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Breast Cancer Treatment: Weighing the Hormonal Options

Tamoxifen has been the standard in hormonal breast cancer treatment for decades. But newer treatments are challenging tamoxifen's superiority.

A Gentler, Milder Drug?

As for side effects, the old standby drug tamoxifen is associated with a higher risk of uterine cancer than the newer aromatase inhibitors. But some studies have shown that women taking aromatase inhibitors are more prone to bone fractures than those taking tamoxifen.

But in general, side effects from aromatase inhibitors are mild, Goss says. Studies on the various aromatase inhibitors have shown that the drugs are generally tolerated about as well as placebo and any side effects appear to be mild. But one side effect in particular, increased bone loss, does concern doctors, but it has not been seen to be a problem in the short term.

Another Hormonal Treatment

Still another type of hormonal therapy is Faslodex. Unlike the other drugs, which are given daily in the form of a pill, Faslodex is given as a monthly injection into the muscle.

The trials so far show only that Falsodex is effective for the treatment of metastatic breast cancer, not for newly diagnosed women undergoing surgery.

One study reported reported in December 2003 showed that Faslodex is about as effective as Arimidex in the treatment of postmenopausal women with advanced breast cancer (large cancers that have spread outside of the breast) whose disease continues to spread after treatment with tamoxifen. Investigator John E. Pippen, MD, of Baylor-Sammons Cancer Center in Dallas, says the findings should give more hope to women with advanced breast cancer, buttressing the fact they have options when other hormonal therapies fail.

Robert W. Carlson, MD, a professor of medicine (oncology) at Stanford University School of Medicine, says that ongoing studies are looking at Faslodex in the treatment of early breast cancer.

So What Should Women Be Doing?

There is no doubt that tamoxifen still has a major place in the prevention and treatment of breast cancer. For starters, aromatase inhibitors only work for postmenopausal women, Carlson points out.

So far, the main role of the aromatase inhibitors appears to be in treating postmenopausal women following breast cancer surgery, he says. But whether they should be on tamoxifen or an aromatase inhibitor following surgery is still an open question.

"Switching from tamoxifen to [aromatase inhibitors] does appear to be an effective strategy," he tells WebMD. "But there is still uncertainty about the optimal time for the switch and long-term side effects."

There are trials pitting the various agents against one another, trying to find the optimal duration of treatment and looking at the anti-aromatase agents for prevention and in the presurgical setting that will give more answers, he says.

"There are over 25 years of experience with tamoxifen in various settings. Aromatase inhibitors are still relative newcomers."

Life After Tamoxifen

As for women who already received the full benefit of five years of tamoxifen therapy, Goss says that Femara or Aromasin treatment may be a good option. "Until now, there was no other treatment option for women after five years of tamoxifen therapy," he says.

"The message here is if a woman has been on tamoxifen coming up on two to three years, she should talk to her specialist about switching to an aromatase inhibitor," Coombes says.

Patients like Anderson say the most important thing to do is talk to your oncologist. With all the data so rapidly coming out, even a primary care doctor might not be up to date on all the findings.

Putting together all the data, Lawrence Wickerham, MD, associate chairman of the National Surgical Adjuvant Breast and Bowel Project in Pittsburgh, tells WebMD, "The bottom line is, women now have a choice."

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