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Abstract
Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.
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Lee CI, Fox P, Balakrishnar B, Balleine RL, Gao B, Provan P, Coulter S, Liddle C, Hui R, Wong M, Gurney H, Wilcken N. Tamoxifen-induced severe hot flashes and endoxifen levels: is dose reduction a safe and effective strategy? Breast 2019; 46:52-57. [PMID: 31082762 DOI: 10.1016/j.breast.2019.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/17/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES Severe hot flash (HF) toxicity due to tamoxifen can compromise compliance. We previously found that HFs did not correlate with endoxifen level or CYP2D6 genotype. In this study, we reduced tamoxifen dose in patients with severe HFs to determine whether HFs were ameliorated whilst maintaining a purported therapeutic endoxifen level of >15 nM. MATERIALS AND METHODS Twenty patients with severe HFs on 20 mg TAM had CYP2D6genotype, trough level tamoxifen and metabolites measured with Loprinzi HF scores (HFS) derived before and after DR of tamoxifen to 10 mg. Other data collected included demographics, smoking, alcohol, menstrual and breast cancer history, previous chemotherapies, concurrent medications, BMI and other tamoxifen toxicities. RESULTS At the 20 mg tamoxifen dose, endoxifen levels were 25.6, 0-91.9 nM (median, range) with HFS 131, 22-1482 (median, range). Upon DR to 10 mg, median endoxifen level fell to 14.1, 0.6-71.9 nM (difference in means p = 0.11, two-tailed T test) with HFS 47, 5-864 (difference in means p = 0.24, two-tailed T test). Despite lacking statistical significance, 85% of patients reported subjective improvement of HFs with DR. After DR, the proportion of patients with endoxifen level <15 nM increased from 20% to 50%. HFS did not correlate with any other parameter. CONCLUSION DR of tamoxifen from 20 mg to 10 mg daily resulted in halving of endoxifen levels and subjective improvement of HF. While half the dose-reduced patients were below a potential therapeutic level of endoxifen, other recent studies suggest that low endoxifen levels may not indicate reduced effectiveness of tamoxifen.
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Affiliation(s)
- Clara I Lee
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, Australia; Faculty of Medicine, University of New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.
| | - Peter Fox
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia
| | | | - Rosemary L Balleine
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Westmead Institute for Medical Research, Westmead, Australia
| | - Bo Gao
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia
| | - Pamela Provan
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Sally Coulter
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia; Westmead Institute for Medical Research, Westmead, Australia
| | - Christopher Liddle
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia; Westmead Institute for Medical Research, Westmead, Australia
| | - Rina Hui
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Mark Wong
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Howard Gurney
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia; Macquarie University, Australia
| | - Nicholas Wilcken
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
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Chuba PJ, Stefani WA, Dul C, Szpunar S, Falk J, Wagner R, Edhayan E, Rabbani A, Browne CH, Aref A. Radiation and depression associated with complications of tissue expander reconstruction. Breast Cancer Res Treat 2017; 164:641-647. [DOI: 10.1007/s10549-017-4277-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
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Adverse effects of non-hormonal pharmacological interventions in breast cancer survivors, suffering from hot flashes: A systematic review and meta-analysis. Breast Cancer Res Treat 2016; 160:223-236. [PMID: 27709351 PMCID: PMC5065610 DOI: 10.1007/s10549-016-4002-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/23/2016] [Indexed: 11/03/2022]
Abstract
PURPOSE To access frequency and severity of adverse effects (AE) of non-hormonal drugs (NHD) for hot flashes in breast cancer survivors compared to controls and analyze adverse-effect risk by reviewing published randomized trials. METHODS Cochrane Central Register for Controlled Trials, Embase, Medline, PsycINFO and PubMed databases were searched. Trials were included where participants were survivors of breast cancer suffering from hot flashes, treatment included self-administered venlafaxine, gabapentin or clonidine, and AE were reported. AE frequency and severity were graded. A meta-analysis of ten trials with sub-group analyses was conducted. RESULTS Forty-nine studies were identified, and 12 were included. A total of 1467 participants experienced 772 adverse effects, 81 % (n = 627) in the treatment group and 19 % (n = 145) in the control group. Sixty-seven percent of AE was graded as mild and 33 % as moderate. The frequency of AE for NHD was overall significant compared to placebo. Sub-group analysis indicated that AE frequency and severity increased at higher doses of venlafaxine and gabapentin compared to placebo. CONCLUSION The odds for experiencing AE was significantly higher in patients randomized to high-dose NHD than those randomized to controls, including placebo, low-dose medication and acupuncture. These therapies should be considered as a potential treatment alternative.
