August 2007: Managing Ongoing Medications

Surgery and radiation without tamoxifen okay?

Question from Leslie: After 3 months I was taken off tamoxifen for severe reactions: cramping, hourly flashes with nausea, head and joint pain and insomnia. I've had surgery and radiation for my DC/LCIS. How protected am I? Thanks.

Answer —Patricia Ganz, M.D.: It sounds like you are premenopausal if you're having these symptoms. This is sometimes a problem in women who are still menstruating. Sometimes because the tamoxifen causes stimulation of the ovaries, this can be very challenging to manage. But your cancer situation is a non-invasive cancer, and you should discuss with your doctor whether any other approach to endocrine (hormonal) therapy would be helpful.

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Femara after Arimidex effective or harmful?

Question from Bend: I recently completed 5 years on Arimidex and my oncologist prescribed 5 more of Femara. Are there any studies that show this being either effective or harmful? Thanks for your help.

Answers —Patricia Ganz, M.D.: There are no long-term studies looking at the safety of more than 5 years of therapy with an aromatase inhibitor. Both Arimidex (chemical name: anastrozole) and Femara (chemical name: letrozole) are aromatase inhibitors. There is currently a research study being conducted by the The National Surgical Adjuvant Breast and Bowel Project (NSABP) that is looking at whether or not 5 additional years of an aromatase inhibitor is safe and effective after 5 years of initial therapy.

Lillie Shockney, R.N., B.S., M.A.S.: If you have an opportunity to participate in a clinical trial regarding this, it may be something you would want to consider.

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Side effects when stopping Arimidex?

Question from Debbi: Are there any side effects when one stops taking Arimidex? My M.D. told me to stop taking it. What should I expect?

Answer —Patricia Ganz, M.D.: There are no known side effects of stopping this medication. You may notice some benefits if you were having side effects.

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Something other than Arimidex to keep estrogen low?

Question from RoseA: I took tamoxifen for 1 year and switched to Arimidex for 4 more years. After that, my doctor told me I couldn't take Arimidex or anything else because I had completed 5 years of treatment. I have been not taking any treatment for the past year and worry every day about it. Isn't there something else I can take to keep the estrogen low so the cancer does not come back?

Answers —Patricia Ganz, M.D.: That's an excellent question, but at this point in time we do not recommend any more than the length of time with Arimidex that you have taken. As noted with the earlier question, there are now research studies underway to determine whether 5 additional years are safe, and who would benefit from the additional therapy. Over the years, the length of time of endocrine therapy has been extended for women with breast cancer. In my practice, every time there has been a change in the length of therapy (for instance 2 years to 5 years, or 5 years of tamoxifen followed by 5 years of an aromatase inhibitor), women are very anxious when they stop therapy. It is best to discuss with your physician whether you can join a research study that would help answer this question, but without evidence of benefit, we would not recommend additional treatment.

Lillie Shockney, R.N., B.S., M.A.S.: Women should feel good about reaching their 5-year mark. Risk of recurrence is highest in the first few years, and having passed that milestone, I hope women are feeling more confident about their health status, rather than less confident.

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Arimidex okay to take every other day?

Question from BHansen: I am taking Arimidex and have severe joint problems. What do you think about taking it every other day? Are there any studies on that, other than not taking it at all?

Answer —Patricia Ganz, M.D.: I would not advise taking it every other day. But you might want to discuss changing to one of these other aromatase inhibitors which are by brand name Femara and Aromasin (chemical name: exemestane). Sometimes switching to one of the other drugs in this class may modify the symptoms

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Dangerous to miss doses while on vacation?

Question from Lynne: I wondered about missing doses when traveling. How dangerous is that?

Answer —Patricia Ganz, M.D.: I think basically you shouldn't worry about missing occasional doses, but you should try to take your doses regularly using a pill box or some other medication dispenser that will remind you to take it.

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Remove ovaries to stop taking tamoxifen?

Question from Eilish Belfast: Is there any logic in having your ovaries removed to lower estrogen and stop taking tamoxifen? I am estrogen and HER2 grade 3 positive and am nearing the end of a 1-year course of Herceptin, and would wish to stop taking medication to let my body recover if possible.

