MANAGE MENOPAUSAL SYMPTOMS IN BREAST CANCER PATIENTS

Most patients with breast cancer will experience symptoms of menopause or clinical manifestations of estrogen deficiency after their therapy is completed. The prevalence of estrogen-deficiency symptoms in this population ranges from 79% to 95%.

Symptoms can vary in severity but may include sleep disorders, vulvovaginal atrophy (VVA), vasomotor symptoms, mood changes, depressive symptoms, cardiovascular disease, osteopenia, and osteoporosis.

A usual treatment for such menopausal symptoms is hormone replacement therapy, but its use is not recommended for those with a history of breast cancer.

So what can be used instead?

A comprehensive review of the evidence to help guide the management of menopausal signs and symptoms in breast cancer survivors, along with recommendations for guiding therapy, has now been published in the Journal of Clinical Endocrinology & Metabolism.

"Following breast cancer, women should generally not be treated with menopausal hormone therapy but should instead focus on lifestyle modifications such as smoking cessation, weight loss, and regular physical activity," lead author, Richard J. Santen, MD, from the University of Virginia Health System in Charlottesville, said in a statement.

"Pharmacologic agents are also available to treat women with severe symptoms," explained Dr Santen. "The most important thing to remember is that therapy must be individualized based on each woman's needs and goals."

For their review, Dr Santen and colleagues gathered evidence from controlled clinical trials, observational studies, evidence-based guidelines, and expert opinion from professional societies.

Key Recommendations

 The authors list several treatment recommendations, as follows:

• After breast cancer, menopause symptoms should generally not be treated with hormone therapy or the hormone-mimicker drug tibolone.
• Instead, lifestyle changes should be emphasized. These include smoking cessation, weight loss (if indicated), limiting or avoiding alcohol, maintaining adequate levels of vitamin D and calcium, eating a healthy diet, and regular physical activity.
• Mind-brain-behavior or nonhormone pharmacologic therapy may benefit women with moderate to severe symptoms.
• The selective serotonin/noradrenaline reuptake inhibitors and gabapentinoid agents may exert beneficial effects on vasomotor symptoms and quality of life, and numerous nonhormonal therapeutics are also available for osteoporosis.
• The authors note that the treatment of VVA "remains an area of unmet need," and while low-dose vaginal estrogen can be absorbed in small amounts without raising blood levels, it could potentially stimulate occult breast cancer cells.
• Vaginal laser therapy is currently being used for VVA, but efficacy from sham-controlled studies has not been established and is lacking.
• For dyspareunia, intravaginal dehydroepiandrosterone and oral ospemifene have been approved, but their safety after breast cancer has not yet been established.

Emerging Approaches

There are many emerging approaches for unmet needs in breast cancer survivors.

Because VVA and the osteopenia/osteoporosis/fracture complex are common issues among breast cancer survivors, a strategy that could help both conditions would be useful. One goal is to develop selective estrogen receptor modulators (SERMs, such as the original drug in this class, tamoxifen) that will not only help prevent breast cancer but also decrease bone resorption and prevent fractures and improve VVA symptoms.

Another approach is tissue selective estrogen complex (TSEC) agents. The authors note that the "concept of combining a SERM with an estrogen to create a TSEC has been studied intensively in the past decade." A TSEC paired with oral conjugated equine estrogen, such as bazedoxifene with conjugated estrogens (Duavee, Pfizer) has already been approved for VVA.

Several of the coauthors have disclosed relationships with industry, as noted in the paper.

J Clin Endocrinol Metab. Published online August 2, 2017. Abstract