Choice of Tamoxifen, or Sudden Menapause + Aromatase Inhibitor?

Too-Ticky

My Oncologist has offered me two different treatment options with regards to the hormone side of things. I'm pre-menapausal, aged 47 and have no plans to have kids.

My options are to start on Tamoxifen for a few months and see how I get on. Then later start Zolpadex* injections for 2 years to shut down my ovaries, and swap the Tamoxifen for Letrozole for 5-10 years.

Or I can miss out the Tamoxifen altogether, and go straight for the instant menapause effect of the Zolpadex injections (still for 2 years) and take Letrazole daily.

Has anyone at any stage of their treatments tried all three medications (not necessarily simultaneously) and can share their experiences of how the different drugs affected you? What was good about any of them, what was bad?

Thanks.

* I'm guessing that some of these drugs might go by alternative names too

ShetlandPony

I have been on tamoxifen, and I have been punted into menopause (by chemo) followed by aromasin (briefly) then letrozole with Ibrance. I see two issues for you to consider. One is your risk level and the effectiveness of the treatment, and the other is side effects. Has your oncologist discussed both of these in detail with you, talked about how to make such an important decision, and given you his/her expert opinion? I assume the option of starting with tamoxifen is to ease you into the menopause-like side effects of hormonal therapy. But in my opinion, it would be a risk I would not take, and here are two reasons:

First, you had a 6 cm tumor, a positive node, and you are young. These things represent more of a recurrence risk, and the risk we are most concerned about is "distant recurrence" which would be stage iv, metastatic, and incurable. If go straight to ovarian suppression and letrozole, you are hitting it hard right away with the stronger treatment.

Second, you had ILC. There is enough concern that tamoxifen may not be so effective for ILC that there is a trial going on to compare tamoxifen, the aromatase inhibitor anastrazole, and fulvestrant/Faslodex in early stage lobular breast cancer. (It is called A Trial of Endocrine Response in Women with Invasive Lobular Breast Cancer (TBCRC037) ClinicalTrials.gov NCT02206984). The BIG-98 study showed better recurrence-free survival among postmenopausal women who took letrozole compared to tamoxifen. There is even a laboratory study showing that with ILC tamoxifen may even feed the cancer. (Will try to find the citation and edit to include it here.) I would not bet my life on tamoxifen. (Oh yeah, I did and that did not turn out so well. Obviously you should not base your decision on someone else's outcome. But do discuss tamoxifen and ILC with your oncologist.)

As far as side effects, I think most women find the side effects of tamoxifen easier. For me it was hot flashes and vaginal dryness that was ok as long as I had KY handy. And maybe some trouble finding words. Letrozole had similar effects on me but I was also more stiff and achy, and movement helped with that, and I needed vaginal moisturizer. Still, though starting with tamoxifen might reduce side effects, that is nothing compared to being in lifetime treatment with the targeted therapies and chemo that would be necessary to buy you a few more years at stage iv.

The other thing to keep in mind is that with either med you may initially feel strong side effects that will diminish as your body adjusts, so give it a little time. My first week on tamoxifen I found my ability to plan and organize a task was affected, but this did not last. Likewise, when I first started the aromatase inhibitor aromasin along with permanent chemopause, I had a period of depression, but this did not last. (It's harder to tease out why as I then switched to letrozole.) Also, know that if you find Zoladex and letrozole intolerable, you can stop them and go to a different therapy. It's reversible. So you can give them a try. (You can easily find lots of complaints about side effects hormonal therapy, but keep in mind that many women do well with them and do not necessarily post that.)

As my oncologist said to me as I left her office, "Enjoy your hot flashes!" Lol. They are kind of interesting.

sarahvancouverisland

Hi Too-Ticky - how did you get on with this? I'm facing the same thing, and we've just confirmed the ovarian suppression and AI option. I'll be starting on Zoladex with Tamoxifen, then once I'm fully in menopause (4-5 months) I'll switch to Letrozole. My MO explained it as a harder hitting version of hormone therapy. My situation is a little different in that I was considering chemo, but as my cancer is the "mucinous" variety apparently it's unlikely to respond to chemo. My MO ended up saying the main benefit of chemo might be that it puts me in menopause so that led us to discussing other ways of achieving that. So I'm not doing chemo, but going straight into ovarian suppression while doing rads.

I actually do still want to have a baby at some point (I'm 36 and we were planning to try for kids this year), so we froze embryos last week, and the ovarian suppression is reversible if later we decide it's safe to do so. It might not be. But it was reassuring to think that also if the side effects are more than expected then I can change things up down the road and try different drugs.

I agree with ShetlandPony in that I'm not sure what the benefit of starting out on Tamoxifen only is. It kinda feels like if you want to be aggressive with the hormone therapy you might as well go straight into it. But obviously you will have your reasons whatever you choose, and it's a very personal decision. Did you decide already or how are you getting on? Best of luck with it all!