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2 November 2020

Endocrine therapy is a key component of breast cancer treatment for those with both early stage and metastatic hormone receptor-positive disease. However, side effects can be significant, and many patients do not complete recommended therapy. Our recent study* showed that over 90% of women and men prescribed endocrine therapy experience treatment-related side effects, and approximately 30% discontinue treatment early. 

Musculoskeletal issues such as bone pain, joint pain and stiffness, and bone loss (osteopenia and osteoporosis) are among the most common side effects related to aromatase inhibitors (AIs). A recent review by Gupta et al* discussed several side effect mitigation strategies and the evidence behind them. The most effective included exercise including yoga, acupuncture, duloxetine (brand name Cymbalta), treatment breaks, changing to a different AI, or changing from an AI to tamoxifen.

In my accompanying editorial*, I noted that there are barriers to successfully managing side effects, including cost, access and adherence to structured exercise programs and acupuncture, reluctance to add a new medication which comes with its own side effects, and anxiety regarding treatment breaks both on the part of the patient and their oncologist. In addition, none of the side effect treatments have been found to be universally effective. In fact, in our survey, only 41% of respondents noted that any side effect management was effective.

Clearly a new approach is needed, focusing on open and active communication between the patient and his or her oncologist. Endocrine therapy is often the “last” phase of breast cancer treatment, and patients may not remember conversations held at the time of diagnosis regarding benefits and side effects of endocrine therapy. Re-visiting the role of endocrine therapy, along with associated side effects and management techniques should occur before treatment. The absolute benefits of treatment should be clearly discussed – statements such as “this will reduce your risk of recurrence by 50%” are not meaningful unless a patient understands what her absolute risk of recurrence is – are we trying to reduce a 50% recurrence risk down to 25% or a 5% recurrence risk down to 2.5%? 

Common and expected side effects, such as bone and joint pains, hot flashes, cognitive dysfunction (commonly termed “chemo-brain”) and impact on sexual function should be discussed, along with the evidence-based strategies to help manage these symptoms. In our study, patients noted that peer support (such as an in-person or virtual support group) as well as a website that provided clear information about side effects and management would be helpful, but these were not often provided. Patients also noted that an in-person or virtual visit with their physicians to discuss side effects would be helpful – this should ideally occur within 4-6 weeks of treatment initiation so that issues and concerns can be promptly addressed. 5-10 years is a long time to take a medication that is having a significant impact on quality of life – it is important that patient concerns are heard and addressed at every visit. 

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

17 August 2020

Last year, we asked the online breast cancer community to participate in a survey to assess experiences with endocrine therapy (ET). We are proud to announce that the study has now been published, in the Journal of Cancer Survivorship*.

First of all, I would like to thank all of the participants – we surpassed our accrual goals and this is the largest survey of ET use by patients who participate in online breast cancer communities! 

About the respondents:

  • 111 respondents did not start the recommended ET, and concern about side effects was the primary reason
  • Of those who took ET (2407), 2353 were women and 54 were men
  • Most of the women (74%) were post-menopausal
  • Mean age at diagnosis was 50 for women (range: 23-82) and 54 for men (range: 24-73)
  • Most (87%) were diagnosed at Stage 1-3
  • 100 (4.2%) were diagnosed with de novo Stage 4 / metastatic breast cancer
  • 12% of those diagnosed at an early stage eventually developed Stage 4 / metastatic breast cancer

Treatment:

  • Aromatase inhibitors (AIs) were the most commonly used medication
  • 91% of respondents reported at least one class of side effect that they felt was related to treatment (92% of women and 74% of men)
  • Musculoskeletal and general physical changes (such as weight gain and unhappiness with body image) were the side effects most commonly reported by women
  • Men most commonly reported sexual and cognitive / mood side effects
  • 33% (33% of women and 50% of men) discontinued therapy early
  • 9% reported that they took treatment breaks or discontinued therapy early either without informing their medical team or against their medical team’s advice

Side effect management:

  • 3 classes of side effect management strategies were felt to be most helpful:
    • Healthy diet, exercise, physical therapy
    • Complementary therapy such as yoga, acupuncture and meditation
    • Vitamins, supplements and herbs including medical marijuana 
  • Only 41% of respondents noted any relief from side effect management strategies

Medical team communication: (multiple responses permitted so this category did not add up to 100%)

  • 70% felt supported by their medical team in attempting to discuss side effects
  • 32% were made to feel that they should be better able to handle side effects or that the side effects were not related to treatment
  • 7% did not discuss side effects with their treatment team, feeling that there were more important issues to discuss, that there was not enough time, or they did not feel comfortable

Some other findings:

  • Respondents with early-stage and metastatic breast cancer reported similar side effects and management experiences, even though these two groups of patients have very different supportive needs
  • Men who responded to our survey were less likely to report side effects but more likely to discontinue therapy early compared to women – more information is needed about the experience of men with breast cancer and those taking endocrine therapy

Clearly, there is room for improvement in terms of medical team support and understanding. In addition, as only 41% of respondents noted any relief from side effect management strategies, we need more effective treatments for ET-related side effects. Thank you to all who participated in this survey! We are hopeful that your responses and comments will inspire researchers devote more time to addressing these important issues.

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

13 May 2019

Note – the survey closed on July 7th 2019. Thank you to all who participated and shared, and we will be sure to post the results when they are available!

Approximately 25-30% of patients with breast cancer who are prescribed endocrine therapy do not complete the full course of treatment, and some patients never start. Side effects of endocrine therapy are well documented but there is very little literature on the role of the medical team in helping patients manage treatment-related side effects. 

This survey is being conducted for research purposes. It is a UCLA research survey, open to women and men with a history of breast cancer who have been treated with or who have received a recommendation for endocrine therapy. 

This survey is voluntary and is completely anonymous – no identifying information, including internet protocol (IP) addresses, will be collected. The survey should take approximately 15 minutes to complete. We value your time and your opinions. 

For questions regarding this study, you may contact principal investigator Dr. Deanna Attai By phone: (818) 333-2555; by email: dattai@mednet.ucla.edu; or by mail: 191 S. Buena Vista #415, Burbank, CA 91505

UCLA Office of the Human Research Protection Program (OHRPP):
If you have questions about your rights as a research subject, or if you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the UCLA OHRPP  By phone: (310) 206-2040; by email: participants@research.ucla.edu; or by mail: Box 951406, Los Angeles, CA  90095-1406

Research Survey Link

11 May 2013

In May 2013, I was invited to give a talk with my colleague Dr. Carol Connor at the annual meeting of the American Society of Breast Surgeons.  Our topic was “Endocrine Therapy for Breast Cancer”, and we discussed the literature supporting the use of tamoxifen and aromatase inhibitors for breast cancer, as well as adverse effects and treatment of adverse effects. We were then invited to submit a manuscript which was published in the Annals of Surgical Oncology. The following is a summary of our talk and manuscript. I would like to express my appreciation to the #BCSM Community, who responded to my request for information about adverse effects  – it allowed me to discuss not only the literature, but also real patient experiences.

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