Managing Patients on Endocrine Therapy: Focus on Quality-of-Life Issues

Patient-reported outcome and survival in premenopausal hormone receptor-positive breast cancer patients at moderate to high risk: comparing toremifene with aromatase inhibitor in a real-world study

Toremifene, a selective estrogen receptor modulator, is commonly used in China for premenopausal breast cancer patients. This real-world study aimed to compare patient-reported outcome (PRO) and survival between toremifene and aromatase inhibitor (AI) plus ovarian function suppression (OFS) in patients with moderate-/high-risk premenopausal hormone receptor (HR)-positive breast cancer. The primary endpoint was PROs, assessed using SF-36 and EQ-5D-5L questionnaires between January and March 2023. A total of 392 patients were included, with 171 receiving toremifene and 221 receiving AI. The toremifene group showed significantly higher scores in the role physical (p = 0.034) and mental health (p = 0.009) dimensions of SF-36 and lower anxiety/depression (AD) scores (p = 0.038) in EQ-5D-5L compared to AI group. The estimated 5- and 8-year disease-free survival (DFS) rates were similar in toremifene and AI groups: 96.5% versus 91.9%, and 87.4% versus 87.8% (p = 0.39), respectively. Adverse event rates were similar in two groups, except for a greater risk of endometrial thickening (p < 0.001) and a lower occurrence of morning stiffness (p < 0.001) in the toremifene compared to the AI group. Premenopausal HR-positive breast cancer patients receiving toremifene plus OFS had better role physical and mental health outcomes and lower AD dimensions than those receiving AI plus OFS. Both treatments had comparable DFS and favorable tolerability profiles.

Health-related quality of life (HRQoL) from HIV patients' perspective: comparison of patient-reported outcome (PRO) measures among people living with hiv (PLWH) and other chronic clinical conditions

Background

People living with HIV (PLWH) are generally known to suffer from a lower quality of life compared to the one of general population, but still very few is known about the self-perception of quality of life when comparing HIV to non-communicable diseases. We performed a comprehensive assessment of patient’s reported outcomes measures (PROMs) among PLWH and patients affected by other chronic conditions (OC) such as diabetes mellitus type 1, rheumatoid arthritis, breast cancer in hormonal therapy, in order to investigate differences in PROMs outcomes between PLWH and other pathologies.

Methods

A cross-sectional observational study was performed by using questionnaires investigating health-related quality of life (Medical Outcomes Study Short Form 36-item Health Survey), work productivity (WPI), and global health status (EQ-5D-3L). They were administered to patients affected by chronic diseases consecutively observed at a single University Hospital during a 10 months period, with comparable disease related aspects. Logistic regression analysis was used to analyze the association between disease group (HIV vs OC) and PROMs.

Results

230 patients were enrolled (89 PLWH, 143 OC). Mean age: 49 years (SD 10), mean time of disease 12 years (10), 96% were Caucasian, 35% assumed polypharmacy, 42% of male were PLWH versus 16% OC (p < 0.001), 19% PLWH versus 6% OC had clinical complications (p < 0.001). HIV infection was independently associated to a better health-related quality of life in several domains compared with the other conditions, except in mental health, whereas a worst health-related quality of life in most domains was reported by older patients and those experiencing polypharmacy.

Conclusions

In this cohort of patients with chronic conditions followed within the same health setting, PLWH showed better self-reported health outcomes compared to other chronic conditions with comparable characteristics of chronicity. The potential detrimental role of older age and polypharmacy in most outcomes suggests the need of longitudinal assessment of PROMs in clinical practice.

The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society

OBJECTIVE

To update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component.

METHODS

A Panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on vaginal hormone therapies as well as on other management options available or in development for GSM. A search of PubMed was conducted identifying medical literature on VVA and GSM published since the 2013 position statement on the role of pharmacologic and nonpharmacologic treatments for VVA in postmenopausal women. The Panel revised and added recommendations on the basis of current evidence. The Panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life. Genitourinary syndrome of menopause is likely underdiagnosed and undertreated. In most cases, symptoms can be effectively managed. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and the estrogen agonist/antagonist ospemifene. Long-term studies on the endometrial safety of vaginal estrogen, vaginal DHEA, and ospemifene are lacking. There are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations.

CONCLUSIONS

Clinicians can resolve many distressing genitourinary symptoms and improve sexual health and the quality of life of postmenopausal women by educating women about, diagnosing, and appropriately managing GSM. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Nonhormone therapies available without a prescription provide sufficient relief for most women with mild symptoms. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman's needs and the recommendations of her oncologist.

Impact of adjuvant endocrine therapy on prognosis in small hormone receptor-positive, HER2-negative early breast cancer

BACKGROUND

The efficacy of adjuvant endocrine therapy for hormone receptor-positive breast cancer has been previously established. However, significant adverse events related to endocrine therapy cannot be ignored. T1 breast cancer is expected to have a good prognosis. Therefore, adjuvant endocrine therapy for T1a breast cancer patients is controversial. Thus, in this study, we examined the effect of endocrine therapy on the prognosis of T1N0 hormone receptor-positive, HER2-negative breast cancer patients in each tumor size group, and re-considered the application of endocrine therapy.