Answer —Patricia Ganz, M.D.: If you are menstruating, it would be a possibility to do an oophorectomy, which is removal of the ovaries. But you would be put into immediate surgical menopause, which often has more side effects and consequences than taking tamoxifen. The side effects of surgical treatment can include severe hot flashes, vaginal dryness and sexual dysfunction, which are usually much more limited with tamoxifen. In addition, if you're having side effects from tamoxifen, it is a pill and you can stop taking it, but once your ovaries are removed, they cannot be replaced.

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What is considered a "missed dose"?

Question from Francesca: I am taking Femara (2.5 mg daily). On the bottle, it states that if I miss a dose, contact your doctor immediately. I take it around the same time every day, but what do they mean if I "miss a dose"? As in 24 hours, 12 hours, etc.? Basically, what I am asking, how long do I have before it's considered missing a dose?

Answers —Patricia Ganz, M.D.: We would like our patients to take their medications regularly, as prescribed, but we are all human, and often will miss a dose which would mean a daily medication in this case. You do not need to contact your doctor if you miss a dose. But what we're more concerned about is if you stop taking the medication altogether.

Lillie Shockney, R.N., B.S., M.A.S.: It is valuable to try to take it at the same time of day. That would help with adhering to a schedule so you remember to take it, and so you're spacing the doses 24 hours apart on average, rather than taking it at bedtime today and at breakfast tomorrow.

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Medication to help with sleep while on Arimidex?

Question from Ilene: I'm on Arimidex. Within days of starting it I developed severe and frequent hot flashes and sleep problems: restlessness, tossing, and turning. Sometimes I wake up exhausted. Is there a medication that can help manage this that won't interfere with Arimidex?

Answers —Patricia Ganz, M.D.: The medication that you're taking is dropping your blood level of estrogen to extremely low levels and with this, your body is sensing the change. This is experienced by you as hot flashes and difficulty with sleeping. These are common menopausal symptoms, which you may have experienced in the past, or which may be new to you. There are a number of medications that can be used to help manage these symptoms, and you should speak to your doctor. But they do include medications that are antidepressants that are used in low doses, and another drug called gabapentin (brand name: Neurontin), which can also help in managing these symptoms. It is also possible that your body will get used to this, and gradually have improvement in symptoms.

Lillie Shockney, R.N., B.S., M.A.S.: Looking at other ways of managing some of the side effects, like wearing cotton rather than a nylon nightgown, will help. Even a Chillow pillow, where the pillow stays cold all night.

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Advice for headaches while on tamoxifen?

Question from Curly: I have been on tamoxifen for 2 1/2 years now and have been getting almost daily, terrible headaches. My oncologist hasn't heard of this, but had me stop for 1 month. The headaches have lessened dramatically. He has since divided the dose, but my headaches have returned. I have to take it for a few more years, but I can't live with these headaches.

Answer —Patricia Ganz, M.D.: Headaches are a side effect of tamoxifen that are not as widely known and recorded, so some physicians may not have seen them. But I have seen them relatively frequently in young premenopausal women or in the time close to menopause when hormonal fluctuations seem to bring on headaches even in healthy women. In general when I have given this to women for breast cancer prevention, we have decided not to continue tamoxifen if it causes troublesome disabling headaches. In your situation where you are being treated for breast cancer, this may be more difficult although there are other endocrine strategies for premenopausal women, which could include giving a drug such as goserelin (brand name: Zoladex) or Lupron (chemical name: leuprolide), which would shut down the ovarian function and be equally effective.

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Long term side effects after treatment?

Question from HLady: After taking Arimidex for less than 6 months, my doctor says I have "chemically induced rheumatoid arthritis and fibromyalgia" from the drug. Is this common? I'm 7 years post diagnosis, and it seems to be getting worse. I also have developed severe neuropathy in my hands. Doctors blame the chemo. Is it common to have these problems so long after ending chemo?

Answers —Patricia Ganz, M.D.: These side effects of joint pain and sometimes muscle aches are seen relatively frequently in women taking drugs like Arimidex (the aromatase inhibitors). This is not usually associated with rheumatoid arthritis and fibromyalgia. If your doctor thinks you truly have rheumatoid arthritis, you should see a specialist in rheumatology to make sure this is truly the diagnosis. We believe that part of the mechanism for women experiencing these symptoms after starting aromatase inhibitors is related to the lowered estrogen in the body. Just as women can get hot flashes and night sweats, the joints may also respond by becoming stiff and painful. As women go through menopause naturally, there is an increase in joint pain brought on by reduced levels of estrogen. One way of dealing with this may be to have a “drug holiday”: going off the medicine for 2-3 months to see if your symptoms subside. Or if you need this therapy, to switch to another medication. It would also be good to get a second opinion from another oncology physician to evaluate your treatment and see if this medication is necessary.

