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Dr. Jennifer Westrup Consultant Medical Oncologist Associate Clinical Professor, UCD

Breast cancer and menopause. Dr. Jennifer Westrup Consultant Medical Oncologist Associate Clinical Professor, UCD. Breast Cancer and Menopause. CASE STUDY ESTROGEN AND BREAST CANCER NON ESTROGENIC STRATEGIES FOR BREAST CANCER PATIENTS WHEN ALL ELSE FAILS. The million dollar questionS.

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Dr. Jennifer Westrup Consultant Medical Oncologist Associate Clinical Professor, UCD

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  1. Breast cancer and menopause Dr. Jennifer Westrup Consultant Medical Oncologist Associate Clinical Professor, UCD

  2. Breast Cancer and Menopause CASE STUDY ESTROGEN AND BREAST CANCER NON ESTROGENIC STRATEGIES FOR BREAST CANCER PATIENTS WHEN ALL ELSE FAILS

  3. The million dollar questionS What is the risk that exogenous hormones will stimulate the growth of microscopic disease and lead to decreased survival and increased recurrence of breast cancer? What symptomatic treatments can women with a history of breast cancer utilise after breast cancer treatment?

  4. Case Study 33 year old single, professional female Diagnosed with bilateral breast cancer High risk, node positive Mother diagnosed with breast cancer 30% of breast cancer diagnoses will be in young women 7-10% diagnosed will be under the age of 40 Breast cancer is the most common type of cancer in reproductive age women

  5. Case Study GOALS: TREAT BREAST CANCER FOR CURE Chemotherapy -> Surgery/Recons -> Radiotherapy -> Endocrine Tx MANAGE PHYSICAL AND PSYCHOLOGIC ISSUES AROUND DIAGNOSIS Infections, side effects of treatment Morbidity and Mortality Body Image Resilience and Stamina Menopausal Symptoms QUERY GENETIC SYNDROME

  6. Case Study Acute ammenorhea: loss of growing follicle population If enough primordial follicles remain intact, they will renew the pool of growing follicles in 3-6 months. Many women may develop infertility after cancer treatment even if they resume menstruation Chemotherapy-induced ovarian failure (or chemotherapy-induced premature menopause) affects the quality of life of female cancer survivors resulting in consequences such as hot flashes, osteoporosis, sexual dysfunction and the risk of infertility.

  7. Case Study NeoAdjuvant Chemotherapy • In Vivo test of efficacy • Chemotherapy efficacy is equivalent pre or post-op in breast cancer • Chemotherapy induced premature menopause. • Allows time for genetic testing, planning surgery and reconstruction GENETICS • LI FRAUMANI SYNDROME • Mutation of p53 tumor suppressor gene • Lifetime risk of multiple cancers: Sarcoma, Breast, Brain • 90% risk of developing breast cancer by age 60, most are under age 45 • Women with this syndrome have100% lifetime risk of developing cancer

  8. Case Study CHEMOTHERAPY -> BILATERAL MASTECTOMY/ALND -> ENDOCRINE TX INITIAL MANAGEMENT: Frank discussion on fertility and potential loss of fertility Frank discussion on contraception Frank discussion on acute menopausal symptoms Offer decapeptyl as ovarian protection • Inhibit folliculogenesis to preserve ovarian reserve • Reduction of primordial follicule pool with age Offer consultation on fertility preservation (6 week delay to treatment) Immediate referral to Gynaecology AND Counselling

  9. Case Study 7 years from diagnosis Currently: no evidence of cancer Main complaints: • ‘I keep getting hot flashes and pour sweat during presentations at work’ • ‘I feel like I am sitting on razor blades!’ • ‘I am just plain irritable, I am never going to get a partner’ • ‘My sleep…it just doesn’t work’