METHODS

We retrospectively obtained clinical and pathological data from medical records of 7635 patients who underwent surgery for breast cancer at Aichi Cancer Hospital between January 2000 and December 2017. The primary end point of our analysis was disease-free survival (DFS). The secondary end points were distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS). The log-rank test, cumulative survival generated curves with Kaplan-Meier methods and the hazard ratio (HR) calculated with a Cox regression model were used to assess the effects of endocrine therapy on prognosis.

RESULTS

The 5-year DFS was worse in the non-endocrine therapy (non-ET) group (78%) than the endocrine therapy (ET) group (95%) in the T1c population (p < 0.001, HR 0.25). However, there was no statistically significant difference in DFS between the ET and the non-ET groups in T1a (ET 96% vs non-ET 93%, p = 0.9314, HR 0.94) and T1b (ET 96% vs non-ET 93%, p = 0.1481HR 0.53) breast cancer. The OS, DDFS, and BCSS of the patients also showed that endocrine therapy was associated with improvement of the prognosis in the T1c group, but not in the T1a and T1b groups.

CONCLUSIONS

Adjuvant endocrine therapy may be essential for T1c breast cancer patients. In contrast, this therapy should be discussed for T1a and T1b luminal breast cancer patients under some circumstances, such as suffering from adverse events.

Engagement of phytoestrogens in breast cancer suppression: Structural classification and mechanistic approach

Cancer is the world's devastating disease, and breast cancer is the most common reason for the death of women worldwide. Many synthetic drugs and medications are provided with their beneficial actions, but all of these have side effects and resistance problems. Natural remedies are coming forward to overcome the disadvantages of synthetic drugs. Among the natural categories, phytoestrogens having a structural similarity of mammalian oestradiol proves its benefit with various mechanisms not only in the treatment of breast cancer but even to prevent the occurrence of postmenopausal symptoms. Phytoestrogens are plant-derived compounds that were utilized in ancient medications and traditional knowledge for its sex hormone properties. Phytoestrogens exert pleiotropic effects on cellular signalling and show effects on estrogen-dependent diseases. However, because of activation/inhibition of steroid hormonal receptor ER-α or ER-β, these compounds induce or inhibit steroid hormonal (estrogen) action and, therefore, have the potential to disrupt hormone (estrogen) signalling pathway. In this review, we have discussed and summarize the effect of certain phytoestrogens and their possible mechanisms that can substantiate advantageous benefits for the treatment of post-menopausal symptoms as well as for breast cancer.

Quality of life in elderly breast cancer patients with localized disease receiving endocrine treatment: a prospective study

PURPOSE

In this paper we study the quality of life (QoL) of elderly breast cancer patients receiving endocrine treatment (ET). More QoL data on elderly patients treated with ET are needed. Our aims are to study QoL in early-stage breast cancer patients throughout the treatment period and compare the QoL of ET groups.

METHODS

148 patients > 65 years who began ET with either tamoxifen or aromatase inhibitor (AI) completed the EORTC QLQ-C30 and QLQ-BR23 and the Interview for Deterioration in Daily Living Activities in Dementia (IDDD) questionnaires three times over 3 years of ET. Linear mixed-effect models were used to evaluate longitudinal QoL changes. ET group comparisons were conducted after 3 years of treatment via ANCOVA adjusted by basal QoL.

RESULTS

QoL scores were high (> 80/100 points) in most QoL areas, with moderate limitations (> 30) in sexual functioning and enjoyment and in future perspective. After 3 years of ET, four QoL areas improved (< 6 points) compared to baseline and 3-month assessments. Hot flushes worsened (8 points) at the 3-month assessment but by 3 years had recovered. AI patients showed more hot flushes, pain and diarrhea and less sexual enjoyment than tamoxifen patients after 3 years of ET (differences 3-12 points).

CONCLUSIONS

Results indicate that elderly early-stage breast cancer patients adapted well to their disease and ET treatment over the 3 years. Few QoL differences were observed between ET groups.

Adjuvant endocrine therapy side-effects among postmenopausal breast cancer patients in Malaysia

OBJECTIVE

This study was conducted to determine the prevalence and severity of menopausal symptoms and their associated risk factors among postmenopausal breast cancer patients receiving adjuvant endocrine therapy.

METHODS

Postmenopausal breast cancer patients on endocrine therapy were recruited at three hospitals in Malaysia. Presence and severity of menopausal symptoms were determined using the Menopause Rating Scale. Sociodemographic and clinical data were collected from medical records.

RESULTS

A total of 192 patients participated in this study. Commonly reported symptoms were musculoskeletal pain (59.9%), physical and mental exhaustion (59.4%), and hot flushes (41.1%). Multivariate analyses indicated that increasing number of years after menopause until the start of endocrine therapy was significantly associated with less likelihood of reporting menopausal symptoms and musculoskeletal pain. Patients with primary or secondary education levels reported significantly less menopausal urogenital symptoms compared to patients with a tertiary education level. Patients using aromatase inhibitors were twice as likely to experience musculoskeletal pain compared to patients using tamoxifen (odds ratio, 2.18; 95% confidence interval, 1.06-4.50; p < 0.05).

CONCLUSION

Menopausal symptoms and musculoskeletal pain are common problems encountered by postmenopausal breast cancer patients receiving adjuvant endocrine therapy and should be closely monitored for successful treatment.

