AROMATASE INHIBITORS:
ESSENTIAL TOOLS IN THE MANAGEMENT OF HORMONE RECEPTOR POSITIVE BREAST CANCER
Aromatase Inhibitors: The Power of a Unified Approach
At Learn Look Locate, we believe that the best care comes from a collaborative approach. By uniting the expertise of oncology pharmacists, medical oncologists, and the real experiences of breast cancer survivors, we create a comprehensive support system. When survivors like Kelly, specialty pharmacists like Alex Cosimano, and experts like Dr. William Audeh come together, it’s not just about managing medication—it’s about offering personalized guidance and addressing every aspect of your journey. This unified approach ensures you have the knowledge, resources, and support you need to navigate aromatase inhibitors and achieve the best possible outcomes.
With Walgreens Specialty Pharmacy as a key resource, you’ll have access to the support you need to navigate aromatase inhibitors with confidence. This unified approach ensures you have the knowledge, resources, and support to achieve the best possible outcomes. We hope this guide becomes your go-to resource, providing you with answers and comfort throughout your journey.
Expert Insights and a Patient’s Perspective
Dr. William Audeh, Medical Oncologist, Medical Advisor for Learn Look Locate and Breast Cancer Survivor-Kelly
Dr. Williams Audeh
Medical Oncologist, Medical Advisor for Learn Look Locate
“Aromatase inhibitors are essential for managing hormone receptor-positive breast cancer and reducing your risk of recurrence. Understanding the benefits and side effects is essential in empowering you to have a robust conversation about your treatment with your care team.”
Alex Cosimano, PharmD
Walgreens Specialty Pharmacist Medical Advisor for Learn Look Locate
“Reading about the potential side effects of aromatase inhibitors can feel overwhelming, especially after the journey you’ve already been through. However, staying on your medication is crucial for your continued health and well-being. By talking to your pharmacist, you can get personalized advice on what to expect and how to manage any side effects. We’re here to support you every step of the way, help us empower you to take control of your health and feel your best.”
The 3 Aromatase Inhibitors:
These medications are widely used to treat various stages of hormone receptor-positive breast cancer.
Anastrozole
(Arimidex®)
Letrozole
(Femara®)
Exemestane
(Aromasin®)
Understanding
Aromatase Inhibitors:
Aromatase inhibitors are a class of medications consisting of three drugs: anastrozole, letrozole and exemestane, that block estrogen uptake in the body. Their primary use is in the treatment of hormone receptor-positive breast cancer.
In early-stage breast cancer, they are often given after surgery (in the adjuvant setting) to decrease the risk of invasive cancer returning. Sometimes they will be given prior to surgery to shrink or slow the growth of the cancer. In advanced-stage (or metastatic) breast cancer, they may be used alone or in combination with other medications to slow the growth of cancer.
You may hear about this class of medication used in women who do not have cancer. Aromatase inhibitors are sometimes used to lower breast cancer risk in women who are found to be at an increased risk.
Your healthcare provider can help you to understand your risk and discuss the pros and cons of using medication to lower risk. Aromatase inhibitors may also be used as a part of fertility treatment and for other hormone imbalances as directed by a healthcare provider.
Concurrent use of aromatase inhibitors with tamoxifen is discouraged.
How Do Aromatase
Inhibitors Function?
Aromatase inhibitors lower estrogen production all over the body, preventing cancer cells from using that estrogen as fuel to grow. After menopause, when the ovaries no longer produce estrogen, it is still produced in smaller amounts in other areas of the body (such as the brain, fat cells, adrenal glands, and the breast tissue itself). In all of these areas of the body, estrogen is produced by an enzyme called aromatase. By blocking the activity of this enzyme, estrogen production is shut down.
Aromatase Inhibitors
Are Typically Prescribed For:
Early-Stage
Hormone Receptor Positive
- Early-stage hormone receptor-positive breast cancer in postmenopausal women
Advanced-Stage
Hormone Receptor Positive
- Advanced-stage hormone receptor-positive breast cancer in postmenopausal women, alone or in combination with another cancer-treating medication
Early/Advanced-Stage
Hormone Receptor Positive
- May also be prescribed for early- or advanced-stage hormone receptor-positive premenopausal women who receive medication to suppress their ovaries
Aromatase
Inhibitors
Should Not
Be Taken By
Women Who:
- Are pregnant or breastfeeding
- Have a history of serious adverse reactions to this class of medications
- Have severe osteoporosis
Advantages
The Advantages of Aromatase Inhibitors
Aromatase inhibitors may decrease the risk of breast cancer recurrence by about 50% and decrease the risk of death from breast cancer by about 30%. *
*Pan, H., et al. 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years. J Engl J Med, 2017 Nov 9;377(19):1836–1846.