  10. “Menopause on top of a breast cancer diagnosis can be more than a major disruption. It can wreck your sex life, dash hopes of having a baby, trigger mood swings, produce debilitating hot flashes, cause weight gain, drain your energy, worsen aches and pains, bring on jealousy or anger or resentment, and leave you feeling bad about yourself. You may find it’s these menopausal changes, not the breast cancer or immediate effects of treatment, that interfere most with your quality of life.” -- Marisa Weiss, M.D., chief medical officer, Breastcancer.org

  11. MANAGING ACUTE MENOPAUSE IN CANCER PATIENTS When do symptoms begin? • Surgical Menopause • Medical Menopause • Natural Menopause What happens after Chemotherapy? • Under age 40: up to 40% permanent menopause • Periods may return up to one year later • Under 40 may still be fertile! • Over age 40: 70 – 90% permanent menopause

  12. Case Study PRACTICAL TIPS: • EXERCISE AND WEIGHT LOSS • AVOID CAFFEINE • SWEAT PROOF MOISTUISER • SWEAT PROOF FOUNDATION • WATERPROOF MASCARA AND EYELINE These 7 Editor-Approved Foundations are Seriously Sweat-ProofRead more at http://www.byrdie.com.au

  13. ESTROGEN AND BREAST CANCER

  14. Estrogen and Breast Cancer • 2/3 of all breast cancers are hormone receptor positive • Estrogen and progesterone are important for breast tumourogenesis RISK FACTORS • Early menarche • Nulliparity • Delayed childbearing • Obesity

  15. Estrogen and Breast Cancer • Sources of estrogen in pre and post menopausal women • Ovary • Adipose Tissue

  16. Estrogen and Breast Cancer • Irregular periods. • Vaginal dryness. • Hot flashes. • Chills. • Night sweats. • Sleep problems. • Mood changes. • Weight gain and slowed metabolism. Just give me ESTROGEN!

  17. Non-Estrogentic Management Journal of clinical oncology editorial 2011 Non Pharmacologic • Acupuncture Trials • Exercise • Yoga / Relaxation • Hypnosis • Natural Products / Supplements • Regelle • Stellate ganglion block Studies do not show consistent benefits Pharmacologic • Vit E • Clonidine • SSRI’s • Gabapentin

  18. Urban Myths? PHYTOESTROGENS Plant sourced estrogen-like substances (soy products) Eating soy foods seems to be safe for breast cancer survivors It is not clear if it can help relieve menopause symptoms. Women can get higher doses of phytoestrogens in some dietary supplements TUMERIC SAGE EVENING PRIMROSE OIL

  19. Non-Estrogenic Strategies Vitamin E • Case reports and trials from the 1940’s • May reduce hot flushes by one per day Clonidine • Studied in the 1970’s in natural and medical menopause • Reduced hot flashes by 15-20% • SE: dry mouth, drowsiness, constipation, dizziness SSRI’s • Studied in the 1980’s, pooled analysis of all DB RCT in 2007 • Significant reductions with venlafaxine and paroxetine, less with sertraline and fluoxetine Gabapentin / Pregabalin • Better than placebo, equivalent to newer anti-depressants

  20. Non-Estrogenic Strategies

  21. What About Estrogen? • The Estrogen Paradox: • Breast cancer depends on estrogenfor growth • At high dose, estrogen is an effective treatment for breast cancer: Diethylstilbesterol (DES) • Tamoxifen replaced this strategy (1977)

  22. What About Estrogen?

  23. What About Estrogen? • LOW DOSE, LOCAL THERAPY • LIMITED EXPOSURE • EXCELLENT RESOLUTION OF SYMPTOMS • OUR ASSAYS DO NOT DETECT LOW LEVELS OF ESTROGEN, AND DO NOT DEMONSTRATE THE RISE IN SYSTEMIC ESTRADIOL LEVELS • ROYAL MARSDEN HOSPITAL

  24. What About Estrogen? VAGIFEM If symptoms remain even after all non-estrogenic strategies: Limit to 1-2 months Every night 2 weeks, then Twice a week 1-2 months Then to Regell every third day

  25. Non-Estrogenic Strategies

  26. Thank you

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