Comparison of quality of life between 2-year and 3-or-more-year administration of leuprorelin acetate every-3-months depot in combination with tamoxifen as adjuvant endocrine treatment in premenopausal patients with endocrine-responsive breast cancer: a randomized controlled trial

Background

We conducted an open-label, randomized controlled trial evaluating the appropriate treatment duration of leuprorelin acetate 3-month depot, TAP-144-SR (3M), administered postsurgically every 3 months for 2 years versus 3 or more (up to 5) years, in combination with tamoxifen, for 5 years in premenopausal endocrine-responsive breast cancer patients and reported similar survival benefit in the two treatment groups. We hereby present patient-reported quality of life (QOL) data obtained from this trial.

Methods

Three self-administered QOL questionnaires (QOL-ACD, QOL-ACD-B, FACT-ES subscale) were used, and the difference in QOL score changes between the two groups was analyzed using a mixed-effects model for repeated measures.

Results

Eligible patients (N = 222) were randomly assigned to a 2-year (2YG, N = 112) or 3-or-more-year treatment group (3YG, N = 110). The time courses of the three QOL scores during the trial period were similar in the two groups. The mean changes in the QOL scores from week 96 were largely stable through week 240 in the 3YG, but showed significantly greater improvement in the score changes from week 96 in the 2YG than the 3YG. Symptoms associated with menopause such as hot flashes and sweating contributed to these results. Menstruation recovery was associated with significantly greater improvement of these symptoms in the 2YG than the 3YG.

Conclusions

Patient-reported menopause-associated symptoms and QOL improved after discontinuation of the LH-RH agonist administration and menstruation recovery. QOL information should be a consideration in long-term treatment.

Provider perspectives on patient-provider communication for adjuvant endocrine therapy symptom management

PURPOSE

Providers' communication skills play a key role in encouraging breast cancer survivors to report symptoms and adhere to long-term treatments such as adjuvant endocrine therapy (AET). The purpose of this study was to examine provider perspectives on patient-provider communication regarding AET symptom management and to explore whether provider perspectives vary across the multi-disciplinary team of providers involved in survivorship care.

METHODS

We conducted three one-hour focus groups with a multi-disciplinary group of health care providers including oncology specialists, primary care physicians, and non-physician providers experienced in caring for breast cancer survivors undergoing AET (n = 13). Themes were organized using Epstein and Street's (2007) Framework for Patient-Centered Communication in Cancer Care.

RESULTS

The findings of this study suggest providers' communication behaviors including managing survivors' uncertainty, responding to survivors' emotions, exchanging information, and enabling self-management influences the quality of patient-provider communication about AET symptoms. Additionally, lack of systematic symptom assessment tools for AET requires providers to use discretion in determining which symptoms to discuss with survivors resulting in approaches that vary based on providers' discipline.

CONCLUSION

There may be AET-specific provider communication skills and behaviors that promote effective patient-provider communication but additional research is needed to identify practices and policies that encourage these skills and behaviors among the many providers involved in survivorship care. Efforts are also needed to coordinate AET symptom assessment across providers, clarify providers' roles in symptom assessment, and determine best practices for AET symptom communication.

Health-related quality of life in women with breast cancer: a literature-based review of psychometric properties of breast cancer-specific measures

BACKGROUND

Breast cancer is one of the most common cancers in women in the world. Health-related quality of life (HRQL) at treatment endpoint in cancer clinical trials is widely considered to be increasingly important. The aim of this review was to provide a literature-based assessment of the validity, reliability and responsiveness of breast cancer-specific HRQL instruments in women breast cancer patients.

MATERIALS AND METHODS

The databases consulted were Medline, PubMed, and Embase. The inclusion criteria required studies to: (1) involve use of HRQL measures; (2) cover women with breast cancer under standard treatment (surgery, radiation therapy, chemotherapy, hormone therapy, and targeted therapy); (3) involve the validity, reliability, or responsiveness of HRQL; (4) deal with validation of breast cancer-specific HRQL instruments.

RESULTS

A total of 16 studies were identified through the literature search that met the 4 inclusion criteria. Some seven instruments were assessed among these 16 studies: EORTC QLQ-BR23, FACT-B, FACT-ES, HFRDIS, LSQ- 32, QLICP-BR, and SLDS-BC. EORTC QLQ-BR23, FACT-B, LSQ-32, QLICP-BR, and SLDS-BC are more general breast cancer-specific HRQL instruments. FACT-EB is the endocrine subscale combined with FACT-B in order to measure the side effects and putative benefits of hormonal treatment administered in breast cancer patients. HFRDIS is the HRQL measure focusing on hot flash concerns.

CONCLUSIONS

This paper provides an overall understanding on the currently available breast cancer-specific HRQL instruments in women breast cancer patients.

Symptoms of hormonal therapy and social support: Is there a connection? Comparison of symptom severity, symptom interference and social support among breast cancer patients receiving and not receiving adjuvant hormonal treatment

BACKGROUND

Although there has been a significant reduction in mortality, breast cancer is the most frequent cancer among women worldwide. This decline in mortality has created a significant survivor population that must manage the post curative treatment phase, in order to have an increased quality of life and well-being. This study examined the relationship between symptom interference and severity with the perception of social support in the lives of women receiving or not receiving, hormonal therapy after initial treatment.

METHODS AND SAMPLE

Participants completed symptom severity and interference questionnaires, (MDASI and BCPT), a social support survey (MSPSS) and demographic and comorbidity questionnaires.