Lillie Shockney, R.N., B.S., M.A.S.: There's a tendency sometimes when we develop a new symptom of something to assume it is related to a medication we're taking. A breast cancer patient can develop other illnesses, just like anyone else, that are totally unrelated to her cancer, such as rheumatoid arthritis.

Patricia Ganz, M.D.: So seeing a specialist can be very helpful.

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Long-term side effects of Aromasin?

Question from Barbara: What are the long-term side effects of Aromasin regarding chronic arthritis and osteoporosis? Can you speak to the dangers in not taking the dose at the same time daily and/or missing a dose?

Answer —Patricia Ganz, M.D.: I think we have covered some of your question in our earlier comments re missing a dose. It's good to be conscientious about taking your medicines, but missing a single dose will not cause the cancer to come back. As far as the long-term effects of these medications, we are just learning about them and women have not been using them for a very long time for us to know whether there are very serious consequences. We do know that many women will lose bone density on the scans that are done to screen for osteoporosis, and that there are medications to help stabilize the bone density. But we do not have 10- and 15- year data yet to know what will happen to women as they age and whether there will be long-term consequences.

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Oral chemotherapies available?

Question from Nancy: I am dealing with the fourth go-around with breast cancer. Have been on pretty much all meds during this time. Presently on Xeloda. Question is whether there are any other oral chemotherapies that may be available sometime soon?

Answer —Patricia Ganz, M.D.: It's very difficult to give medical advice to a patient that I have not seen and don't have their full record, so it would be difficult to make recommendations about your specific situation.

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How to tell side effects from menopause?

Question from DeannaH: I have been taking Arimidex for over a year. When joint pain occurs or the joy of hot flashes, how do you know when to attribute it to a side effect from Arimidex or when it's a normal effect from forced menopause? This would be helpful in deciding whether to change to a different hormonal therapy or keep the course.

Answer —Patricia Ganz, M.D.: The best way to evaluate your situation is to consider a brief drug holiday. This drug is relatively rapidly passed through the body, and if you were to stop taking it for about 3-4 weeks and had improvement in your symptoms, then it's likely due to the medication rather than your menopausal status.

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Black cohosh okay to manage hot flashes?

Question from MGren: Are there risks to taking black cohosh to manage hot flashes? I am taking Aromasin since my estrogen-positive breast cancer 2 years ago. The summer here in Texas is hot enough without adding hot flashes, and UNBELIEVABLE levels of anger. Thank you.

Answers —Patricia Ganz, M.D.: Studies have not shown that black cohosh alleviates hot flashes any better than placebo. In addition, there have been some biochemical studies looking at blood levels of estrogen and these have not necessarily shown that it is harmful, but you should consult with your physician before taking anything that is not prescribed.

Lillie Shockney, R.N., B.S., M.A.S.: I was glad this question was asked. Often people think that if it's something that can be obtained over the counter, it's safe to self prescribe. But in fact, even herbal substances can have interactions. Therefore, it is important to discuss with your doctor before trying something on your own.

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Safety of estrogen ring on Arimidex?

Question from SalH: I am on Arimidex and find intercourse extremely painful due to dryness. How safe is the estrogen ring?

Answer —Patricia Ganz, M.D.: Using vaginal estrogen even in low dose may complicate the management of your treatment on Arimidex. We have felt comfortable using vaginal estrogen supplements such as Vagifem or Estring for women who are on tamoxifen because tamoxifen blocks the uptake of any blood level of estrogen that could get into breast cancer cells. However, the strategy of using Arimidex and the other aromatase inhibitors is to lower the estrogen level as low as possible, down to nearly zero. If you use a vaginal estrogen preparation, even in these low doses, it will raise the estrogen level in the blood so that you may be counteracting the benefits of the aromatase inhibitor. I am currently measuring estradiol blood levels in my patients who are using vaginal estrogen because I want to make sure it doesn't elevate the levels. So you might be defeating the purpose of the aromatase inhibitor. If this were to be used, it would have to be used with great caution and with monitoring. You can also use other non-estrogen preparations. One is Replens, a vaginal moisturizer used twice a week. In a randomized trial that we did several years ago, we found that women's vaginal symptoms improved and their sexual functioning also improved. You can also use a preparation as a lubricant at the time of sexual intercourse, which may also help, and there is a variety available at the drug store. You should also know that vaginal dryness is a common symptom of women as they age, so what you are experiencing is an exaggeration of the symptoms that women in postmenopausal years experience.