Early Breast Cancer Tiralists’ Collaborative Group. Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomized trials. The Lancet, October 03, 2015; Volume 386, Issue 10001p1341-1352.
How to take
Aromatase Inhibitors
Duration:
How to take Aromatase Inhibitors:
These medications can be taken at any time of day, with or without food. You should be consistent with the time of day at which you choose to take them.
Each medication comes as a standard dose and should be taken once daily. These medications have equal efficacy and similar potential side effects. The duration of therapy depends on diagnosis, tolerance, and other factors but is commonly recommended for 5 years following surgery.
Your team may use a genomic test to determine the benefit of taking these medications for longer than 5 years. Discuss your plan with your care team.
Side Effects:
Some women may take aromatase inhibitors without any noticeable side effects. However, many women will experience mild side effects, and it is important to talk to your health care team about your symptoms. Many side effects will resolve soon after the medication is stopped.
Though there are three different medications in this class, they have similar potential side effects. Sometimes, women will take one of the medications and have difficulties with side effects, yet a different medication will be well tolerated. Again, it is so very important to discuss how you are feeling with your care team! There are many ways they can help you manage.
Common potential side effects include: hot flashes, fatigue, vaginal dryness, difficulty sleeping, mood changes, joint or muscle aches, brain fog, and hair thinning. Less common side effects include elevated cholesterol and blood pressure, and heart problems. Another possible side effect of aromatase inhibitors is bone density loss. This is not a side effect that you will feel. Your health care provider will monitor the health of your bones with a bone density scan (DXA) and may recommend exercise or supplements to keep your bones strong. Your health care provider may recommend a baseline bone density test.
Medications to Avoid:
In general, aromatase inhibitors are safe to take with most medications and foods.
Always tell your health care team about all medications, herbs, supplements, or vitamins that you are taking, as these may interfere with your cancer or cancer treatment.
With all three aromatase inhibitors, it is important to avoid estrogen derivatives or estrogen supplements (like estradiol).
If you are taking any of the following medications, please discuss with your healthcare team before starting an aromatase inhibitor: aripiprazole (Abilify®), dofetilide (Tikosyn®), rifampin, rifabutin (Mycobutin®), St. John’s Wort, carbamazepine (Tegretol®), phenobarbital, or phenytoin (Dilantin®). These are only some of the medications that may interact with an aromatase inhibitor. Discuss all medications, vitamins and supplements you take with your healthcare team.
Affordability:
Cost of Aromatase Inhibitors
This class of medications is generally affordable. They are widely covered by commercial insurance and Medicare Part D. The cost can vary depending on the specific medication, whether it is brand-name or generic, and the pharmacy. There may also be coupons available (ex. GoodRx).
A one-month supply of generic medication may cost around $15. Exemestane (Aromasin®) may be slightly more expensive. Please notify your healthcare team if you are not able to afford the medication prescribed.
FAQS
Got Questions?:
Provided by Walgreens Specialty Pharmacy
Meet Kelly-Breast Cancer Survivor
“Be an advocate for yourself and your own cancer journey.
Establish a relationship with your medical oncologist. This means having the ability to have open conversations around your options and knowing they will have your back through the tough days. Also, although aromatase inhibitors are available at any pharmacy, my oncology specialty pharmacist was my cheerleader in staying the course. These two professionals are critical in your long-term care through cancer.
Create milestones for yourself and celebrate with a massage or a weekend getaway. But on those bad days, remember it is temporary….you can get through it.”
Aromatase Inhibitor
Patient Guide
Provided by Walgreens Specialty Pharmacy
Table of Contents
Common Survivor FAQs
Aromatase Inhibitors
Tamoxifen
Table of Contents
(click to scroll back to TOC)
What is this Aromatase Inhibitor Guide and who should use it?
- This guide answers common questions about hormone therapy for breast cancer in cisgender women (meaning women who were assigned female at birth).
- Because there are different considerations for cisgender men, transgender men, and transgender women, people who are not cisgender women should talk with their cancer care team about their specific treatment plan.
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What is Hormone Therapy?
(also called Endocrine Therapy)
- Before we talk about hormone therapy, we should first talk about hormones.