RESULTS

Of the 210 women participants, higher symptom severity correlated with unemployment, living alone or being religious. Participants who were currently taking hormonal treatment (n = 84), reported a significant negative correlation between symptom severity, measured by MDASI, and social support (p = 0.006). Consequently, as symptom severity increased, perceived social support decreased. In the BCPT assessment, decreased cognitive functioning (p < 0.05), pain (p < 0.05), bladder dysfunction (p = 0.001), and reduced self-image (p < 0.01) were significantly negatively correlated with social support for those participants currently taking hormonal therapy. Participants who had not previously received hormonal therapy (n = 64), cognitive dysfunction and bladder dysfunction were negatively correlated with social support. Women with preexisting heart or pulmonary dysfunction and arthritis reported statistically significant higher levels of symptom severity and decreased perceptions of social support.

CONCLUSIONS

Identifying socio-demographic variables and comorbidities that affect hormonal therapy symptom burden is essential for offering adequate support for breast cancer survivors.

Immunoexpression of aromatase cytochrome P450 and 17β-hydroxysteroid dehydrogenase in women's ovaries after menopause

Background

Menopause results in a lack of regular menstrual cycles, leading to the reduction of estrogen production. On the other hand, ovarian androgen synthesis is still present at reduced levels and requires expression of several steroidogenic enzymes.

Methods

This study was performed on 104 postmenopausal women hospitalized due to uterine leiomyomas, endometriosis, and/or a prolapsed uterus. Patients were divided into three groups depending on the time from menopause. Group A patients experienced menopause 1–5 years before enrollment in the study (42 women). Group B included women who had their last menstruation 5–10 years before the study (40 women). Group C consisted of 22 women who were more than 10 years past menopause. Hysterectomy or removal of the uterine corpus with adnexa was performed during laparotomy. We evaluated the expression of aromatase cytochrome P450 (CYP 19) and 17β-hydroxysteroid dehydrogenase (17β HSD) by employing immunohistochemistry.

Results

Activity of 17β-HSD and CYP19 was demonstrated in the cytoplasm of stromal cells of postmenopausal ovaries, epithelium cells coating the ovaries, vascular endothelial cells, and epithelial inclusion cysts. However, overall expression of both 17β-HSD and CYP 19 decreased with time after menopause.

Conclusion

Demonstration of the activity of the key enzymes of ovarian steroidogenesis, CYP 19 and 17β-HSD, confirms steroidogenic activity in the ovaries of postmenopausal women. Nevertheless, ovarian steroidogenic activity decreases with time, and its significant decrease occurs 10 years after menopause.

Potential adverse impact of ovariectomy on physical and psychological function of younger women with breast cancer

OBJECTIVE

The aims of this study were to investigate menopausal symptoms, psychological function, sexual function, and body image as experienced by younger Australian women with breast cancer and to examine the effect of different breast cancer treatments on these parameters.

METHODS

A questionnaire study was completed by 114 women aged 40 to 51 years with nonmetastatic breast cancer. Women were recruited from outpatient clinics or the community. Descriptive statistics and univariate analyses were conducted using Student's t tests and nonparametric tests, where appropriate.

RESULTS

The mean age of breast cancer women was 47.2 years. The most common symptoms reported were as follows: feeling tired/lacking energy (88%), loss of libido (87%), and hot flushes (83%). Anxiety and depression scores were high (18.00 ± 2.53 and 15.56 ± 1.56, respectively). Psychological symptoms (13.25 ± 6.91 vs 8.52 ± 5.61; P = 0.009), vasomotor symptoms (4.00 ± 1.90 vs 2.74 ± 1.91; P = 0.035), and sexual dysfunction scores (2.25 ± 0.86 vs 1.58 ± 1.01; P = 0.031) were significantly higher in breast cancer women with ovariectomy compared with breast cancer women without ovariectomy. Sexual feelings for partners (P = 0.02) and sexual frequency (P = 0.01) were less in women with ovariectomy compared with women without ovariectomy. Feelings of physical health, attractiveness, overall appearance, and satisfaction were significantly lower in ovariectomized women (P < 0.05).

CONCLUSION

Menopausal symptoms, anxiety, and depression are common in younger breast cancer women. Importantly, ovariectomy in breast cancer women is associated with significant adverse menopausal physical symptoms, psychological impact, and sexual function. Both healthcare providers and women with breast cancer need to be aware of the impact of ovariectomy in younger women with breast cancer, and further education resources and support for these women should be targeted.

Relationship between severity of symptoms and quality of life in patients with breast cancer receiving adjuvant hormonal therapy

PURPOSE/OBJECTIVES

To describe symptoms and quality of life (QOL) of patients with breast cancer receiving adjuvant hormonal therapy and to examine possible relationships between the two measurements.

DESIGN

Descriptive, correlational study.

SETTING

An oncology clinic within a tertiary medical center in Israel.

SAMPLE

Convenience sample of 132 patients diagnosed with primary breast cancer receiving hormonal therapy.

METHODS

Data collection was conducted through the self-administered Functional Assessment of Cancer Therapy endocrine subscale and a sociodemographic and medical information questionnaire.

MAIN RESEARCH VARIABLES

QOL and symptoms of hormonal therapy.