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Leg pains from tamoxifen?

Question from Schaffer: I am on tamoxifen 20 mg. I was wondering if I could have leg pains from this medication. My oncologist does not believe it's from tamoxifen and states that none of his other patients ever complained of this. Any thoughts?

Answer —Patricia Ganz, M.D.: That's what I used to think. But we recently completed the STAR trial, which was a test of tamoxifen compared to raloxifene (brand name: Evista) in healthy women who were at high risk for breast cancer. In doing the quality of life study for that trial, we included a question about leg cramp, because raloxifene had been reported to cause leg cramps in healthy women receiving that medication for osteoporosis prevention. Much to my surprise, when I analyzed the data comparing raloxifene to tamoxifen, the healthy women who took tamoxifen had more leg cramps than women who took raloxifene. So the answer is tamoxifen can cause leg cramps. They are not all that frequent or severe, but if they began after you started the medication, it's probably related to that. If you have a pain that's persistent at one location in your leg, you should report it to your physician because rarely tamoxifen can cause blood clots. But the kind of symptoms you're describing are very common in women as they age, and are made worse by tamoxifen.

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Long-term impact of low-estrogen levels?

Question from AEM: Although we know Arimidex is an important drug in the treatment of some types of early stage breast cancer, I often worry about the long-term effects of life with practically no estrogen and its influence upon heart disease, bone health, even skin and hair. Do you have any comments?

Answer —Patricia Ganz, M.D.: You have very appropriate concerns because we don't have long term information about the impact of a low-estrogen state. So what is very important is that you make sure the indications for you taking this medication are firm, and that you are not being treated unnecessarily with a medication that could have long term side effects if you don't need it.

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Medications for triple-negative coming?

Question from Patty: I am not on any of the medications you are talking about as I am triple-negative. Are there any other meds for us coming out in the near future? I have chemo-induced menopause. I was diagnosed in Dec 03, I am almost 4 years out and doing great.

Answers —Patricia Ganz, M.D.: In general, we do not add additional therapy to someone who is free this many years out after their treatment. This could obviously change, but it sounds like you have had therapy and I'm assuming you have had regular follow-up. It's now almost 4 years and you've not had a recurrence, so we would be very optimistic about your future.

Lillie Shockney, R.N., B.S., M.A.S.: We're glad you're doing great!

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Difference between aromatase inhibitors?

Question from Elizabeth: Are there any studies comparing the 3 different aromatase inhibitors? Is any one better than another?

Answer —Patricia Ganz, M.D.: At this time, we do not have any what we would call head-to-head comparisons of the 3 drugs. I believe there is a trial underway now that may be looking at this. There is some speculation that exemestane, which is Aromasin, may be safer for the bones because it is a steroidal aromatase inhibitor. But there have been no studies to demonstrate that.

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Managing memory loss due to chemo?

Question from LinAnh: I have Stage 4 breast cancer and will have to have chemo treatments for life. Any way to manage the memory loss? It seems to get worse over time. Thank you.

Answers —Lillie Shockney, R.N., B.S., M.A.S.: This is an understandable concern. It may not be totally related to the medications that you're taking, but also the additional stress that you're under, having to deal with a chronic disease.

Patricia Ganz, M.D.: Getting organized and making sure that you don't put yourself in a situation where you have to do too many things at the same time may also help.

Editor’s Note: For more information on breast cancer treatment and memory problems, read the August 2006 Ask-the-Expert transcript, Thinking and Memory Challenges.

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Damaging to miss days of Arimidex?

Question from Hopper: I have taken Arimidex for 16 months now and have become comfortable with it; however, when life gets busy I will miss 2 or 3 days in a row. How damaging is this? Thanks for your reply.

Answers —Patricia Ganz, M.D.: I think we have tried to address your concerns that if you miss a dose or two, you don't need to worry. The critical thing is to try to take it at the same time every day. Use strategies to help you remember to take the medication: take it at the same time every day, such as after breakfast or at bedtime or when you brush your teeth. Use a pill dispenser that has the 7 days of the week filled, so you know whether you've taken it or not.