- Hormones are chemical messengers made in the body that travel through your bloodstream to different cells and tissues.
- Estrogen and progesterone are hormones produced in the ovaries in premenopausal women. In all women, other tissues can also make these hormones (like fat cells and the skin).
- Some types of breast cancer (called hormone receptor-positive or simply HR-positive) use estrogen and/or progesterone to grow. About 67% to 80% of breast cancers in women are HR-positive.
- Hormone therapy is used in HR-positive breast cancer to either
- Stop the body from making these hormones or
- Change how these hormones work with the cancer cells. When used as treatment, the goal is to slow or stop the growth of the cancer cells.
Sometimes hormone therapy can also be used to prevent cancer from coming back.
- This guide talks about the two main types of hormone therapy:
- Aromatase inhibitors (includes anastrozole, exemestane, and letrozole)
- Selective estrogen receptor modulators (namely tamoxifen)
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Will Hormone Therapy Affect My Fertility?
- Many women ask if hormone therapy will affect their ability to get pregnant in the future. Concerns about infertility may even lead some women not to take their medication, putting them at risk for their cancer to return, grow, or spread.
- Some cancer therapy, including hormone therapy, can affect your reproductive health and fertility. The effects may be permanent or may be temporary.
- Premenopausal women can talk to an oncofertility specialist about different fertility preservation options for patients with cancer. These options may include embryo banking (using IVF) or egg banking.
- Walgreens is here to help support your unique journey.
Click here for more info - Return to the table of contents
What If I’m Having a Hard Time Taking My Medication Every Day?
- It’s hard! The good news is that whether it’s from forgetting, side effects or concerns about the medication, your cancer care team (including your pharmacist) is here to help.
- Depending on where you are in your cancer journey, your hormone therapy may be to help prevent your cancer from coming back, growing, or spreading. But remember, the medication only works if you take it.
- If you’re having a hard time remembering to take your medication:
- Use reminder aids such as cell phone alarms, silent watch alarms, cell phone apps, or other electronic reminders (email, calendar, text).
- Use a paper or digital calendar to record when your medication is taken.
- Build it into your existing routine, timing your dose with something you already do every day (brushing your teeth, your morning coffee, favorite show, etc.).
- Store medications in a visible, easy to spot location, such as your nightstand or next to where you charge your phone.
- Ask family members or friends to help you remember to take your medication.
- If you’re having or are worried about having side effects:
- Your pharmacist and cancer care team can give recommendations that can help you self-manage your side effects at home.
- They can also help you create a plan so you’re prepared if you do start experiencing side effects.
- If you’re unsure or hesitant about your medication:
- Ask your pharmacist and cancer care team any questions you have about your medication. Having a better understanding of the what and the why can help you stay motivated throughout your treatment plan.
- No matter the reason, your pharmacists and cancer care team are here to help.
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What is an Aromatase Inhibitor?
- Aromatase inhibitors are a type of medication that lowers estrogen levels in the body. They do this by stopping the enzyme aromatase from turning other hormones into estrogen.
- There are three aromatase inhibitors. They all work the same way and have very similar side effects, but because everyone is different, some people may respond better to one over the others.
- Anastrozole (Arimidex®)
- Exemestane (Aromasin®)
- Letrozole (Femara®)
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Who Should Take An Aromatase Inhibitor?
- Aromatase inhibitors are used in hormone receptor-positive breast cancer. With this type of cancer, the cancer cells use estrogen to grow. By lowering the amount of estrogen in the body, the cancer cells can’t get the estrogen they need to grow.
- Aromatase inhibitors can be used in early breast cancer and in advanced breast cancer.
- Aromatase inhibitors should only be used in postmenopausal women. Women can become postmenopausal in different ways.
Natural menopause: when the body permanently stops menstruation due to reaching a new stage in life.
Surgical menopause: When both ovaries are removed (called a bilateral oophorectomy).
Medical menopause: when a premenopausal woman takes medication that suppresses the ovaries.
- Premenopausal women (meaning women who have not reached menopause) would need either surgery or medication to stop their ovaries from making estrogen. Surgical intervention is permanent, but medicine-induced menopause with hormone suppression is normally temporary.
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Who Should Not Take an Aromatase Inhibitor?
- Women with ovaries that produce estrogen should not take aromatase inhibitors. The aromatase inhibitors will not work in women that have not yet gone through menopause. Premenopausal women would need either surgery or ovarian-suppressing medicine to induce menopause before starting an aromatase inhibitors.