FINDINGS

Ten symptoms were categorized by more than 20% of the participants as "very much" or "quite a bit." The mean QOL score for the participants was higher than that for a healthy population, although a correlation was found between fewer symptoms and higher QOL. Mood swings and irritability were the symptoms most strongly associated with a decrease in QOL. Patients who exercised had higher QOL scores.

CONCLUSIONS

Adjuvant hormonal therapy did not affect the QOL of a majority of patients with primary breast cancer. A reduced number of symptoms indicated a higher QOL. Mood swings and irritability have a negative impact on QOL.

IMPLICATIONS FOR NURSING

A need exists to design a program to follow up on hormonal symptoms and the QOL of patients receiving hormonal therapy and to encourage patients to engage in regular exercise.

Musculoskeletal adverse events associated with adjuvant aromatase inhibitors

Musculoskeletal symptoms including arthralgia and myalgia occur frequently in aging women, particularly during the transition to menopause, when plasma estrogens precipitously decline. In postmenopausal women (PMW) with breast cancer, third-generation aromatase inhibitors (AIs) as adjuvant hormonal therapy have proven to be more effective, and to have a more predictable side effect profile, than tamoxifen. However, AIs further reduce plasma estrogens in PMW, exacerbating musculoskeletal symptoms. Clinical trial data have shown significantly higher incidences of arthralgia and myalgia with AIs compared with women on tamoxifen or placebo. Symptoms may be severe enough to significantly affect quality of life; musculoskeletal symptoms are a frequent reason for discontinuing therapy. In many cases, symptoms can be effectively managed with oral analgesics or other strategies. Early recognition and effective management of musculoskeletal symptoms can help maximize treatment compliance, enabling patients to derive optimal benefit from therapy in terms of preventing recurrence.

Adjuvant aromatase inhibitor therapy: outcomes and safety

Adjuvant therapy with the third-generation aromatase inhibitors (AIs) anastrozole, letrozole, and exemestane has largely replaced the use of tamoxifen (TAM) as standard adjuvant endocrine treatment for postmenopausal women with hormone-sensitive early breast cancer. Treatment strategies investigated in large, randomized, well-controlled clinical studies include the use of an AI as an upfront replacement for TAM, as an alternative to continued treatment with TAM, and in the extended adjuvant setting after at least 5 years of TAM. The efficacy of AIs over TAM has been demonstrated, particularly in terms of improving disease-free survival (DFS), and reductions in early distant metastasis with AIs may ultimately translate into improved overall survival. As AI therapy offers prolonged DFS, safety is an important concern over the long term. The AIs are better tolerated than TAM in terms of troublesome gynecologic adverse events such as vaginal bleeding and discharge, as well as life-threatening complications such as venous thromboembolic events and endometrial cancer. On the other hand, AI therapy has been associated with losses in bone density and a potential effect on lipids and cardiovascular risk. In trials comparing AIs with TAM, only limited conclusions can be made because of the putative cardioprotective, lipid-lowering, and bone-sparing effects of TAM. Studies comparing AIs with placebo, and/or in healthy women, may be more useful in understanding the long-term safety of adjuvant AI therapy. Results of ongoing safety analyses within some of the large AI trials should provide further insight into the long-term tolerability of AI therapy in the adjuvant setting.

Clinical usefulness of high-dose toremifene in patients relapsed on treatment with an aromatase inhibitor

BACKGROUND

Aromatase inhibitors (AIs) have been employed as adjuvant therapy or as treatment for recurrent cases. However, when AI treatment fails, it is unclear which endocrine therapy is the most appropriate to introduce at this point and how effective it will be. In this study, we investigated the efficacy and safety of toremifene (TOR, Fareston(®)), a selective estrogen receptor modulator (SERM).

METHODS

Patients with recurrent or advanced breast cancer who had measurable or evaluable lesions, and were diagnosed as having progressive disease during AI treatment and subsequently given TOR at 120 mg/day (TOR120) as endocrine therapy were selected and analyzed retrospectively in relation to their medical history.

RESULTS

Of a total of 83 cases examined, 80 were evaluable. The objective response rate (ORR) was 15.0% (12/80), the clinical benefit (CB) rate was 45.0% (36/80), and median time to failure (TTF) was 7.8 months. TOR120 was also effective in the progressive disease cases relapsed on AI treatment. When TOR120 was used, as a first-, second- or third-line treatment, the CB rate was 57% (32/56); this fell to 17% (4/24) when TOR120 was used as a fourth-line or later treatment. There was no response in the five estrogen receptor (ER)-negative cases, compared with an ORR of 15% (10/67) in ER-positive cases. In cases with a human epidermal growth factor receptor 2 (HER2) score of 0, 1+, and 2+, the ORR was 11% (7/61), while there was no response in the five cases with scores of 3+. TOR120 was effective in cases previously treated with tamoxifen (TAM), with an ORR and CB rate of 12 and 29%, respectively. The last AI used was anastrozole in 30 cases and examestane in 46; the response rates to TOR120 were similar in both groups. With regard to adverse effects, hot flushes and/or night sweating was observed in 10 and 12 cases, respectively, but all of them were categorized as grade 1, and the treatment was rated excellent in acceptability.

CONCLUSIONS

TOR120 was rated excellent in acceptability, and high efficacy was observed when it was used up to third-line treatment for AI-failure cases, although this study may show some selection bias because of the retrospective study. In addition, it was also considered effective for TAM-failure cases.