Lillie Shockney, R.N., B.S., M.A.S.: I like what you said about brushing your teeth. No matter how busy we are, we always brush our teeth, so take the medication in conjunction with something you know you'll do every day.

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Does tamoxifen affect thyroid?

Question from Lam: I would like to know how much tamoxifen interferes with thyroid function. After starting tamoxifen I started having hypothyroid symptoms and now take meds to manage them. Thank you for your consideration of my question and any responses that may follow.

Answer —Patricia Ganz, M.D.: This is a good question, and one that we don't have systematic clinical information about. But we do know that the proteins in the blood that transport tamoxifen are also involved in transporting thyroid hormone, and there may be changes in the blood levels of thyroid as a result of taking a drug like tamoxifen or almost any other hormone. The other observation from my own clinical practice is many women may have sub-clinical hypothyroidism and they haven't been going to the doctor for any medical problem. But when they come under our care for breast cancer and we start to do routine blood work, it will more likely be diagnosed. So there are some advantages to having breast cancer; there are more doctors looking after you, and more attention is paid to how you're feeling. Whereas if you're a middle-aged woman who goes to the doctor just once a year, you may not be diagnosed as quickly.

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Menopause permanent after treatment?

Question from Star: I'm 31 and have been in menopause since last year due to chemotherapy. Now I'm taking tamoxifen for 5 years, and I'm afraid I'm going to stay in menopause. Is there a chance I won't come out of menopause?

Answer —Patricia Ganz, M.D.: Yes, there is a chance you won't, but there's also a possibility that you will. What happens is that during chemotherapy, the ovaries may shut down and may not be functioning regularly. There may be recovery of their function over several years, even 2-3 years later. When you take tamoxifen it may mask the recovery of your ovaries and when you stop the tamoxifen, you could have regular periods again. But it's hard to predict what's going to happen.

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Help to maintain weight on tamoxifen?

Question from Wynn: I've only been taking tamoxifen for 8 months. At first I lost weight while on tamoxifen, but for the last 2.5 months I've gained. I'm thinking about decreasing my dosage or asking my doctor to go to a different brand. I run approx. 25 miles a week and use a personal trainer. Any advice?

Answer —Patricia Ganz, M.D.: The first point is that there is no other brand of tamoxifen other than what you're taking. The generic and the brand name are both the same. In addition, reducing the dose would not be advised because we want to make sure if you take a medication you get its benefit. Sometimes if you reduce the dose, you get side effects, but no benefit. I don't know how old you are, but weight gain is a problem for many mid-life women and as we get older we have less testosterone because our ovaries decrease production of testosterone. Testosterone is critical for the maintenance of muscle; that's why men have muscles and we have less. Also with more muscle, we burn more calories. So starting in our 40s we are declining muscle mass and we will tend to gain a pound or so a year if we're not careful. So you are doing the right thing with your running, but you may also want to do some work with free weights to maintain your muscle mass. And regrettably, you may have to eat less.

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Miss monthly dose of Faslodex?

Question from KathyK: I have a shot of Faslodex once a month. What if I miss a dose?

Answer —Patricia Ganz, M.D.: It's difficult to answer your question because I’m not sure if you're getting this for recurrent or metastatic cancer, or if you're taking it in an adjuvant setting. But this medication really is effective for a 1-month period of time, and if you miss a dose, you're not getting the benefits of the drug.

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Will hot flashes from tamoxifen ease up?

Question from LydiaS: I just started taking tamoxifen 2 weeks ago and I'm hot flashing more than ever. Will this ever ease up? It’s making me sick and fatigued and I can't imagine trying to go back to work like this. HELP!!!!

Answer —Lillie Shockney, R.N., B.S., M.A.S.: This is not unusual to be experiencing side effects like this, especially when starting tamoxifen. Give it more time before feeling like you want to throw in the towel. Your body is trying to go through an adjustment, so try to wait it out a bit longer. Take a look at the information on the Breastcancer.org site that provides specific recommendations to deal with the symptoms you're experiencing, since this is new for you. If it continues to persist, notify your doctor to see if he/she wants to prescribe something for you to relieve the symptoms.

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Femara even when not tested for receptors?

Question from NancieR: I had DCIS and radiation therapy. I'm on Femara, which makes my joints ache and gives me additional trouble sleeping. Because they did not test the DCIS for whether it was hormone positive (said it wasn't done in such cases), I question the value of taking Femara. I feel 10 years older in the year I've taken it.

