Ovaries Out Even if You are Gene Negative?

Hi KCMC:

I think she is suggesting consideration of oophorectomy plus an aromatase inhibitor. This combination is a relatively intensive approach to endocrine therapy, which may or may not be warranted in the individual case, depending on recurrence risk profile.

Recommended approaches to endocrine therapy depend on a variety of factors, and so this is a question for a person with the appropriate expertise: a Medical Oncologist.

In post-menopausal women, including those who have received a bilateral oophorectomy, tissues other than the ovary produce clinically significant amounts of estrogen. Aromatase Inhibitors ("AI") block the synthesis of estrogen by such non-ovarian tissues.

In contrast, Tamoxifen can be used in those who are either pre-menopausal or post-menopausal. This is because it works by blocking the action of estrogen at the level of the estrogen receptor in breast cells (e.g., in any remaining breast tissue or in rogue breast cells at distant sites), regardless of the source of the estrogen (be it the ovary or other tissues).

In general, initial adjuvant (post-surgical) endocrine therapy options may include one or more of the following, depending on various factors, such as type of cancer (e.g., DCIS, IDC), recurrence risk profile, and co-morbidities:

Pre-menopausal:

(a) Tamoxifen alone; or

(b) Tamoxifen plus Ovarian Suppression (a second drug to suppress/shut down ovarian function); or

(c) Ovarian Suppression ("OS") plus an Aromatase Inhibitor ("AI") (in pre-menopausal women, use of an AI requires added OS to shut down ovarian function; using both is intended to stop estrogen production from all sources)

=> If oophorectomy is received, see post-menopausal options

Post-menopausal (this includes patients whose ovaries have been removed by bilateral oophorectomy):

(a) Tamoxifen; or

(b) Aromatase inhibitor

Tamoxifen, aromatase inhibitors, and the drugs used to induce ovarian suppression have different side effect profiles. Oophorectomy has different health impacts. In pre-menopausal women, the choice between tamoxifen alone and other more intensive approaches entails a personalized risk/benefit analysis.

In all cases, such decisions should be made in consultation with a Medical Oncologist in light of one's risks of loco-regional and distant recurrence, risk of new disease, menopausal status, and overall health and presentation, including medical history or co-morbidities that may be potentially relevant to the particular side effect profiles of a specific drug or intervention.

Best wishes as you gather more information about what is right for you.

BarredOwl

I was on Tamoxifen two years and started having uterine issues, all were benign but I decided to have my ovaries out anyway to move on to an AI. I was on the AIs for a total of ten months before I threw in the towel and went back to Tamoxifen. I have had genetic testing for Brca, Bart, and the 19 gene panel from Color Genomics and no mutations were found. The surgery is easy, menopause? Not so much.

Yes KCMC this is the procedure............even my head started to spin

Hi ladies! I am in the middle of trying to decide the same thing: stay on Tamox or go to Lupron shots + then switch to an AI. I have been told to read the SOFT and the TEXT studies?! Basically, my MO told me that in my case, Tamox is almost as good as they can offer. Shutting down my ovaries medically and then switching to an AI is an option - but she said it would potentially make my chances better by 1-2% - So that is what I have learned so far and am deciding. I'm premenopausal, 43. Any other women who have gone this route?

Hi abg712:

Very generally, adding ovarian suppression tends to be used in situations where more intensive treatment is warranted by recurrence risk. If your medical oncologist has presented you with more than one option and you are unsure what to choose, you may find a second opinion with another medical oncologist at an independent institution to be helpful.

BarredOwl

For those who are pre-menopausal and would like to read about Ovarian Suppression (plus tamoxifen or an AI) and to consult SOFT and TEXT/SOFT study publications to further inform discussions with their medical oncologist, I have the following bookmarked.

This is NOT a comprehensive list of publications related to the SOFT and TEXT trials.

These documents are not a substitute for current, case-specific, expert professional medical advice from a Medical Oncologist ("MO"). It is easy to misunderstand such highly technical documents and whether and how their guidance should be applied in the individual case. Guidelines represent snapshots in time, and there may be appropriate exceptions to what is provided for the general case. There may be additional, more recent studies and/or conflicting studies. Therefore, if a document influences your thinking in any way, it is essential to confirm your understanding, as well as currency and applicability to your case, with your MO.

ASCO 2016 Guideline Update re Ovarian Suppression:

Burstein (2016), "Adjuvant Endocrine Therapy for Women With Hormone Receptor–Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update on Ovarian Suppression"

http://ascopubs.org/doi/full/10.1200/JCO.2015.65.9573

(Free PDF version available under PDF tab; See also, Supplements tab)

The Update above was issued in light of the results of the following SOFT and TEXT publications:

SOFT: Francis (2015), "Adjuvant Ovarian Suppression in Premenopausal Breast Cancer"

"[R]esults of the planned primary analysis in SOFT comparing adjuvant tamoxifen plus ovarian suppression with tamoxifen alone after a median follow-up of 67 months"

Main Page: http://www.nejm.org/doi/full/10.1056/nejmoa1412379#t=article

PDF version: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1412379

Supplementary Appendix to Francis: http://www.nejm.org/doi/suppl/10.1056/NEJMoa1412379/suppl_file/nejmoa1412379_appendix.pdf

TEXT/SOFT: Pagani (2014), "Adjuvant Exemestane with Ovarian Suppression in Premenopausal Breast Cancer"

"[P]rimary combined analysis of data from TEXT and SOFT comparing adjuvant exemestane plus ovarian suppression with adjuvant tamoxifen plus ovarian suppression after a median follow-up of 68 months"

Main Page: http://www.nejm.org/doi/full/10.1056/nejmoa1404037#t=article

PDF version: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404037

Supplementary Appendix to Pagani: http://www.nejm.org/doi/suppl/10.1056/NEJMoa1404037/suppl_file/nejmoa1404037_appendix.pdf

[[[EDIT: Since the above results and Guideline Update were published, additional results are now available:

SOFT/TEXT: Francis et al. (2018), "Tailoring Adjuvant Endocrine Therapy for Premenopausal Breast Cancer"

Main Page: https://www.nejm.org/doi/full/10.1056/NEJMoa1803164

PDF version: https://www.nejm.org/doi/pdf/10.1056/NEJMoa1803164

Supplementary Appendix to Francis (2018): https://www.nejm.org/doi/suppl/10.1056/NEJMoa1803164/suppl_file/nejmoa1803164_appendix.pdf ]]]

For those with Lobular disease (ILC), ask your MO about BIG 1-98 and other studies:

Filho (2015): http://ascopubs.org/doi/full/10.1200/JCO.2015.60.8133

(Free PDF version under PDF tab; See also, Supplements tab)

ASCO Post Article re BIG 1-98, "Benefit of Adjuvant Letrozole vs Tamoxifen Is Greater in Lobular Than in Ductal Breast Cancer": http://www.ascopost.com/News/31718