Breast Cancer and Hormonal Therapy
Hormonal therapy is essential for estrogen sensitive breast cancers. If you've been diagnosed with breast cancer, there's an 80% chance that your tumor is estrogen receptor-positive. This means that you will benefit from estrogen blocking medications, usually pills, for up to 10 years. But your survival decrease the chance of your cancer, coming back in assets, lessening the chance that you could die of your estrogen receptor-positive cancer.
So, having an estrogen receptor-positive cancer does not entirely mean that you will not need or benefit from chemotherapy in addition to hormonal therapy.
In this article I'm going to tell you exactly what hormonal therapy is and what are the different medications that we use. I'm going to go over what tumor receptor patterns with suggest hormonal therapy. I'm going to go over the benefits and the side-effects of hormonal therapy. And I'm also going to go over genomic assays and how they can play a role in your care. So, let's get started.
What is hormonal therapy for estrogen receptor positive breast cancers? These estrogen blocking or anti estrogen medications, usually pills, but there's some other forms, are incredibly effective at killing cancer cells or suppressing cancer cells from growing. There are two types that are used the most. One is called Tamoxifen, and there are some other variations.
We've been using this drug to great effect for the last 30 or 40 years. There's another class of drugs called aromatase inhibitors. And there are three or four versions of those. They're generally used more for postmenopausal women. They work almost as effectively. And they have some different advantages and disadvantages.
Let’s talk about the estrogen receptor. So, let's pretend we have one cancer cell, and it has estrogen receptors on it, estrogen receptor positive. If it's negative, it doesn't have any of these growth light switches. And, when these estrogen receptors interact with estrogen, it turns the growth switch to on, telling that cell and encouraging that cell to grow or divide from 1 to 2, from 2 to 4, tumor grows and spreads. It's a problem.
These medications, hormonal therapy, do one of several things. But they can take that growth switch and turn it from “on” to “off” sometimes killing the seller and keeping it from growing. Or there are other situations, where it can deprive the tumor of estrogen, and so, the “on” switch is always in the “off” position. It's much more complicated than that. But there is threat to your life. When you walked into your surgeon's office before you've had surgery and treated your cancer there might have been cancer cells elsewhere in your body, your bone, your brain, your liver. Over time the cancer can grow and threaten your life. That's what people die of, of breast cancer.
So, hormonal therapy is so effective, because it can interact with any of those cells that may or may not be there. For up to 10 years, suppressing them or killing them, increasing the chance of us curing your cancer, there are many different other more new hormonal therapies. They work even more sophisticated ways, beyond the scope of this discussion your medical oncologist is such a key part of your breast cancer team. Medical oncologist prescribes hormonal therapy, prescribes the more sophisticated drugs, and your medical oncologist can help to determine whether or not you will benefit from chemotherapy in addition to hormonal therapy.
Next I'm going to tell you a little bit more about tumor receptors. So, what are grass tumor receptors that might need hormonal therapy? Well your tumor receptors are key information in guiding you and your doctors, especially, your medical oncologist, determining how we treat your cancer with medication. So, it's one of many factors including the size of your tumor, whether you have cancer in your lymph nodes or elsewhere in your body, but let me walk you through some principles. If you have an estrogen receptor positive breast cancer, invariably, you are going to benefit from hormonal therapy.
The three different receptors are estrogen receptor, progesterone receptor, which plays a much smaller role, and her2 receptors, which play a very strong role for suggesting chemotherapy and immunotherapy. So, let me walk you through this. Estrogen receptor positive tumor benefits from hormonal therapy. If you're estrogen receptor positive, and your progesterone receptor, which is a hormone therapy type of receptor, is positive or negative, then you're still going to benefit from hormonal therapy.
Her2 is only positive in 20% of patients, and you will benefit from chemotherapy and targeted immune-therapy. But, even if you have a her2 positive breast cancer, and there is estrogen receptor-positive, you do chemotherapy targeted immunotherapy, and then you take hormonal therapy for ten years.