Recommendations for research priorities in breast cancer by the Coalition of Cancer Cooperative Groups Scientific Leadership Council: systemic therapy and therapeutic individualization

Over 9,000 women with breast cancer are enrolled annually on clinical trials sponsored by the National Cancer Institute (NCI), accounting for about one-third of all patients enrolled on NCI-sponsored trials. Thousands are also enrolled on pharmaceutical-sponsored studies. Although breast cancer mortality rates have recently declined for the first time in part due to systemic therapeutic advances, coordinated efforts will be necessary to maintain this trend. The Coalition of Cancer Cooperative Groups convened the Scientific Leadership Council in breast cancer (BC), an expert panel, to identify priorities for future research and current trials with greatest practice-changing potential. Panelists formed a consensus on research priorities for chemoprevention, development and application of molecular markers for predicting therapeutic benefit and toxicity, intermediate markers predictive of therapeutic effect, pathogenesis-based therapeutic approaches, utilization of adaptive designs requiring fewer patients to achieve objectives, special and minority populations, and effects of BC and treatment on patients and families. Panelists identified 13 ongoing studies as High Priority and identified gaps in the current trial portfolio. We propose priorities for current and future clinical breast cancer research evaluating systemic therapies that may serve to improve the efficiency of clinical trials, identify individuals most likely to derive therapeutic benefit, and prioritize therapeutic strategies.

Improving compliance and persistence to adjuvant tamoxifen and aromatase inhibitor therapy

Better compliance and persistence with therapy are associated with improved patient outcomes. As more and more patients survive breast cancer, compliance with adjuvant therapy becomes increasingly important. In clinical trials, compliance with adjuvant endocrine therapy among women with breast cancer is usually high. Retrospective analyses of databases and medical records from clinical practice, insurance databases of prescription refills, and survey data show a significant decrease in persistence after 12 months of therapy. With ongoing therapy, a further decline in persistence of up to 50% has been reported. A consistent methodology is needed to measure patient behavior and identify patients who are not adhering to therapy. Promising strategies for enhancing adherence to treatment in clinical practice include improving access to health care, increasing patient satisfaction, managing side effects, patient education, and better communication between the patient and health care provider. Positive relationships between patients and their health care providers, and frequent monitoring and feedback, may be most effective. While the lack of conformity across studies in measuring makes cross-study comparisons difficult, this review evaluates the available data regarding compliance and persistence with adjuvant endocrine therapies for breast cancer (tamoxifen and aromatase inhibitors) and presents strategies for improving adherence.

The influence of endocrine treatments for breast cancer on health-related quality of life

Many hormonal modalities are available for breast cancer treatment, such as selective oestrogen receptor modulators (SERMs), aromatase inhibitors, progestins and luteinising hormone-releasing hormone (LHRH) agonists. The long-term impact of these endocrine manipulations is an issue, because the duration of adjuvant treatment is still increasing, as is the number of breast cancer survivors. Premature menopause is induced at a young age, and may often be permanent after chemotherapy. The purpose of this review is to provide a literature-based overview of the side effects of endocrine treatment in pre- and postmenopausal breast cancer patients and the influence on HRQoL, especially on sexual functioning. The collection of health-related quality of life (HRQoL) data can result in better treatment recommendations during endocrine therapy.

METHODS

This review was limited to prospective randomised studies in English literature from between 1977 and 2007 and provides an overview of the effects on HRQoL and sexuality of various hormonal treatment in pre- and postmenopausal breast cancer patients, both in the adjuvant and palliative setting. Relevant clinical studies were identified by using the Medline database.

RESULTS

HRQoL mostly is severely influenced by chemotherapy and part of these symptoms may be lasting, especially when associated with the induction of premature menopause. Similar symptoms may be encountered during ovarian suppression therapy by LHRH analogs, but they will usually prove to be reversible. The varying side effect profiles of tamoxifen and aromatase inhibitors did not lead to significant difference in overall HRQoL. HRQoL during progestins and the SERM fulvestrant has been compared to this during aromatase inhibitors, and a large number of studies on HRQoL during endocrine therapy will be discussed.

Changes in quality of life among breast cancer patients three years post-diagnosis

OBJECTIVES

To evaluate changes in quality of life (QOL) and identify medical and socio-demographic predictors of QOL among breast cancer survivors 3 years after diagnosis.

METHODS

Between April 2002 and March 2004 2,232 women with breast cancer were recruited into the Shanghai Breast Cancer Survival Study, a population-based cohort study, approximately 6 months after cancer diagnosis. QOL was evaluated at 6 and 36 months post-diagnosis using the General Quality of Life Inventory. Multiple linear regression models were used to evaluate changes in QOL and their associations with socio-demographic and medical factors.

RESULTS

In general, breast cancer patients showed significant improvement over time in the physical, psychological, and social well-being domains, as well as overall QOL. However, QOL scores in several facets did not improve or even deteriorated, including increased negative feelings, reduced social support and interpersonal relationships, and worsened financial situation and living environment. Age at diagnosis was inversely associated with QOL changes in physical and psychological well-being and overall QOL scores. Compared with those who were disease-free, patients with a recurrence of disease had significantly poorer QOL scores across all well-being domains and almost all facets. Patients who received radiotherapy experienced significant improvements in physical and social well-being and overall QOL. Mixed ER/PR status was associated with improved scores in physical and psychological well-being and overall QOL. Education, body mass index, Charlson comorbidity score, TNM stage, type of surgery, chemotherapy, and immunotherapy were only associated with changes in certain well-being domains and/or facets, but not overall QOL. Tamoxifen use was not associated with changes in QOL outcomes.