Answer —Patricia Ganz, M.D.: Please ask your doctor to have your tissue tested for estrogen and progesterone receptors. This is a standard assay that can be done on your tissue. If you are hormone-receptor-positive, we would recommend tamoxifen, which is the standard therapy in this situation. You might tolerate that better than the Femara. But rather than having me give you specific advice, you might wish to seek a second opinion to review your case in detail.

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Importance of taking tamoxifen on time?

Question from Jennifer: How important is it for me to take my tamoxifen at the same time every day? I take it between 8-11 p.m. depending on when I go to bed. Thanks.

Answer —Patricia Ganz, M.D.: Unlike the aromatase inhibitors, tamoxifen has a very long half life and after you have been taking it for months, you have steady blood levels. So if you miss several doses or don't take it at the same time every day, there is very little variation in the blood level. Nevertheless, it's wise to try to take it at the same time every day so you don't forget, but not rigidly at the same hour.

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Advice on tamoxifen and flying?

Question from RSmith: Do you make any special recommendations for women on tamoxifen who go on long flights, besides getting up and moving periodically, i.e. support hose or baby aspirin?

Answer —Patricia Ganz, M.D.: I do not. And my reasoning for this is that we had 30 or 40 million women in the U.S. who were taking hormone replacement therapy at the menopause who traveled and did not use support hose or baby aspirin while they were taking the hormone replacement therapy. The risk of blood clots and other complications similar to that are the same with tamoxifen as they are with hormone replacement therapy. Also, there's no evidence that aspirin helps with the venous clotting which is what the complication is with tamoxifen and hormone replacement therapy.

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Evista effective? Weight gain normal?

Question from RMoore: My hormonal therapy drug is Evista because I can't, for medical reasons, take any other med. Do you think Evista is as effective as some of the other drugs for preventing a return of breast cancer? Is weight gain on Evista normal? Thank you.

Answer —Patricia Ganz, M.D.: Evista, otherwise known as raloxifene, is not approved for the treatment of breast cancer. I don't know if you are taking this medication for prevention or treatment of breast cancer, but I suggest you either discuss it with your doctor or seek another opinion if it is being given for treatment of breast cancer. Evista was tested in the recent STAR trial for prevention of breast cancer in high risk postmenopausal women. It was shown in the prevention setting to be equally effective as tamoxifen in preventing invasive breast cancer, but less effective in precancerous changes in the breast. Currently Evista is pending FDA approval for breast cancer prevention. However, it has not ever been tested or shown effective in the treatment of breast cancer. It is not as effective as the standard therapy that would be used for endocrine treatment, which includes tamoxifen and the aromatase inhibitors.

Editor's Note: In September 2007, the U.S. Food and Drug Administration (FDA) approved using Evista to reduce the risk of breast cancer in post-menopausal women who are at high risk. The FDA also approved using Evista to reduce the risk of breast cancer in post-menopausal women with osteoporosis.

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Safe to conceive on tamoxifen?

Question from ISingh: I'm taking tamoxifen but I intend to try to get pregnant while I'm still premenopausal. Is tamoxifen safe while trying to conceive?

Answers —Patricia Ganz, M.D.: Absolutely not. Tamoxifen should be used with some sort of barrier contraception, like an IUD or diaphragm or condoms. If you get pregnant while you are on tamoxifen, the tamoxifen could damage the fetus and termination of pregnancy would be recommended as a result. Also, tamoxifen causes hyperovulation, which means you are at increased risk of getting pregnant while on tamoxifen, so you should use some form of contraception. However, when you stop your treatment, the tamoxifen will be out of your system and it will be safe to have a child then.

Lillie Shockney, R.N., B.S., M.A.S.: We usually recommend even if the women isn't menstruating that she still use some form of contraception.

Editor’s Note: Learn more about tamoxifen and pregnancy.

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Neurontin for hot flashes okay with tamoxifen?

Question from FTS: What is your opinion of taking Neurontin for hot flashes while taking tamoxifen?

Answer —Patricia Ganz, M.D.: This particular medication with the generic name gabapentin has been shown to be beneficial in the treatment of hot flashes for women taking tamoxifen. It is a reasonable strategy for controlling the symptom.

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Tamoxifen dosage same no matter weight?