So, all of this is quite complicated. The take-home message is: know what your receptors are; know if your estrogen receptor positive or negative; know if your her2 positive or negative. Engage your breast surgeon early and engage your medical oncologist, when you see them.
So, what are the benefits and side-effects of hormonal therapy? Well, the benefits are tremendous. It's an incredible cancer treating, medication and therapy for hormone positive cancer. And if you think about it, if you're taking these medications for 5-10 years, they're protecting you. They're suppressing any cancer cells from growing back in recurrent.
One way to think about hormonal therapy is that in many different situations it lessens the chance of cancer growing back by about 50%. So, let me give you an example. Let's say, you have a hormone only positive breast cancer, and that's all you need, but you don't take the medication, and the chance of the cancer is of coming back and threatening your life is 20%. If you take these medications, it can cut in half that number 20 to 10% of the chance of your cancer coming back and threatening your life. So, in general, it lessens the chance of things recurring, it lessens the chance the cancer threatening you vs. not taking it by half, which is a powerful effective cancer.
If you cover everyone, about 30-40% of people really have a few side effects or no side effects at all from these hormonal therapy. But, let’s talk about Tamoxifen and aromatase inhibitors, and those are the two main classes. As for Tamoxifen, you can have hot flashes with it. One of the positive side effects is that it tends to strengthen your bones or offset some of the normal bone walls. So, that's a positive side effect. It can increase the chance of you developing a rare cancer, called in the material or uterine cancer, slightly. And also as you get older the chance of developing blood clots increases, while you're on Tamoxifen. And you can't take it if you're trying to have children.
As for aromatase inhibitors, which we use for postmenopausal women, you can get hot flashes. It also can cause muscle aches and joint pains in some women. And we have a number of remedies that can cure them. It can also tend to increase bone loss, and we have some countermeasures and medications to offset that.
So, in the end, as for benefits and risks, then benefits are tremendous from a cancer perspective. Side-effects are there or they are not insignificant, but the benefits are dramatically strong. The side effects are generally there, but they are tolerable. And so, that's why we strongly recommend taking hormonal therapy for an estrogen receptor-positive cancer.
What are genomic assays in breast cancer? Well, we already know that if your estrogen receptor is positive, then you're going to benefit from hormonal therapy. But they're still in many situations some unanswered questions that need more information. We might think that you'll just benefit from hormonal therapy, but you might have a higher risk cancer we don't know about and might benefit from chemotherapy in addition to it.
There are some situations which are based on how long you need to take hormonal therapy and what the benefit from 5-10 years is. What if I'm having side effects from five years of hormonal therapy? For example, I really don't want to take it 6,7,8,9 years, as I don’t know exactly how much it benefits, and how much side effects there are. The questions are evolving, and we're finding better ways to answer them.
Genomic assays look inside your cancer cells a little deeper than receptors and other aspects of it to tell us whether or not your cancer is more aggressive, than we would think, or less aggressive, or as aggressive as we think. And the concept here is: sometimes we can look into your cancer cells with these advanced sophisticated tests and determine that someone that we would give hormonal therapy is someone that really has a high-risk tumor and will benefit from chemotherapy.
So, there are the assays that are the most used: the predominant one of the United States is an Oncotype DX assay. There's also another assay called a mammoth print. But most of these assays apply to hormonally sensitive breast cancers. So, research this more, engage your doctors to determine whether or not in your unique situation you might benefit from a genomic assay.
Most breast cancers are estrogen receptor-positive and really benefit from hormonal therapy to lessen cancer recurrence and quite simply reduce the chance of you dying of estrogen receptor-positive breast cancer. Hormonal therapy is today usually recommended for 10 years and generally well tolerated. But it is essential that you work closely with your medical oncologists to navigate any side-effects that you may experience without stopping hormonal therapy. Chemotherapy is sometimes needed in addition to hormonal therapy and in some genomic assays can play a role in this difficult decision you need to know.