CONCLUSIONS

Our study provides valuable information for developing strategies/interventions for improving the QOL of breast cancer patients.

Safely promoting breast-conserving surgery and preventing early relapses with an aromatase inhibitor

Neoadjuvant therapy improves patient outcomes substantially by increasing the rate of breast-conserving surgery. Following primary surgery, women with hormone-sensitive early breast cancer remain at risk for loco-regional and systemic recurrence. The most common relapse event, distant metastases, is associated with the poorest outcomes. As a neoadjuvant therapy, anastrozole, letrozole, and exemestane have been investigated in phase 3 studies and have shown efficacy in this setting. All three aromatase inhibitors (AIs) significantly improved the rate of breast-conserving surgery. As initial adjuvant therapy, the third-generation AIs anastrozole and letrozole more effectively reduce recurrence risk compared with tamoxifen following surgery, especially in the first 2 years, when the risk is greatest. Tamoxifen, once the standard initial therapy, is associated with improved disease-free survival but may be more effective at reducing loco-regional recurrence than distant metastases. Initial adjuvant letrozole therapy has also shown a pronounced reduction in the risk of distant metastases early on in the course of therapy. If AIs are not used upfront, sequential use of exemestane or anastrozole following tamoxifen provides greater protection against relapse than continuing on tamoxifen. Side effects associated with estrogen deprivation of AIs are less serious than those of tamoxifen and are easily managed. Various molecular markers are under study as surrogates to predict response to neoadjuvant therapy, which may in turn predict responsiveness to adjuvant therapy. Surgeons treating breast cancer patients and prescribing endocrine therapy should be aware of all treatment strategies, including neoadjuvant and adjuvant hormonal therapy, and inform their patients of the benefits and the potential side effects. Early and long-term-risk reduction with AI treatment should be discussed with patients, as should the management of common AI-associated adverse events.

The patient experience

The impact of improved treatments for the management of hormone-sensitive breast cancer extends beyond clinical responses. Thanks to appropriate literature and access to the internet, patient awareness of treatment options has grown and patients are now, in many cases, able to engage their oncologists in informed conversations regarding treatment and what to expect in terms of efficacy and safety. Indeed, patients realize that although there is no cure for metastatic disease, treatment can greatly reduce the risk of progression and in the adjuvant setting, where treatment is administered with a curative intent, current treatment options reduce the risk of relapse. The approval of letrozole throughout the breast cancer continuum has provided patients with many reassuring options. The improvement in outcome with letrozole is achieved without a detrimental effect on overall quality of life. Adverse events such as hot flushes, arthralgia, vaginal dryness, and potential osteoporosis are most significant from the patient's perspective, and it is important that caregivers pay attention to patients experiencing these events, as they can impact compliance unless effectively explained and managed. The major benefits of letrozole are to improve prospects for long-term survivorship in the adjuvant setting and to delay progression and the need for chemotherapy in the metastatic setting.

Recognition and management of treatment-related side effects for breast cancer patients receiving adjuvant endocrine therapy

In postmenopausal women with hormone receptor-positive early-stage breast cancer, the use of aromatase inhibitors (AIs) to suppress estrogen is associated with improved clinical outcomes compared with tamoxifen therapy. Women receiving such endocrine therapy may experience treatment-related side effects that negatively affect health-related quality of life (QoL) and adherence to therapy. In published clinical trials and in clinical practice, adverse events (AEs) constitute the main reason for nonadherence to endocrine treatment. Serious AEs are sometimes resolved by switching to a different agent, whereas other side effects can often be managed to allow patients to remain on therapy without sacrificing QoL. Across all adjuvant endocrine trials, regardless of the treatment received, vasomotor symptoms such as hot flashes are the most common side effects. Other frequently reported side effects, such as vaginal discharge, vaginal dryness, dyspareunia, and arthralgia, vary in prevalence between tamoxifen and AIs. Here we provide an overview of reported AEs of adjuvant endocrine therapy, focusing on those that are amenable to pharmacologic or nonpharmacologic management without treatment discontinuation. Also highlighted are specific management strategies that may improve patient QoL and thereby optimize adherence to therapy, which in turn might improve patient outcomes.

Application of aromatase inhibitors in endocrine responsive breast cancers

Aromatase (estrogen synthetase) inhibitors (AIs) have been incorporated into adjuvant treatment of early-stage breast cancer in post-menopausal women and their role in pre-menopausal is being investigated. Several questions regarding AIs remain unanswered: optimal sequence with tamoxifen; optimal duration and the best agent in the class. The benefits of extending therapy beyond 5 years has been established by the MA17 trial and many follow-on trials are exploring prolonged therapy. Several strategies to overcome de novo and acquired resistance are being explored. Improving on the "total estrogen blockade" by adding fulvestrant is one example; blocking collaborating cell signaling pathways is another. Candidate targets for this include the erbB2, IGF1R and the mTOR cell survival pathway. Identification of both host (pharmacogenomic) and tumor (genomic) signatures as prognostic and predictive factors will help to select patients for appropriate therapies in the future and reduce the number needed to treat to benefit a few.