Question from Jul: Why is the dose of tamoxifen the same for a woman who weighs 300 pounds and a woman who weighs 115? Have any studies been done on the effectiveness of a lower dose for smaller woman? Thank you!

Answer —Patricia Ganz, M.D.: In the early days of breast cancer treatment with tamoxifen, primarily for women with metastatic disease but later in the adjuvant setting, there were studies that looked at a variation in dose between 20 and 40 mg per day. There have been no studies done looking at lower doses, except for a few select research studies looking at prevention. Like other hormone drugs, doses are often chosen irrespective of weight because of the general hormonal effect, rather than a dose limiting toxicity. When we give chemotherapy, we have a dose that if exceeded, will cause harm to some organs in the body. That is not the case in general with hormones, although there may be some toxicity at high doses. In the studies that were done looking at higher doses, there was no benefit, so the dose is standardized at 20 mg per day.

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How long to use Abraxane?

Question from Isabel: I’m taking Abraxane as maintenance every 1-2 weeks for a second primary, this time inflammatory. Abraxane causes severe diarrhea and stomach cramps. What is suggested, since most anti-nausea meds cause a reaction? Also, how long can you use Abraxane?

Answer —Patricia Ganz, M.D.: In general, Abraxane is used as long as the treatment is working. I am not sure if you are getting this because you have measurable metastatic disease or in an adjuvant setting. It is really best to ask your doctor about your personal situation.

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Research on weight changes on tamoxifen?

Question from Kiel: Is there research to support weight loss or gain while taking tamoxifen?

Answer —Patricia Ganz, M.D.: In the breast cancer prevention trial, which was the study of women at high risk for breast cancer where we prescribed tamoxifen or a placebo, there was no difference in self-reported weight change according to whether or not a woman took tamoxifen. As I described earlier, women have natural tendencies to gain weight as they age, which is related to changes in their metabolism. If they do not exercise more or eat less, they may gain weight and this is irrespective of whether they take a drug such as tamoxifen.

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Side effects differ for Arimidex, Aromasin?

Question from Amy: Are there any known differences in side effects between Arimidex and Aromasin

Answer —Patricia Ganz, M.D.: Not that I know of.

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Tamoxifen causes water retention? Remedies?

Question from Syd31: I have been taking tamoxifen for 3 months now. Is water retention an effect of this, and are there any natural ways to help this?

Answer —Patricia Ganz, M.D.: Water retention is not a known side effect of tamoxifen, but sometimes when women are perimenopausal, in the years just preceding menopause, they may have fluctuations in their salt and water retention which may be related to their ovarian function. Sometimes it may be helpful to use a mild diuretic to help if you are uncomfortable. You should discuss this with your doctor.

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Hormonal therapy during or after radiation?

Question from Ruth: Should a person start hormonal therapy during radiation, or wait until radiation has been completed

Answers —Patricia Ganz, M.D.: That's a good question. We don't really have an answer for you, because no studies have been done looking at whether there is a difference in outcome for women who take hormonal therapy with radiation or after radiation. In general, I start the hormonal therapy after radiation simply because it's easier to separate symptoms and problems women could be having related to the hormone therapy if I give it after radiation is completed. But there are other physicians who give it during radiation, so there isn't a correct answer.

Lillie Shockney, R.N., B.S., M.A.S.: We really have decided to let it be the physician's preference.

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Reconstruction while on Herceptin?

Question from Elizabeth: While on Herceptin treatment, would you suggest reconstructive surgery?

Answers —Patricia Ganz, M.D.: I think that's a question that you need to speak to your treating physicians about. It depends on the extent of surgery and the evaluation of the people caring for you.

Lillie Shockney, R.N., B.S., M.A.S.: We usually prefer to have the patient complete their Herceptin therapy. Many reconstructions may take several weeks to recover from, and we don't want the patient to have breaks in her Herceptin therapy for an elective reason of breast reconstruction. So we opt to do the reconstruction at the end, and it's something she can look forward to as she completes her treatment.

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Irregular bleeding from menopause?

Question from Teresa: I am currently on Navelbine, Herceptin, and Aredia. I am a 52-year old premenopausal woman with regular periods. About 5 weeks ago I started bleeding and have not stopped yet. Is this normal? Does this happen when you go into menopause?

Answers —Patricia Ganz, M.D.: Sometimes during the beginning of menopause, there can be irregular or heavy bleeding. But this is a very long time to have bleeding and you should definitely see a gynecologist.