- Aromatase inhibitors will not work in women that have hormone receptor-negative breast cancer.
- Anyone who has had a severe allergic reaction to an aromatase inhibitors in the past should not take that aromatase inhibitors again.
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How Does an Aromatase Inhibitor Help Me?
- Aromatase inhibitors can be used to treat cancer or prevent it from recurring.
- When used to treat cancer, aromatase inhibitors are only effective against hormone receptor-positive breast cancer. With this type of cancer, the cancer cells use estrogen to grow.
- By lowering the amount of estrogen in the body, aromatase inhibitors starve the cancer cells of the estrogen they need to grow.
- Aromatase inhibitors are used to treat both early and advanced breast cancer.
- Early Breast Cancer
- Neoadjuvant Therapy: Aromatase inhibitors are used to shrink the tumor before surgery.
- Adjuvant Therapy: Aromatase inhibitors are used to reduce the risk of breast cancer returning and can even reduce the risk of dying from breast cancer after surgery.
- Advanced Breast Cancer
- Aromatase inhibitors can also be used if the cancer has come back after treatment (recurs) or has spread to other parts of the body (metastatic breast cancer). They can slow the growth of the tumor or may shrink it for a period of time. They may be prescribed alone or with a targeted therapy.
- Early Breast Cancer
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What are the Side Effects of Aromatase Inhibitors?
- Some common side effects of aromatase inhibitors include:
- Bone pain
- Feeling tired
- Headache
- Hot flashes
- Joint pain, stiffness, or swelling
- Muscle pains
- Nausea
- Vaginal dryness
- Your healthcare provider will pay close attention to your bone health while you are on aromatase inhibitor therapy.
Because aromatase inhibitors lower the amount of estrogen in your body, they could reduce your bone mineral density (BMD) over time, which means your bones could become thinner and weaker. This may increase your risk of experiencing a bone fracture.
Your care team will check your bones during your aromatase inhibitor treatment to see if you have or are at risk for developing osteoporosis, which is when the bones become fragile and more likely to fracture.
Your care team may recommend certain weight-bearing exercises to help strengthen your bones. They may also prescribe medication that can help protect your bones.
- Talking openly with your care team, including your pharmacist, is important. Talk about your concerns and any side effects you may be experiencing. They can help give you tips to manage these side effects at home.
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How Long Will I Need to Take and an Aromatase Inhibitor?
- Your healthcare provider will tell you how long you can plan on taking your aromatase inhibitor. It’s important to keep taking your aromatase inhibitor every day until your healthcare provider tells you to stop.
- Early breast cancer:
It’s common to take an aromatase inhibitor for 5 to 10 years. Some women may benefit from taking it for longer.
When taken every day for at least 5 years, your aromatase inhibitor can help prevent your cancer from coming back and can reduce the risk of dying from breast cancer.
- Advanced breast cancer:
Often women with advanced breast cancer will take their aromatase inhibitor every day until the medication stops working. Some women may take their aromatase inhibitor for many years. If your aromatase inhibitor stops working, your healthcare provider may talk with you about switching to a different aromatase inhibitor or to a different hormone therapy.
- If you’re having a hard time taking your aromatase inhibitor every day, you’re not alone. Speak to your pharmacist or oncology care team for help.
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Are There Any Drug Interactions with Aromatase Inhibitors?
- While the aromatase inhibitors are very similar, they have different drug interactions to be aware of.
- It’s important to talk with your pharmacist and cancer care team about all the medications you take, both prescription and non-prescription, including herbal supplements, nutraceuticals, or over-the-counter remedies.
- Anastrozole:
- Do not take with tamoxifen.
Do not take with estrogen-containing therapies such as hormone replacement therapy, estrogen creams or vaginal suppositories, or hormonal contraceptive vaginal rings, patches, or pills (i.e., birth control pills).
- Exemestane:
- Do not take with grapefruit or grapefruit juice.
- Do not take with the herbal remedy called St. John’s wort.
- Do not take with estrogen-containing therapies such as hormone replacement therapy, estrogen creams or vaginal suppositories, or hormonal contraceptive vaginal rings, patches, or pills (i.e., birth control pills).
- Letrozole:
- Do not take with tamoxifen.
- Do not take with estrogen-containing therapies such as hormone replacement therapy, estrogen creams or vaginal suppositories, or hormonal contraceptive vaginal rings, patches, or pills (i.e., birth control pills).
