Want to make sure I ask the right questions about hormonals

Anonymous

Want to make sure I ask the right questions about hormonals

LeesaD

I just finished by third round of TC chemo last week. Final treatment scheduled for July 11 and then on to radiation and hormonal therapy. I have an appointment with my MO on Wed and I sometimes feel like I'm not informed enough during some appointments to ask the right questions so I am hoping to get some wisdom from here as I've gotten so much in the past couple of months. I remember in a prior appointment, my MO said that after chemo, I would be put on an AI. I thought because I am premenopausal, I would be put on Tamoxifan. I am 49 and prior to my chemo I was getting regular periods still. My last one actually started day of my first chemo treatment. Have missed last period which I am assuming is due to chemo. Is there any reasoning I would go right to AI and not Tamoxifen? Any benefit or negative for either or does it not make a difference? Also, do I have to wait to finish radiation to start the hormone therapy? My start date for radiation is still pending but it's looking like end of July and will go for five weeks. If I have to wait then it looks like start date for hormone treatment around Sept. I was hoping I could do hormone treatment along with radiation as I am kind of anxious to get going on it as I've been told that will help fight my cancer the most as my Oncotype is a 3. I did the chemo as I had 2 sentinel nodes with micromets and I pushed for ALND and they found 2 of 14 fully positive axillary nodes so there are 4 nodes involved in some way. But my MO said he is not even sure if the chemo is doing much so I feel like the quicker the better as far as hormone therapy. Is it usual to start hormone and radiation at the same time? Is it detrimental to wait that long for what I feel like will help me the most? I will go over all my questions with my oncologist on Wed. but I've gotten such valuable info on this site that I want to be as prepared as possible going in there. Any thoughts/ experience would be greatly appreciated. Thank You so much!

SpecialK

leesa - unless you have an oophorectomy or use ovarian suppression drugs, if you are truly pre-menopausal you can't take an aromatase inhibitor - you would need to take Tamoxifen. This is because AI drugs assume your ovaries are not producing estrogen and this class of drugs does not block the receptors on the breast cells like Tamoxifen does, and will not suppress ovarian produced estrogen. Femara, Arimidex and Aromasin all prevent estrogen fueling by inhibiting the ability of the enzyme aromatase from converting androgens to estrogen. If you are not post-menopausal the three AI drugs would not protect you enough. I am wondering if your MO thought you were post-menopausal for some reason, or thought chemo would kick you into menopause. AI drugs have a performance edge to Tamoxifen - and this is known because there is data on Tamoxifen for both pre and post meno patients since for a long period of time it was the only anti-hormonal drug used until AI drugs came on the market. This recurrence/survival edge may be for a variety of reasons, among which is how each patient metabolizes Tamoxifen. It is a drug that uses a pathway (CYP2D6), and you can be tested to determine whether you are a good or poor metabolizer, but your MO may not be a believer in that testing - not all are, and it is not routinely done. You would probably have to request this test, and you still might get some push-back. You have the option of using an AI drug with ovarian suppression, and for younger pre-meno women there is study data indicating better stats with this approach. Here are links:

http://ascopubs.org/doi/abs/10.1200/jco.2015.64.3171?journalCode=jco

http://www.ascopost.com/issues/june-25-2014/exemestaneovarian-suppression-reduces-recurrence-vs-tamoxifenovarian-suppression-in-premenopausal-breast-cancer/

Some oncologists start hormonal therapy simultaneously with radiation, some wait until afterward in an effort to properly attribute side effects to each treatment modality. I think this is open to your wishes and you should discuss with your MO, but as far as I know there is no concrete reason not to start anti-hormonal therapy when starting rads.

LeesaD

SpecialK - Thank You so much for responding and for the information and for the links to the studies which I have just read! So very informative and so appreciated.

My MO definitely knew I was pre menopausal and he mentioned the AI's all in same conversation where he asked me if I still got my period and I had said I do and he then said chemo might stop that which it has but I've only missed one period. Not sure what the threshold is for being in full menopause but I doubt it's just one. I do remember also at the same time he said 'after chemo we'll shut everything down' and then went on to say about the AI's. So maybe he was thinking ovarian suppression also by making that comment. I was naive at the time to even ask any questions at all or put any of what he was saying in any sort of context. So AI's with ovarian suppression would be an option for me and if stats are better I would be ok with that. My MO is a real stat guy anyway and always quoting me statistics and studies so hopefully he is aware of this and that is why he mentioned the AI's. I will find out on Wed for sure but I do feel more informed going in. Thank You again!!