Hormone therapy - is a systemic treatment, slow down and stop the development and spread of abnormal cells due to changes in hormone levels. Hormones are chemical substances that are produced by glands in the body or are created artificially in the laboratory. To change their level of using drugs, surgery and radiation .
Estrogen and progesterone - a hormone that is synthesized in the body women primarily by the ovaries. After menopause, these organs are no longer produce estrogen, but a small amount of hormone produced continues via the aromatase enzyme.
Estrogen and progesterone can stimulate the growth of malignant breast tumors . Healthy organ cells and certain cancer types have estrogen and progesterone receptors within or on the surface.
Hormone therapy is used only in women diagnosed with estrogen-receptor positive (ER +) and progesterone receptor positive (PR +) breast cancer. Approximately two-thirds of all cases of the disease, the tumor contains receptors for estrogen, progesterone, or both, i.e. hormones stimulate the growth of malignant cells. If tumors are hormone-receptor negative hormone therapy in breast cancer is not applicable.
Tissue cancer cells tested to see if they have mentioned hormone receptors by determining receptor status of the tumor.
Hormonal therapy for breast cancer in the clinic Assuta prescribed:
- After surgery and radiation, in order to eliminate any remaining abnormal segments and reduce the likelihood of a return of the disease.
- Before surgery to reduce the size of the initial outbreak, especially in older women with breast cancer ER +, PR + or both.
- As part of a combined approach in locally advanced form of the disease.
- To reduce the risk of disease in the other breast.
- In the treatment of relapse.
- To facilitate the control of pain and symptoms of tumor spread.
The decision on the choice of hormone therapy in breast cancer
The selection and duration of treatment will be determined by the following factors:
- whether the patient has reached menopause. In different periods of women receive different types of therapy.
- Stage of the disease.
- whether there are other health problems (such as osteoporosis or high likelihood of thrombus formation), which will be a contraindication to this treatment.
- The presence of prior hormonal therapy.
- Progression of the disease. With the ineffectiveness of one type of treatment, can try another.
Anti-estrogen drugs have no effect on the hormone in the body. They counteract the cancer cells in the production of estrogen by blocking tissue receptors.
Tamoxifen (Nolvadex, Tamofen)
Tamoxifen is assigned more often in premenopausal and postmenopausal periods. It is administered orally in the form of tablets or liquids. The recommended dose usually is 20 mg per day.
When prescribed as adjuvant hormonal therapy for breast cancer at low risk, treatment is carried out for five years after surgery.
- For women in menopause after two or three years of taking the drug therapy may vary on aromatase inhibitors.
- Patients in the premenopausal period may be advised by ovarian ablation LHRH agonist in combination with tamoxifen.
In the treatment of advanced or recurrent breast cancer, tamoxifen is taken up as long as the disease progresses.
The majority of women in pre-menopausal ovaries continue to work and to stimulate ovulation, that is may be possible to the child's conception. Therefore, during the hormone therapy of breast cancer need to use contraception.
Gradually, in women who have not reached menopause, periods become irregular and eventually stop. In general, they are restored after taking the drug, unless menopause does not occur naturally during hormonal therapy for breast cancer or chemotherapy does not cause its premature appearance.
Among the common side effects of Nolvadex notice mood swings, loss of libido, hot flashes, night sweats, vaginal dryness. Other effects of treatment include headache, joint pain, digestive disorders, cramps in the legs. Among the rare events mark vision problems, loss or thinning hair, weight gain, increased facial hair.
In women after menopause, tamoxifen slows down the natural process of bone loss, reduces the likelihood of osteoporosis, but those who have not reached menopause are at risk of thinning bones under his influence.
Tamoxifen increases the chance of developing endometrial cancer, deep vein thrombosis (DVT), stroke, and heart attack. Therefore, when administered necessarily take into account the personal and family history.
Fulvestrant - a drug hormonal therapy for breast cancer, which reduces the number of estrogen receptors in breast cancer cells, carrying out down-regulation. It also blocks the action of hormones: binds to the receptors, changing their shape and stopping work. It is administered by injection.
It is used to treat locally advanced or metastatic breast cancer that has progressed following tamoxifen in women postmenopausal.
The majority of women taking fulvestrant, observed weak side effects. Nevertheless, the degree of their manifestation in each case is different. Possible symptoms of menopause such as hot flushes and night sweats, and nausea and malaise.
Less common adverse effects include: headaches, pain in the joints and bones; loss of appetite, vomiting, diarrhea, constipation; skin rash, urinary tract infection. There is an increased risk of deep vein thrombosis, liver disease. Rarely observed the isolation and / or bleeding from the vagina.
Aromatase is an enzyme involved in the production of estrogen in the body. Aromatase inhibitors are the drugs of hormonal therapy for breast cancer, which stop block the hormone synthesis and enzyme action, which lowers estrogen content.
These medicinal products are prescribed only to women during menopause, because they have a much smaller amount of hormone in the body, so blocking aromatase activity is effective to reduce the level of estrogen. Since data drugs do not affect the ovaries during menopause to their use impractical.
Aromatase inhibitors are administered orally, the most common are: letrozole (femara), anastrozole (Arimidex), exemestane (aromazinâ).