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How Should I Take My Aromatase Inhibitor?
- Be sure to take your medication exactly as your cancer care team tells you. Continue taking your aromatase inhibitor until your healthcare provider tells you to stop.
- Usually, an aromatase inhibitor is taken once a day, every day.
- If you are taking anastrozole or letrozole, you may take it with or without food.
- If you are taking exemestane, you should take it after a meal.
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What is a selective estrogen receptor modulator (SERM)?
- A SERM is a type of medication that binds to estrogen receptors on cells, which prevents estrogen from affecting the cells. This means that a SERM doesn’t lower the amount of estrogen in your body, but it can block the cancer cells in breast tissue from being able to use the estrogen.
- Tamoxifen is the most common SERM used for breast cancer.
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Who should take Tamoxifen?
- Tamoxifen is used in hormone receptor-positive breast cancer. With this type of cancer, the cancer cells use estrogen to grow. tamoxifen prevents estrogen from binding to cancer cells, so the cancer cells can’t get the estrogen they need to grow.
- Tamoxifen can be used by both premenopausal and postmenopausal women.
- Tamoxifen can be used in early breast cancer and in advanced breast cancer.
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Who Should not take Tamoxifen?
Tamoxifen will not work in women that have hormone receptor-negative breast cancer.
Anyone who has had a severe allergic reaction to tamoxifen in the past should not take tamoxifen again.
- Tamoxifen should not be taken in women with a history of blood clots (known as thromboembolism), such as deep vein thrombosis (DVT), pulmonary embolism (PE), or stroke. tamoxifen should not be taken by women who need to take warfarin to prevent blood clots.
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How Does Tamoxifen Help Me?
Tamoxifen has been a beacon of hope for countless individuals diagnosed with hormone receptor-positive breast cancer. Its benefits include:
- Diminishing the risk of breast cancer recurrence by up to 50%.
- Halving the risk of developing cancer in the opposite breast.
- Ancillary health benefits, such as improved bone density post-menopause and cholesterol level reduction.
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How Does Tamoxifen function?
Tamoxifen operates by hindering estrogen’s influence on hormone receptor-positive breast cancer cells. It achieves this by occupying the estrogen receptors on these cells, preventing estrogen from driving the growth and multiplication of these malignant cells. Notably, its efficacy is limited to hormone receptor-positive breast cancer.
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Side Effects of Tamoxifen?
Tamoxifen is available both as a pill and liquid, catering to individual preferences. Typically, it’s taken daily, with consistency in timing being crucial. Duration varies based on diagnosis and individual factors, but it’s generally prescribed for five years post-surgery. Ongoing consultations with oncologists help .
While tamoxifen has undoubted benefits, it’s not without its side effects. Common ones include:
- Hot flashes
- Mood fluctuations
- Fatigue
- Nausea
However, some rare but severe side effects necessitate immediate medical attention, including:
- Signs of endometrial cancer
- Blood clot symptoms
- Stroke indications
- Cataract development
- Liver complications
Regular communication with healthcare providers can ensure effective side effect management and timely interventions.
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How long will I need to take Tamoxifen?
Typically, tamoxifen is taken for five years after surgery, but different options are available depending on individual circumstances. Some patients may benefit from taking 2-3 years of tamoxifen followed by an aromatase inhibitor, while others may benefit from up to 10 years of tamoxifen therapy. Consult with your oncologist to determine the optimal treatment duration for your specific situation.
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Are there any drug interactions with Tamoxifen?
Certain medications can diminish tamoxifen’s effectiveness. It’s crucial to consult healthcare providers regarding any potential drug interactions, especially such as with certain medications you may take for depression or overactive bladder.
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What does Tamoxifen cost?
Tamoxifen’s long-standing generic availability means there are no dedicated pharmaceutical support programs. However, for those prescribed the liquid form, Soltamox, there may be prescription card eligibility. Patients facing financial constraints are advised to explore local programs or consult their care team for assistance.
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Common Survivor FAQs About Aromatase Inhibitors
Provided by Walgreens Specialty Pharmacy
1. If I am a grade one stage one ultra low MammaPrint® breast cancer patient, do I have to take tamoxifen?”
People with MammaPrint® UltraLow Risk may be able to safely discontinue endocrine therapy early and avoid unnecessary toxicity. A study published in JAMA Oncology found 20 years after their diagnosis, postmenopausal women with early-stage breast cancer had a 97% breast cancer specific survival (BCSS) rate with 2-5 years of tamoxifen. Talk to your doctor about the best option for you.