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Abstract
INTRODUCTION Vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) are recognized as the most frequent and bothersome symptoms associated with menopause. There are different treatments for both groups of symptoms, being necessary to individualize them. AREAS COVERED There are different therapies for VMS including hormonal treatments with estrogen, with and without progestins; the new alternative, tissue-selective estrogen complex (TSEC), tibolone, phytoestrogens and only progestins. Evidence also shows efficacy with selective serotonin reuptake inhibitors. Other nonhormonal alternatives exist as second-line treatments, all with not conclusive results. The GSM can be treated with nonhormonal treatments such as vaginal lubricants and moisturizers, other alternatives as vaginal laser needs to have more evidence. On the other hand, there is the possibility to use the hormonal treatments with systemic or local estrogen, which are the most effective treatment, the TSEC and the newest selective estrogen receptor modulator (SERM), ospemifene. Therapies with testosterone and dehydroepiandrosterone (DHEA) are still under study. The GSM can be treated with nonhormonal treatments such as vaginal lubricants and moisturizers, and other alternatives as vaginal laser need to have more evidence. On the other hand, there is the possibility to use the hormonal treatments with systemic or local estrogen, which are the most effective treatment, the TSEC and the newest SERM, ospemifene. Therapies with testosterone and DHEA are still under study. EXPERT OPINION The increasing numbers of therapies for menopausal symptoms open up new options, but we must individualize treatments. New possibilities arise in patients who did not have them and which can improve compliance and is also important to design strategies using combined or sequential treatments.
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Affiliation(s)
- Santiago Palacios
- a Institute Palacios of Women's Health , Madrid, Spain +34 9 15 78 05 17 ; +34 9 14 31 99 51 ;
| | - Andrea Mejias
- a Institute Palacios of Women's Health , Madrid, Spain +34 9 15 78 05 17 ; +34 9 14 31 99 51 ;
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Abstract
Aromatase is an enzyme that converts testosterones to estrogens. Inhibition of this enzyme has been shown to have several clinical utilities in breast cancer. Currently, there are three aromatase inhibitors (AIs) in clinical use, namely anastrozole, letrozole, and exemestane. AIs have been used in various clinical settings for breast cancer, ranging from chemoprevention in breast cancer to treating breast cancer in both early stage in the adjuvant setting and metastatic disease. This article reviews mechanism of action, AI classification, and clinical utilities of AIs in various clinical settings in the context of breast cancer.
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Affiliation(s)
- Saranya Chumsri
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
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Abstract
Depression, anxiety, delirium, and other psychiatric symptoms are highly prevalent in the cancer setting, and pharmacological intervention is an important component in the overall psychosocial care of the patient. Psychopharmacology is also used as a primary or adjuvant treatment for the management of cancer-related symptoms stemming from the disease itself and/or its treatment, including sleep disturbance, loss of appetite, neuropathic pain, nausea, fatigue, and hot flashes. Psychiatrists, oncologists, and palliative care physicians working as members of a multidisciplinary team have the opportunity to target multiple symptoms that negatively affect a patient's quality of life with the strategic use of psychotropic medications when deemed appropriate. This article aims to review the indications for use of antidepressants, psychostimulants, anxiolytics, antipsychotics, and mood stabilizers in oncology. An updated review of the relevant literature is discussed and referenced in each section.
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Affiliation(s)
- Seema M Thekdi
- The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Unit 1454, Houston, TX, 77230-1402, USA,
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Kaplan M, Mahon S. Hot Flash Management: Update of the Evidence for Patients With Cancer. Clin J Oncol Nurs 2014; 18 Suppl:59-67. [DOI: 10.1188/14.cjon.s3.59-67] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ruan X, Mueck A. Systemic progesterone therapy—Oral, vaginal, injections and even transdermal? Maturitas 2014; 79:248-55. [DOI: 10.1016/j.maturitas.2014.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 07/09/2014] [Indexed: 10/25/2022]
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Abstract
CLINICAL SCENARIO A 51-year-old postmenopausal third-grade teacher requests help for her hot flashes. She finds them especially troubling as she stands in front of her class and starts sweating. Although one student offers her tissues, others make fun of her--disrupting the class. Her sleep is interrupted several times a night. She refuses to use any form of estrogen because her mother died of breast cancer at the age of 60 years. Perhaps alternative therapies can help her.
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Barba M, Pizzuti L, Sergi D, Maugeri-Saccà M, Vincenzoni C, Conti F, Tomao F, Vizza E, Di Lauro L, Di Filippo F, Carpano S, Mariani L, Vici P. Hot flushes in women with breast cancer: state of the art and future perspectives. Expert Rev Anticancer Ther 2013; 14:185-98. [DOI: 10.1586/14737140.2013.856271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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The effect of oral evening primrose oil on menopausal hot flashes: a randomized clinical trial. Arch Gynecol Obstet 2013; 288:1075-9. [PMID: 23625331 DOI: 10.1007/s00404-013-2852-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Hot flashes are common experience for menopausal women, and for many, are severe enough to significantly compromise their overall sense of well being and quality of life. The aim of this study was to compare the efficacy of evening primrose with placebo in improvement of menopausal hot flashes. METHODS In a 6-week randomized clinical trial, a total of 56 menopausal women aged 45-59 years were participated in this study. The patients were asked for their hot flashes characteristics and responded to HFRDIS (hot flash related daily interference scale) questionnaire before and after the intervention. The participants were randomly assigned to take two capsules per day (totally 90 capsules for 6 weeks) of placebo or evening primrose (500 mg) for continuous 6 weeks. Then, the improvement in hot flashes was compared between two groups. RESULTS The percent of improvement in hot flash frequency, severity and duration were 39, 42 and 19 %, in evening primrose group compared with 32, 32 and 18 % in placebo group, respectively. Although all three characters of hot flash was ameliorated in evening primrose arm, only its severity was significantly better in this arm compared with placebo group (P < 0.05). All HFRDIS score were significantly improved in two groups, but the percentage of improvement in social activities, relations with others, and sexuality was significantly superior to placebo group (P < 0.05). CONCLUSIONS The application of oral evening primrose oil compared with placebo for controlling hot flashes may decrease more the intensity of attacks as well as ameliorating the HFRDIS score.
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Affiliation(s)
- Carolyn Casey Lefkowits
- Section of Palliative Care and Medical Ethics, UPMC Montefiore, Suite 933W, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Abstract
The impact of oncologic treatments on fertility and menopausal symptoms is often significant for patients with cancer. Surgery, radiation, and chemotherapy can all damage the reproductive organs or the hypothalamic pituitary axis that controls them, impairing fertility and causing hormonally mediated symptoms such as hot flashes. Understanding these risks and strategies to mitigate them may substantially improve cancer survivorship care. For both female and male patients who desire a future biologic child, there are a variety of fertility preservation techniques that should be considered. For cancer survivors who experience menopausal symptoms, lifestyle changes may be beneficial, and hormonal and nonhormonal pharmacologic agents are well proven to reduce symptom burden.
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Affiliation(s)
- Kathryn J. Ruddy
- All authors: Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Ann H. Partridge
- All authors: Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
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