Quality of life issues in relation to the aromatase inhibitor

Maturing data from aromatase inhibitor (AI) trials reveal benefits to many women who might otherwise have relapsed and died from breast cancer. In advanced disease the case for the use of AIs is well established but in the adjuvant and chemoprevention settings some worries about long-term safety remain. Large numbers of women may already be cured by surgery, chemotherapy and radiotherapy making further adjuvant treatment unnecessary. In chemoprevention the ratio of risks to putative benefits remains very unclear, so results from major trials are needed to clarify. When making decisions about treatment women need information about: the available options, likely therapeutic gains, predicted side-effects and convenience of treatment. Adherence is then dependent on the actual burden experienced and impact on QoL. Healthcare professionals often underestimate non-life-threatening but QoL-threatening side-effects, making treatments appear more favorable and acceptable during discussion about therapeutic options. It was hoped that AIs would enhance efficacy without producing unacceptable side-effects that diminish QoL and reduce adherence. Recently published results from the QoL sub-protocols of ATAC, IES and MA-17, looking at anastrozole, exemestane and letrozole, respectively, provide useful indications about the QoL associated with AIs. More information gained from longer-term patient follow-up and preference studies are needed to help clinicians making treatment recommendations and to assist development of ameliorative interventions needed to accompany the most efficacious therapies.

Breast Cancer Adjuvant Endocrine Therapy

Adjuvant endocrine therapy with the selective estrogen receptor modulator, tamoxifen, has significantly improved mortality from early-stage breast cancer for both pre- and postmenopausal women with hormone receptor-positive breast cancer. Recent large clinical trials have demonstrated a clear and consistent benefit for the incorporation of aromatase inhibitor (AI) therapy within adjuvant endocrine regimens for postmenopausal women. The AIs, which are associated with myalgias, arthralgias, and a reduction in bone mineral density, are generally well tolerated and have lower risks of endometrial carcinoma and thromboembolic events than tamoxifen. Data are awaited from ongoing trials to better define the optimal sequencing strategy, duration, and AI agent. Attempts to further optimize adjuvant endocrine therapy by identifying predictive biomarkers of response, as well as by developing strategies to overcome endocrine resistance are underway. In premenopausal women AI monotherapy is currently contraindicated and tamoxifen remains the standard of care. The role of ovarian function suppression in addition to tamoxifen or combined with AI therapy is being explored. The hope is that continued advances in endocrine therapy will translate into improved survival among both pre- and postmenopausal women with receptor-positive breast cancer.

The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women

OBJECTIVE

To create an evidence-based position statement published by The North American Menopause Society (NAMS) on the role of local vaginal estrogen therapy (ET) for the treatment of vaginal atrophy in postmenopausal women.

DESIGN

NAMS followed the general principles established for evidence-based guidelines to create this document. A panel of clinicians and researchers acknowledged to be experts in the field of genitourinary disease was enlisted to review, synthesize, and interpret the current evidence on vaginal ET for vaginal atrophy, develop conclusions, and make recommendations. Their advice was used to assist the NAMS Board of Trustees in publishing this position statement.

RESULTS

Randomized controlled trials, albeit limited, have shown that low-dose, local vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy. All of the low-dose vaginal estrogen products approved in the United States for treatment of vaginal atrophy are equally effective at the doses recommended in labeling.

CONCLUSIONS

The choice of therapy should be guided by clinical experience and patient preference. Progestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy. Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal ET. Vaginal ET should be continued for women as long as distressful symptoms remain. For women treated for non-hormone-dependent cancer, management of vaginal atrophy is similar to that for women without a cancer history. For women with a history of hormone-dependent cancer, management recommendations are dependent upon each woman's preference in consultation with her oncologist.

Impact of newly diagnosed breast cancer on quality of life among Chinese women

BACKGROUND

Being diagnosed with breast cancer is a very stressful event that has a profound impact on multiple aspects of a patient's daily life. Little is known about the quality of life (QOL) of Chinese women with newly diagnosed breast cancer.

METHODS

The authors evaluated QOL in 2,236 Chinese women with newly diagnosed breast cancer who were recruited into the Shanghai Breast Cancer Survival Study between April 1, 2002 and March 31, 2004. Patients' QOL was assessed after cancer diagnosis (median time 6.4 months; range 3.6-11.1 months) by using the General Quality of Life Inventory. Multiple linear regression models were used to analyze the associations of QOL outcomes with medical and socio-demographic factors.

RESULTS

Patients showed significantly worse overall QOL and perceived health status than healthy women, reflected mainly by lower QOL scores in physical and psychological well-being domains. Completion of radiotherapy, ever use of tamoxifen, being underweight, having an increased number of chronic diseases, and low household income were significantly associated with lower overall QOL scores after adjusting for other factors. Age at diagnosis was inversely associated with physical well-being, positively associated with material well-being, and had minimal influence on overall QOL. Stage of disease, chemotherapy, and education were only associated with certain domains, but had no influence on overall QOL. Estrogen receptor/progesterone receptor status and type of surgery or immunotherapy did not appear to be associated with QOL.

CONCLUSIONS

The findings of the present study provide important information on QOL and their correlates among Chinese women with newly diagnosed breast cancer and are helpful in developing treatment strategies accordingly.