Lillie Shockney, R.N., B.S., M.A.S.: And have some blood work done.

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Depo-Provera safe for hot flashes?

Question from Rose: What about taking Depo-Provera shots for hot flashes after diagnosis of early stage breast cancer, HER2 positive, Herceptin, and Aromasin?

Answer —Patricia Ganz, M.D.: I would not recommend such therapy. Depo-Provera is a hormone which could stimulate growth of hormone-receptor-positive tumors and counteract any benefit you might be receiving from the aromatase inhibitors.

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Advice for hand-foot syndrome with Xeloda?

Question from Bobdolly: I take Xeloda but have a lot of trouble with the hand-foot syndrome. Is it better to stop taking it before the end of my 2 weeks when it gets real bad, or to cut the dosage?

Answer —Patricia Ganz, M.D.: You need to talk to your doctor about what is best for your situation.

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Side effects of aromatase inhibitors?

Question from Renee: Can you give us a list of what is typical and expected symptoms with the significant (and often immediate) decrease in estrogen as we are experiencing with the aromatase inhibitors? We know of the hot flashes/night sweats, vaginal dryness, decrease in bone density...what are other symptoms or signs from estrogen depletion so that we can manage our concerns better?

Answers —Patricia Ganz, M.D.: I think the only common one you missed is the joint aches and pains, which are reported in 40-50% of women. The ones you listed are the most common, but it's so variable. Many women have no symptoms at all, and others are very troubled.

Lillie Shockney, R.N., B.S., M.A.S.: You may see others, such as nausea and headaches.

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Tamoxifen with elevated liver enzymes?

Question from Martha: My doctor put me on Arimidex for 5 years rather than tamoxifen because of my elevated liver enzymes. I'm concerned about the fact that we don't know what the long-term effects this drug will have. How harmful would be it to take tamoxifen with elevated liver enzymes? If not tamoxifen, is there a different drug I can take, rather than Arimidex, where we know more about long-term effects?

Answer —Patricia Ganz, M.D.: It's difficult to give medical advice about your personal situation. I would suggest you get a second opinion from a breast cancer specialist to discuss whether it is safe for you to take tamoxifen.

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Tell doctor about side effects from Arimidex?

Question from Rhonda: I'm having terrible side effects from Arimidex but I'm afraid to tell my doctor. I think he really wants me to stay on it. I tried tamoxifen and had trouble with that too. How can I explain that I'm having trouble with the new drug without annoying him?

Answers —Patricia Ganz, M.D.: It's in your best interest to tell the doctor you're having difficulty. As I mentioned earlier, you may benefit from switching to another aromatase inhibitor. Sometimes people do better with an alternative. Also, as we have discussed, your symptoms could be managed with medication or behavioral strategies. If you’re having vaginal symptoms, there are ways to manage that.

Lillie Shockney, R.N., B.S., M.A.S.: Your doctor will want to know if you're having problems. I think he would be more uncomfortable in not knowing.

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Male experiencing female side effects?

Question from 45m: It seems I'm experiencing most of the female side effects with tamoxifen: the flashes, night sweats, weight gain, mood swings, additional hair growth. Will these conditions stop when I finish my prescription in 4 years?

Answer —Patricia Ganz, M.D.: It sounds as if you are a man who is taking tamoxifen for breast cancer. If so, these side effects are not all that common. I have treated a number of men with tamoxifen and they seem to tolerate it fairly well. You could be having hot flashes and night sweats if you have had a lowering of your estrogen response in the brain. But again, without knowing your age and your gender for sure, it is hard to answer this properly.

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Bloating, gas, nausea normal with Femara?

Question from Lake: I am taking Femara and since switching from tamoxifen, I have had problems with stomach bloating and problems with lots of gas. I also am nauseous every day, especially in the morning. Is this a normal side effect for Femara?

Answers —Patricia Ganz, M.D.: We have not seen this particular side effect, so you need to discuss it with your physician.

Lillie Shockney, R.N., B.S., M.A.S.: Don't assume that these symptoms are related to the medication switch. You may need to have other tests done to determine the cause.

Patricia Ganz, M.D.: It has been very interesting for me to spend time with you tonight to see how you are having challenges from taking the aromatase inhibitors. Your questions about the long-term effects of these drugs are important, and I hope we will have more research in the future that will enable us to answer your questions more properly.

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