All three drugs are used in hormone therapy for breast cancer. The choice will depend on the characteristics of the disease and other factors.
Aromatase inhibitors are prescribed:
1. After receiving tamoxifen for 2-5 years. There are different options.
- "Early switchover" - transfer of the patient after treatment with tamoxifen for two to three years to aromatase inhibitors.
- "Later switching" - translated into aromatase blockers to complete treatment Nolvadex more than 3 years, or to reach menopause in connection with this therapy. It is also known as the extended adjuvant hormone therapy in breast cancer.
Receiving aromatase inhibitor is performed within 2-3 years, the treatment with letrozole can reach 5.
2. Upon completion of tamoxifen therapy.
According to the results of studies in women who took letrozole for five years after the end of treatment Nolvadex decreased likelihood of recurrence of the disease.
3. As the basic hormonal therapy to five years instead of tamoxifen for women with breast cancer or at high risk stage II or III.
4. If there are contraindications to tamoxifen because of severe adverse effects of treatment.
5. At relapse of disease instead Nolvadex. When there is a diagnosis - a common tumor, the drug is carried out as long as the disease progresses.
Among the frequently occurring adverse effects of therapy say hot flashes, night sweats, vaginal dryness or irritation, loss of libido, joint pain, decreased bone strength (is scanned to check bone density up to - and during hormone therapy in breast cancer).
Less common effects include depression, hair thinning, skin rash, drowsiness, headache, diarrhea, vomiting or nausea. Rare symptom is vaginal bleeding.
Hormone therapy for breast cancer - ovarian ablation
Ovarian ablation or suppression of ovarian function is a method of therapy that stops the synthesis of estrogen. Reduction of its amount will help prevent and stop the growth of malignant cells.
Ovarian ablation is not often used as auxiliary techniques in breast cancer hormonotherapy are not used in combination with tamoxifen or treatment with cytostatics. At present, the conducted clinical trials on a combination of ablation with Nolvadex or aromatase blocker.
This type of treatment prescribed to women during menopause when estrogen-receptor positive breast cancer:
- If there are contraindications to other therapies in connection with any medical problems, or she does not desire of chemotherapy .
- For treatment of metastatic or recurrent disease.
Ovarian ablation can be performed in three ways: surgery, medication, or by irradiation.
Operative intervention (ovariectomy) involves removal of the ovaries. It is preferable for older women in premenopausal, who no longer want to have children.
The operation can be performed by laparoscopy through three small incisions. Sometimes, this option is not available, for example, in the case of previous surgery in this area. Then the abdominal approach is used through a short incision below the bikini line. With the help of surgery stops the ovaries immediately and permanently.
Luteinizing hormone-releasing hormone (LHRH)
LHRH produced in the hypothalamus. It stimulates the pituitary gland to produce luteinizing hormone (LH), which in turn promotes the production of estrogen by the ovaries.
LHRH-agonists is drugs that act on the pituitary to synthesize more of LHRH. In the end, the pituitary gland stops responding to stimulation, respectively, stops the production of estrogen by the ovaries. LHRH agonists are also prescribed in combination with tamoxifen to reduce the amount of the hormone, as well as reduce the number of estrogen receptors on diseased cells.
The most common agonists of LHRH, which are used for the ablation of ovarian are: goserelin (Zoladex), leuprolide (Lupron, Lupron Depot, Eligard), buserelin (Suprefact).
The drugs are given via an injection under the skin. Depending on the medication made monthly or every third month.
This type of hormone therapy for breast cancer may continue:
- as adjuvant treatment for three to five years;
- in metastatic or recurrent tumor as long as the disease progresses.
The advantage of medical treatment is, in fact, that its effects are usually reversible, but not always.
Beam radiation to the ovaries can destroy their ability to produce estrogen. Usually takes about 3 months after radiation therapy to the estrogen level has decreased. Irradiation is rarely used as a method of ovarian ablation, it can offer women who have contraindications for surgery or receiving LHRH agonists.
Side effects of the procedure removal of the ovaries or the oppression of their functions will depend on the method used. Most often note the following menopausal symptoms: loss of libido, vaginal irritation and dryness, night sweats, hot flashes. The absence of estrogen for a long time may increase your risk of osteoporosis.
Progestins are hormonal agents, like progesterone. They are used for the following purposes:
- to neutralize the negative effects of estrogen;
- to stop the production of estrogen;
- compete with progesterone receptors on the cancer cells.
The most common drug - megestrol (Megace, Apo-megestrol, Nu-megestrol, Lin-megestrol). Reception is performed orally. Treatment continues for as long as there is evidence that the cancer is progressing.
Progestins are rarely used in hormone therapy for breast cancer. They are prescribed to women with metastatic cancer:
- When there is no response to other hormones.
- There is a resistance to tamoxifen.
Androgens - male hormones it. Androgenic drugs are prescribed to block the pituitary gland's ability to control the production of estrogen. The most common of these is fluoxymesterone (Halotestin). He is taken by mouth as long as there is evidence that the cancer is progressing.
Androgens are seldom used as a method of ovarian ablation. They are prescribed for the treatment of women:
- with metastatic tumor which does not respond to other drugs hormone therapy of breast cancer;
- with recurrent disease.