Who Is Hormonal Therapy For?

Hormonal therapy is an important option for anyone with hormone-receptor-positive breast cancer. That includes women of all ages, with any stage of disease, and together with or separate from other forms of treatment. Some types of hormonal therapy can also help women who've never had breast cancer but who are at increased risk for developing the disease.

You might benefit from hormonal therapy if you have:

• non-invasive disease, such as DCIS (ductal carcinoma in situ). Hormonal therapy lowers the risk of the non-invasive cancer coming back. More importantly, it also lowers the risk of developing a more serious INVASIVE cancer in either breast.
• early-stage invasive disease. Hormonal therapy can reduce the risk of the cancer coming back as well as the risk of developing a new breast cancer in either breast.
• a large cancer in the breast. Hormonal therapy can help shrink the size of the cancer before surgery to help you keep your breast and avoid mastectomy.
• a recurrence of a prior cancer. If the cancer that comes back is hormone-receptor-positive, then hormonal therapy can help. Hormonal therapy is used differently depending on whether the recurrence is:
  • local (involves just the breast)
  • regional (involves the lymph nodes next to the breast), or
  • metastatic (involves other parts of the body).
• advanced (metastatic) disease. Hormonal therapy can help get metastatic disease under control, shrink it, and limit further spread.
• a high risk of breast cancer but no prior personal history of the disease. Hormonal therapy can help reduce the risk of ever getting breast cancer for women with:
  • a strong family history of breast cancer
  • a known breast cancer gene abnormality or
  • a prior breast biopsy showing abnormal cell growth.

Women who have breast cancers that are hormone-receptor-negative will want to consider other options for treatment. Without estrogen and progesterone receptors for hormonal therapies to work on, hormonal therapy offers hardly any benefit. And it's not worth dealing with side effects if there are no real benefits.

Factors to Consider In Choosing a Hormonal Therapy

Hormonal therapy can produce remarkable results with relatively few side effects in many women. But it's not perfect. There are factors you must sort out, and pros and cons you must weigh, before you start hormonal therapy. You and your doctor will go over the issues, balancing the potential benefits and side effects for your unique situation. You'll also want to discuss how these benefits and side effects may be influenced by your other health concerns.

Together with your doctor, first think about your cancer-related concerns. Learn as much as you can about the various types of hormonal therapy. Figure out which kind, or kinds, might help you. Next, look at the hormonal therapy's side effects. Then see how the hormonal therapy might influence your other medical conditions.

Step 1: Find out whether hormonal therapy is right for you.

Here are the cancer-related concerns to help you and your doctor decide:

• The cancer's hormone-receptor status—Does the cancer have hormone receptors for estrogen or progesterone (is it hormone-receptor-positive or hormone-receptor-negative)?
• Other treatments you've had—Have you already had chemotherapy and/or radiation? Have you had other forms of hormonal therapy before?
• Your risk of recurrence—Do any factors put you at high risk for breast cancer recurrence or a new breast cancer, and what can you do to lower your risk?

Step 2: With your doctor, choose the hormonal therapy that's right for you

If the answers to the above questions indicate that hormonal therapy will help you, the next step is for you and your doctor to choose the treatment plan that's the best one for you. You will need to consider all the factors below:

Menopausal status

• Are you pre-menopausal (still getting your period every month), peri-menopausal (having irregular periods), or post-menopausal (no longer having periods)? (In addition to a change in menses, menopause brings with it a variety of other changes in the body, including bone loss.)
• Tamoxifen is standard of care for pre-menopausal women.
• Ovarian shutdown or removal is another option for pre-menopausal women, sometimes combined with another form of hormonal therapy.
• Aromatase inhibitors are only for post-menopausal women.
• Faslodex (chemical name: fulvestrant) is another option for post-menopausal women with advanced disease.

Stage of breast cancer

• Tamoxifen is the only hormonal therapy approved to reduce risk for women at high risk (with no personal history of breast cancer) and for women with non-invasive breast cancer. It is standard of care for pre-menopausal women with any stage of disease.
• Studies of aromatase inhibitors for risk reduction for women with no personal history of breast cancer are under way.
• Aromatase inhibitors are the first choice of hormonal treatment for post-menopausal women with any stage of hormone-receptor-positive invasive breast cancer.
• Other hormonal therapies may also be used, depending on the cancer's stage and your personal situation.

Nature of the cancer

• There is early evidence that HER2-positive breast cancer in post-menopausal women may respond better to an aromatase inhibitor than tamoxifen. A study suggested choosing hormonal therapy in part based on the cancer's combined estrogen and progesterone receptor-status (ER+/PR+ or ER+/PR-).

Step 3: Consider health concerns other than breast cancer

You may have other health concerns, unrelated to breast cancer, that might require extra management while you are taking hormonal therapy. These health concerns usually will not be the deciding factor in which hormonal therapy you should use. Rather, these health issues together with possible side effects of hormonal therapy may require extra attention and management during your course of therapy.

• A personal history of blood clots
  
  If you have had blood clots, your doctor will probably want you to avoid tamoxifen. But if you are pre-menopausal, your history of blood clots was not serious, and tamoxifen is an important part of your care, your doctor may recommend taking a blood thinner (such as baby aspirin) along with tamoxifen.
• Serious osteoporosis
  
  Some doctors will want to do bone tests before starting you on hormonal medication, because many of these medicines have been shown to affect bone health. If you have had a test to measure your bone density (a DEXA scan), your doctor will have told you whether you have osteoporosis (bone loss). If you do, you may be put on a bone-building medicine. If you don't respond to the medicine, and you've had broken bones already, then your doctor may recommend tamoxifen over an aromatase inhibitor. But if your doctor thinks that it's critical for you to be on an aromatase inhibitor, then a more effective bone-building plan may be recommended along with the aromatase inhibitor.
• Arthritis
  
  Arthritis is common in women with or without a diagnosis of breast cancer. Aromatase inhibitors can cause joint and muscle pain. This might be a new symptom for you, or hormonal therapy may make existing aches and pains worse.
• No hysterectomy (you still have a uterus)
  
  If you have NOT had a hysterectomy and still have your uterus, your doctor may suggest that you avoid tamoxifen, which is associated with a higher incidence of uterine cancer.

So the answer to the question, "who is hormonal therapy for?" includes a pretty wide range of people. All along the way, you and your doctor will re-evaluate the balance of benefits and side effects.

Learning all about the different hormonal treatments will help you to have a more informed conversation with your doctor.