Aromatase Therapy Timing Key in Breast Cancer Survival

Renya,

The Stage IV women will have more experience answering your quesiton.  It's great that your mets are receeding.  

Those of us ER+ w/o mets are expected to be on antihomornals like Aromasin for 5 years.  Some MOs want their patients to be on these longer.  I would be very surprised if your MO would suggest anything less than 5 years.  

Renya, I too am losing hair but I guess it is a small price to pay if it keeps the beast at bay. I have another three and half years to go.

If I'm understanding the risk/benefits of tamoxifen vs aromatase inhibitors and the oncotype score correctly, then I'm not understanding my oncologists treatment regime for me.  I had stage !!A ER+,PR+ invasive ductal with 1 positive node.  I had a bilateral mastectomy because of my extremely dense breast, and had 26 lymph nodes removed. I had  early menopause long before my cancer and have been osteoporotic for 12 years, since I was 48.  I have already been on bisphosphonates for 7 years and have been on 50,000 vitamin D weekly for 12 years.  My  bone density has steadily increased with treatment, but I still have areas with osteoporosis, the rest are osteopenic.  I was on a 5 year drug holiday  from bisphophonates and was on a hormone patch  when I was diagnosed with cancer.  Because of my bone history, my oncologist wants me to be on Tamoxifen for 2-2 1/2 years and then switch to an aromatase inhibitor.   I am currently taking Tamoxifen and am experiencing few side effects.  I don't see the risk/benefit of an aromatase inhibitor as favorable for me.  My oncotype score gave me only a 4% chance of recurrance in 10 years if on Tamoxifen for 5.

I'm starting on Tamoxifen to help build bone density.  I would like to stay on Tamoxifen the entire 5 years.  I don't want to take a chance with my bones on an AI.  I know an AI would be given with a bisphosphonate, but you can't stay on bisphosphonates indefinatley and I want my bones to last a potentially long time.  I will never be able to take hormones again for my bones, so my bone med options are becoming limited.  I'd like to stay on Tamoxifen as a bone builder and for cancer, and save the bisphosphonate for down the road.  My oncotype score was 1, so my tumor should be very responsive to Tamoxifen.  I feel blessed to have onlly a  4% chance of recurrance with 5 years of Tamoxifen.  I also feel my life is just as threatened by osteoporosis as cancer.

You know, I thought I read somewhere that the anti-hormonals didn't realize do much to prevent cancer from occurring in the other breast.  I was surprised when my doc. said that; I had never heard that before.

I did some reading last night, and came across something that said the greatest chance of recurrance is in the first 3 years.  I think that depends on how fast growing your cancer is.  That's why some doctors start with the strongest med first.  Overall, the chance of serious side effects of each med are decreased on the switch regime since their likelyhood of the worst effects increases with treatment duration. 

april485, I know a little of your pain.  I was on Raloxifene, , at one point for 1 year, before cancer, to treat my osteoporosis.  I was also on a bisphosphonate at that time.  I had injured my hip years before in a car accident but didn't have pain until Raloxifene.  The aching stiffness in my hip was so awful. I also had pain in my femur.  That's when I was taken off both those meds and was only on the hormone patch.  My life was so much better on hormones.  Alas, they're a thing of the past.  Because of the problems I had with Raloxifene, which is a milder drug than Tamoxifen, I was leary of what would happen on Tamoxifen.  I really haven't had any problems on it.  Maybe because I went a few months without hormones after I pulled my patch before starting Tam.  Maybe because I'm older now.  I did have a hip replacement inbetween both experiences, so I'm sure that had a major impact, but I'm generally doing much better this tiime.  Mild hot flashes, compared to drenching constant ones, sleeping normally compared to insomnia.  My understanding is that the AIs are much worse in the aching bone pain department. 