REFERENCES –
2. I started letrozole on May 5th, and my doctor mentioned a 5-year treatment plan with a possible extension to 10 years. Are there any risks associated with taking it beyond 10 years?
The optimal duration of endocrine therapy is still a matter of debate. The benefit beyond 5 years is based on the individual’s risk of relapse while taking into consideration the long-term side effects of the treatment. There is no evidence to suggest the benefit of endocrine therapy beyond 10 years. A review of studies showed that extended endocrine therapy with aromatase inhibitors increased the risk of cardiotoxicity, bone pain, osteoporosis, fractures, arthralgia, myalgia, and hot flashes. While extended endocrine therapy increased the risk of these side effects, it also reduced the risk of breast cancer recurrence, whether local, distant, or opposite breast, and second cancers.
REFERENCES –
3. Why did my oncologist advise against taking turkey tail and does it have an effect on aromatose inhibitors?
There is limited research on whether turkey tail extract may help with breast cancer. In one older and very small phase 1 clinical trial, nine participants with stage 1, 2, or 3 breast cancer underwent standard chemotherapy and radiation treatments. They then took 3, 6, or 9 grams of turkey tail extract in divided doses each day for 6 weeks. After their analyses, the researchers found that the extract contributed to increased levels of cancer-fighting cells in the immune system. However, this was a very low number of participants. More clinical trials involving larger numbers of participants are necessary to draw any conclusions.
An upcoming phase 2 trial will test how well turkey tail mushroom (TTM) works in treating post-menopausal women with HER2-negative, estrogen receptor (ER)-positive breast cancer undergoing surgery. There is previous evidence of significant tumor shrinkage occurring in the 2-month window between diagnosis and surgery in women who have taken TTM. Giving TTM may be effective in treating post-menopausal women with HER2-negative, ER-positive breast cancer undergoing surgery
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4. I am currently taking anastrozole and my doctor is adding abemaciclib. I am concerned about the side effects. How can I manage my side effects?
In a study of abemaciclib (Verzenio®) taken with an aromatase inhibitor, it was common for women to experience diarrhea, which was sometimes severe. In some cases, diarrhea led to dehydration or infection. Diarrhea was most common during the first month and then decreased.
The diarrhea can typically be managed by an anti-diarrheal medicine (for example, loperamide, which is sometimes sold under the brand name Imodium®) and/or by your oncologist reducing the dose.
REFERENCES –
5. I am on letrozole, the joint, muscle bone pain is awful, is there anything to make the pain more bearable?
Aromatase inhibitors, such as letrozole, are associated with muscular and skeletal side effects known as the aromatase inhibitor-associated musculoskeletal syndrome (AIMSS). AIMSS is mainly comprised of aromatase inhibitors associated bone loss and joint pain, stiffness, aching, or soreness but can also include carpal tunnel syndrome (CTS), muscle pain, and muscle weakness.
Nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen, etc.) and acetaminophen (Tylenol®) can be used for pain control in the short-term.
Some studies have shown improvements in AIMSS symptoms with exercise and yoga. The exercise program included 150 minutes of aerobic exercise and 2 strength-training sessions per week. This could include walking, cycling, swimming, planks, overhead press, and squats. Yoga was performed 5 times per week.
In a small study, acupuncture was found to decease AIMSS pain. Participants received twelve 30-45 minute sessions over 6 weeks (2 per week), followed by 1 session per week for 6 weeks.
The prescription medication Cymbalta® (duloxetine) was shown to provide a pain relieving effect in people with AIMSS. However, Cymbalta® can cause fatigue, nausea, dry mouth, and headache which may limit use in some people.
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6. If breast cancer is fueled by estrogen, why aren't hormone tests routinely done before starting medication after menopause?
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7. Why do hormone blockers have such debilitating side effects? Be sure to take talk to your pharmacist
Estrogen regulates important processes in your skeletal, cardiovascular, and central nervous systems that impact your overall health. Estrogen affects:
• Cholesterol levels.
• Blood sugar levels.
• Bone and muscle mass.
• Circulation and blood flow.
• Collagen production and moisture in your skin.
• Brain function, including your ability to focus.
Hormone therapy for breast cancer includes therapies that block estrogen production or block the effects of estrogen. The decrease in estrogen levels means that the above functions are impaired and leads to side effects such as hot flashes, night sweats, vaginal dryness, bone loss, joint pain, and mood swings or depression.
