Panel Reviews Management of Tamoxifen-Related Side Effects

An expert panel of seven cancer researchers and a representativeof the National Alliance of Breast Cancer Organizations (NABCO)came together at the San Antonio Breast Cancer Symposium for aroundtable discussion of the use of tamoxifen (Nolvadex), sponsoredby PRR, Inc., publisher of Oncology News International, PrimaryCare & Cancer, and the journal ONCOLOGY.

Previous articles in this series have focused on the possiblerisks of secondary cancers with tamoxifen use (February), theappropriate duration of tamoxifen treatment (March), and the possiblenoncancer benefits of tamoxifen (April). In this last articlein the series, the panel discusses the management of tamoxifen-associatedmenopausal symptoms.

SAN ANTONIO--The treatment of hot flashes in breast cancer patientstaking tamoxifen can be problematic because of the need to limitestrogen use, said roundtable chairman V. Craig

Jordan, PhD, DSc, of Northwestern University. He asked the otherpanel members how they deal with their patients on tamoxifen whocomplain of menopausal symptoms.

"We've tried various interventions such as Bellergal-S [belladonna,pheno-barbital, and ergotamine tartrate], the Catapres [clonidine]patch, and vitamin E," said Norman Wolmark, MD, chairmanof the NSABP (National Surgical Adjuvant Breast and Bowel Project).

Although these treatments have all been used successfully on occasion,he said, none can be recommended as a standard intervention.

Dr. Wolmark noted that when hot flashes are severe enough to significantlyinterfere with a woman's quality of life, then more aggressivetherapy should be considered, including intravaginal estrogenpreparations and even systemic estrogens.

"I want to make it very clear that I am not recommendingsystemic estrogens as a routine adjunct to tamoxifen to deal withsymptoms." Rather, he said, its use should be restrictedto selected cases of women with severe acute symptoms.

Younger women on tamoxifen may find it especially difficult tocope when "thrust into menopausal symptoms," said AmyS. Langer, executive director, National Alliance of Breast CancerOrganizations (NABCO). "The thoughtful on-cologist will oftengive brief estrogen interventions to alleviate severe acute symptoms,"she said.

She added that it may not be commonly known in the medical communitythat this practice is acceptable. "So it's always usefulat a conference like this to learn what experts are doing,"she said, and to relay that information to the general physicianswho may be following these women long term.

C. Kent Osborne, MD, of the University of Texas Health ScienceCenter, San Antonio, noted that "luckily, hot flashes arenot all that common," and they may be attributed both totamoxifen and to the fact that many postmenopausal women stophormone replacement therapy once breast cancer is diagnosed.

He said that, anecdotally, he has had success in a handful ofpatients using serotonin reuptake inhibitors, such as venlafaxine(Effexor), at doses that are subtherapeutic for antidepressiveaction.

Joseph Ragaz, MD, of the Vancouver Cancer Centre, British ColumbiaCancer Agency, noted that in his experience women who increasetheir physical activity, through jogging or other regular exercise,often see a decrease in their hot flashes.

I. Craig Henderson, MD, of the University of California, San Francisco,mentioned that a number of his patients on tamoxifen have soughtrelief of hot flashes with phytoestrogen preparations that aresold over the counter at health food stores.

"In general, I feel that these are probably neither safernor more harmful than short courses of estrogen," he said,"but I try to make certain that patients who use them arefully informed."

Dr. Osborne said that he has been hesitant to recommend thesephytoestrogen preparations because of uncertainty about theiringredients. "It's a little bit of a black box," hesaid.

Treating Vaginal Dryness

Vaginal dryness is generally easily managed with use of estrogencreams, Dr. Osborne said. "In a patient who is taking tamoxifen,I have little fear of absorption of estrogen from the vagina."Short-term treatment of only a few weeks is often effective, "andyou may not have to treat the patient again for months or evenyears," he said.

Richard R. Barakat, MD, of Memorial Sloan-Kettering Cancer Center,added that local applications of lubricating agents such as Replensor Astroglide gel may also help patients with vaginal dryness.Dr. Ragaz commented that some of his patients with vaginal drynesshave reported benefits with use of over-the-counter lubricantscontaining primrose oil or jelly.

Quality of Life Studies Needed

Dr. Ragaz emphasized that the number of breast cancer survivorswho are on tamoxifen is now approaching the millions. "Itlooks to me that we as oncologists have an obligation to do largerandomized quality of life studies of these patients and to testsome of the remedies we've discussed."

Roundtable Participants

Moderator: V. Craig Jordan, PhD, DSc, Robert H. Lurie Cancer Center,Northwestern University Medical School, Chicago

Richard R. Barakat, MD, The New York Hospital and Memorial Sloan-KetteringCancer Center, New York City

I. Craig Henderson, MD, University of California, San Francisco

Amy S. Langer, National Alliance of Breast Cancer Organizations(NABCO), New York City

Monica Morrow, MD, Northwestern University Medical School, Chicago

C. Kent Osborne, MD, University of Texas Health Science Center,San Antonio

Joseph Ragaz, MD, Vancouver Cancer Centre, British Columbia CancerAgency, and University of British Columbia

Norman Wolmark, MD, Medical College of Pennsylvania/HahnemannUniversity, Allegheny Campus, Pittsburgh, and Chairman of theNational Surgical Adjuvant Breast and Bowel Project (NSABP)