My MO recommended an AI for 2.5 years and then switch to Tamoxifen as he felt there were some treatment advantages. I went for a second opinion at an NCI designated research center and the doctor did not feel there was much difference in outcomes changing the order and felt going with Tamoxifen first would give me time to "work on your bones". I am osteopenic and also have a strong family history of heart disease so want my weight, cholesterol, etc., to be as low as I can get them before starting the AI. My MO concurred. So I've been on Tamoxifen for a little over a year and will make the switch as planned. I also read a number of the studies the MO referred to myself and did not feel the differences in which order you took the drugs were always significant but that you had both over time seemed more important. My internist has offered the option of starting on one of the bone building drugs a year or so before I switch to an AI. I have DEXA scans once a year and have held steady but not improved. My Vitamin D levels though have actually fallen, in spite of daily supplements, so I've upped the amount to 4,000 IU a day and am getting out in the sun! 

I am considering asking my MO to switch me to Tamoxifen. I am so achey, hurt so much in the morning, improves over the day but makes me nervous about anything but modest exercise. Does Tamoxifen give you the body aches like Aromasin?
And I know what you mean about wishing it were easier- my sister had no issues with Tamoxifen or Aromasin, total of 6 years. Luck of the draw, I guess.

wow! So what did you do? and how did you find that out about your estrogen levels?? That is wild!

Bumping again!

I was on Arimedex 3 mos, Aromasin 9 mos, Femara 1 mo- and now Tamoxifen 3 mos. Tamoxifen is better (hands better and I can go down stairs etc) but my back and hips are still paintful most of the time. In bed especially. So  I don't know. My onc said if it gets worse he will do a bonescan. Ugh, I'd rather just take ibuprofen for a while!

O dear, I am so sorry to hear of your suffering.  I did not feel bad on Tamoxifen, I had hot flashes, but mostly felt fine.  I was premenopausal for a year after chemo, but the chemo took out my ovaries so then I was switched to an A.I. I bit the bullet taking Anastrozole for months and felt so anxious.  Then went to Femara (letrozole).  So much sadness and worry!!! But it did seem to let me sleep better.  I have had a year on A.I.s and now I just switched to aromasin (exemestane).  I am still feeling unhappy but its a lot better.  My dreams are troubling, but I don't wake up and cry for half an hour.  I encourage you to ask about changing A. I.s; you just need to stick with them for about 2.75 years then the benefit is the same as taking Tamoxifen and you can switch back to that if your doctor says its fine.  I can walk instead of hobbling now and its only been a couple weeks.  The arthritis and spine pain with femara were aweful and I was diagnosed with osteopenia.  Also my finger joints are much more smooth, they were starting to get so swollen they were locking sometimes on femara.  I wish you the best.  It might help to keep a daily log of your observations; weight, joint pain, exercise, sleep etc.  I noticed a huge drop in my activity on femara just because moving was so much more painful.  Everyone is different and each body will respond to the medicine in its own way.  I sure hope I get a better ride with aromisin than femara (!!!)  You might also ask if Zometa or zolodronic acid infusion every 6 mo. to protect your bones and also it is shown to reduce recurrence about 30% better than with out it.  Many blessings and good healing to you!

b8eekatt,

The osteo infusion lowered recurrence of cancer? Or fractures?

Thanks for the info!

hollyboo

I was on the 3 different AIs for 13 mos (Arimedex 3, Aromasin 9, Femara 1). My MO changed me to Tamoxifen for all the reasons you guys  list above. I am postmenopausal and ovaries are out. It's been 4 mos and it is better than the AIs were though I still have back and hip pain. He said that while the AIs are marginally better in cancer prevention for people in my age group etc, some people can't tolerate it and Tamoxifen is far better than nothing. Sigh.

Have any of you tried Cymbalta to help with stress and joint pain? When first diagnosed, I sent myself into a tizzy with worry. My doc chose Cymbalta as I had been interviewing ONC's and two of three said taxol, which has joint pain as a side effect. I sailed through chemo with very little joint pain or neuropathy. 

Onc said if I have too many problems with joint pain, He will prescribe it again to see if it will help.