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8. How do you stop the horrible brain fog ?
Brain fog – Most of the research into cancer-related cognitive impairment (CRCI) has been in women with breast cancer who have had chemotherapy before starting endocrine therapy (ET). The literature suggests cognitive symptoms are more common with chemotherapy than ET. For more information on chemo brain, see the American Cancer Society webpage.
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9. I have Lichen Sclerosus, which is linked to low estrogen levels. I'm about to start tamoxifen and radiation therapy, and I'm worried that my condition might worsen. Could these treatments exacerbate my Lichen sclerosus?
Women taking medications that lower estrogen may be at an increased risk for developing lichen sclerosus. The recommended treatment is a prescribed topical steroid ointment. After 3 months, about 70% of adult female patients achieve remission. Treatment should be continued in a regular regimen once or twice per week for ongoing active lichen sclerosus disease.
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10. I had a hysterectomy. Do I need letrozole if my cancer was estrogen receptor positive?
A hysterectomy is the surgical removal of the uterus and may or may not include the removal of the cervix, ovaries and fallopian tubes. If the ovaries are removed as part of a hysterectomy, a woman will immediately enter menopause.
Before menopause, most estrogen is made by the ovaries. After menopause, estrogen is still made in body fat by an enzyme called aromatase. Therefore, treatment with an aromatase inhibitor, such as letrozole, is still needed to prevent aromatase from making estrogen.
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11. I am taking anastrozole every other day to decrease the impact of side effects. What are the outcomes of this type of dosing?
No studies have been conducted on the efficacy of taking anastrozole every other day. A study of intermittent versus continuous dosing of letrozole was conducted in postmenopausal women who had completed 4-6 years of adjuvant endocrine therapy and were clinically disease free of breast cancer. Patients received either continuous letrozole (2.5 mg daily for 5 years) or intermittent use (2.5 mg daily for 9 months followed by a 3-month break in years 1-4 and then 2.5 mg daily in year 5). This study found that intermittent dosing can result in better tolerability without significantly affecting disease outcomes.
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12. What are the guidelines to check bone density yearly? How about cardiac what tests to check the health of heart and how often?
The National Comprehensive Cancer Network (NCCN) guidelines for breast cancer v4.2024 recommends that patients on an aromatase inhibitor or who experience ovarian failure (early menopause) due to treatment should receive a bone mineral density determination at baseline and periodically thereafter.
The 2013 National Comprehensive Cancer Network task force report on bone health in cancer care recommends that patients with cancer with elevated fracture risk should be evaluated with dual-energy x-ray absorptiometry (DEXA) every 24 months. In some cases, such as when the risk of bone loss has changed significantly or a major new treatment has been started, having a 12-month follow-up DEXA is reasonable. Changes in DEXA scan in response to bone treatment typically occur over a long period, so DEXA scans should generally not be performed more than once a year.
The American Heart Association scientific statement on hormonal therapies for cancer notes that there are no definitive guidelines for monitoring and managing hormonal therapy–related cardiac toxicity. Much of the monitoring for women receiving endocrine therapy for breast cancer should depend on prior use of chemotherapy such as anthracyclines, targeted therapy such as Herceptin (trastuzumab), and radiation therapy because these agents have direct cardiotoxic effects. Monitoring patients who have undergone prior treatment with these therapies may include routine annual ECGs, biomarkers (with BNP [brain natriuretic peptide] or troponins), and cardiovascular imaging (with 2-dimensional or 3-dimensional echocardiography with speckle tracking imaging, cardiac magnetic resonance imaging, or stress tests as appropriate) for improved cardiovascular disease risk identification during endocrine therapy, depending on prior therapy received for individual cancer
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13. Is taking anastrozole effective for an estrogen receptor diagnosis of 5%, or do the side effects outweigh the benefits?
Breast cancers with 1-10% estrogen receptor (ER) positivity are considered ER-low-positive. There are limited data on the benefit of endocrine therapies in this group, but they suggest possible benefit from endocrine treatment, so patients are considered eligible for this treatment. Individualized consideration of the risk versus benefits of endocrine therapy and any additional treatments should be taken into consideration when determining the treatment plan.
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14. Could gasping for air be a side effect of letrozole?
Shortness of breath was reported in clinical trials of letrozole in 5-18% of participants. See the American Cancer Society webpage for information on managing this side effect.
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15. Been advised to go have all my dental work done, what impact does this have on our oral health?
In a study sample of 423 female breast cancer survivors, 7.1% were taking tamoxifen, 7.8% were taking anastrozole, 4.3% were taking letrozole, and 2.9% were taking exemestane. Compared with the survivors not taking such therapy, a greater proportion of those taking it had decayed teeth, gum disease/problems, and were recommended for imminent dental care after oral health examination by dentists. The survivors who were not taking adjuvant endocrine therapy had more cavities.
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16. I had lobular breast cancer and am on tamoxifen, planned for 2-5 years before switching to an aromatase inhibitors. Since I’m doing well on tamoxifen and my hormone levels are low, can I continue with tamoxifen instead?
Some people have stayed on tamoxifen for up to 10 years. However, tamoxifen is associated with an increased risk of endometrial cancer and some people develop resistance to therapy.
A trial of women with postmenopausal, node-positive, ER-positive breast cancer investigated the efficacy of switching from tamoxifen to anastrozole after 2-3 years of tamoxifen treatment. Participants in one group continued to receive tamoxifen 20 mg daily while the other group switched to anastrozole 1 mg daily for a total of 5 years of treatment. Those in the anastrozole group experienced longer relapse-free survival than those in the tamoxifen group.
Whether someone should stay on tamoxifen or switch to an aromatase inhibitor depends on their specific cancer type, menopause status, and risk of side effects.
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17. I have gained 20lbs since I have been on letrozole, but primary doctor said that is not the cause-could it be?
In one study of 2,448 people taking letrozole, 13% gained weight and about 6% lost weight.
However, the body’s metabolism naturally slows as we age and people often lose muscle mass. People also become less physically active as they get older. All of this can also contribute to weight gain.
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18. On anastrozole and have been bleeding every month, should I change to tamoxifen?
In a trial comparing anastrozole and tamoxifen for breast cancer, the women taking anastrozole were less likely to have problems with vaginal bleeding and discharge, blood clots in the veins (deep vein thrombosis, or DVT) and hot flushes.
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19. I have not slept a night in 4 years on exemestane, please help.
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20. Does Claritin® or Zyrtec® help joint pain from aromatase inhibitors?
There are no studies supporting the use of Claritin® or Zyrtec® to help manage joint pain from aromatase inhibitors.
21. How can we protect our bones?
The 2013 National Comprehensive Cancer Network task force report on bone health in cancer care recommends that patients with cancer with elevated fracture risk should:
• Be evaluated with dual-energy x-ray absorptiometry (DEXA) every 24 months. In some cases, such as when the risk of bone loss has changed significantly or a major new treatment has been started, having a 12-month follow-up DEXA is reasonable. Changes in DEXA scan in response to bone treatment typically occur over a long period, so DEXA scans should generally not be performed more than once a year.
• Implement lifestyle modifications such as at least 30 minutes per day of moderate physical activity (walking, cycling, swimming) and regular weight-bearing exercise. Avoiding tobacco use and excessive alcohol consumption as these can increase the risk of osteoporosis and fracture.
• Receive calcium and vitamin D supplementation. The Institute of Medicine (IOM) recommendations are 1200 mg/d of calcium for women and 1000 mg/d for men between 51 and 70 years, and 1200 mg for all individuals older than 70 years, with an upper level intake of 2000 mg/d. Calcium supplements are available as calcium carbonate or calcium citrate. Calcium carbonate requires gastric acid for optimal absorption and should therefore be taken with food. Calcium citrate does not require gastric acid for absorption, can be taken in between meals, and is the preferred option in patients receiving proton pump inhibitors. For optimal absorption, calcium supplements should be taken in divided doses of no more than 600 mg at one time.
The National Comprehensive Cancer Network (NCCN) guidelines for breast cancer v4.2024 states that the use of a bisphosphonate (oral or intravenous) or denosumab is acceptable to maintain or to improve bone mineral density and reduce risk of fractures in postmenopausal (natural or induced) patients receiving adjuvant aromatase inibitor therapy. The optimal duration of either therapy has not been established.
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22. My dose of letrozole seems to be standard. Can it be prescribed based on level of body fat?
Letrozole is metabolized by the liver which means that the liver helps break down the drug to be used by the body and then eliminates it from the body. Due to this process, dose adjustments are only required in people with liver cirrhosis or severe liver dysfunction. Body fat does not play a role in the metabolism of letrozole.
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REFERENCES
Arimidex® (anastrozole). Package insert. ANI Pharmaceuticals Inc; 2018.· Aromasin® (exemestane). