Dealing with menopausal symptoms in breast cancer patients
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1 Dealing with menopausal symptoms in breast cancer patients Christian Egarter Prof, MD Head: Dept. Gyn. Endocrinology & Reproductive Medicine Medical University of Vienna
2 Disclosure Gideon Richter: Speaker at sponsored symposia, consultant MSD (previously Organon): Advisory board, consultant, speaker at sponsored symposia Actavis: Speaker at sponsored symposia, consultant Bayer/Schering: Speaker at sponsored symposia Pfizer: Speaker at sponsored symposia Exeltis: Consultant, speaker at sponsored symposia Lenus Pharma: Speaker at sponsored symposia Apomedica: Speaker at sponsored symposia Mylan: Speaker at sponsored symposia
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4 Cumulative Hazards Breast Cancer WHI: CE + MPA CE+MPA Placebo Time, y WHI JAMA 2002
5 Cumulative Hazards Breast Cancer WHI: Estrogen only Stefanick MI, et al. JAMA 2006 Anderson GL. et al. Lancet Oncol 2012
6 HRT and Breast Cancer 11 European Countries Antoine C. et al. Maturitas 2016
7 Relative Risk (95%-KI) Standardised Incidence- (95%-KI) Association of HRT and Breast Cancer Type of Progestogen French Cohort Study E3N (n = 80,377) Duration of observation: mean 8.1 years Age: years (mean 53.1 ± 4.5) Finnish Cohort Study (n = 221,551) Duration of observation: max. 11 years Age: > 50 years (62.5% between 50 54a) Background risk without HRT E / P E / DYD E / other P 0 Background risk without HRT E / DYD E / MPA E / NETA E / other P Significant difference to risk without HRT E: Estrogen P: Progesterone DYD: Dydrogesterone P: Progestogens Fournier A. et al. Breast Cancer Res Treat 2008 KI: Konfidenzintervall Fournier A et al. Breast Cancer Res Treat 2008;107:103 11; Lyytinen H et al. Obst Gyn 2009;113:65 73 Lyytinen H. et al. Obst Gyn 2009
8 Risk Situation after Diagnosis of Breast Cancer GDS_70000_Title_v1 8 Davis SR et al. Nature Rev 2015
9 Prevalence and Intensity of Menopausal Symptoms Natural vs. Chemotherapy-induced Menopause Functional Assessment of Cancer Therapy Endocrine symptoms (FACT-ES) Mar Fan HG. Et al, Annals Oncol 2010
10 Tamoxifen induced side effects by lenghth of treatment Lorizio W. et al, Breast Cancer Res Treat 2012
11 Mortality in Breast Cancer Patients Prediagnosis HRT MARIEplus Study, Follow-up 6.1 a Obi N. et al. Int J Cancer 2016
12 Mortality in Breast Cancer Patients Pre-diagnosis HRT Yu X. et al. Breast Cancer 2017
13 Mortality in Breast Cancer Patients Post-diagnosis HRT Yu X. et al. Breast Cancer 2017
14 Mortality in Breast Cancer Patients Post-diagnosis HRT HABITS Study Holmberg L. et al. J Natl Cancer 2008
15 Pathophysiology of Hot Flushes Antihypertensive drugs (Clonidine) Peripheral (cutaneous) vasodilatation due to small increases in basal temperature Decrease in Estrogen Phyto-Estrogens Accelerated response of thermoregulatory system Sympathetic activation of central α2-receptors that are involved with temperature regulation Selective Serotonin Re-uptake Inhibitors (SSRIs) Serotonin Noradrenaline Re-uptake Inhibitors (SNRIs) Symptomatic women: tight thermoregulatory margin small changes of body temperature lead to hot flushes and chills Other psychotropic substances Unknown mode of action Anticonvulsant drugs
16 SNRIs Efficacy in hot flushes Ramaswami R. et al Breast Cancer Res Treat 2015
17 SSRIs Efficacy in hot flushes Citalopram different dosis Barton DL. et al J Clin Oncol 2010
18 SSRI/SNRI Safety, Efficacy, and Cost for Treatment Stubbs C. et al J Okla State Med Assoc. 2017
19 Phyto-Estrogens Black Cohosh Clinical data: +++ Results: contradictory Hot flushes? Red Clover Clinical data: ++ Results: only 1/6 RCTs demonstrated efficacy Hot flushes? St. John s Wort Clinical data: + Hot flushes? Missing data concerning long-term safety Hall et al 2011
20 Erbium:YAG Laser versus topical Estriol VVA papillomatosis neo-angiogenesis Gaspar A et al, Lasers Surg Med 2017
21 Change in bone mineral density (BMD) Lustberg M. et al. J Clin Oncol 2012
22 Treatment of Postmenopausal Osteoporosis Reginster JY et al, Drugs 2011
23 Conclusion Breast cancer risk probably lower (or absent) with bioidentical hormones (Progesterone, Dydrogesterone) Breast cancer-specific and overall mortality unrelated to prediagnosis HRT Climacteric symptoms in breast cancer patients Medical treatment of hot flushes: SSRI or SNRI HRT or Phyto-Estrogens?? Prophylaxis of osteoporosis (AI): Bisphosphonate or Denosumab
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