer may become operable.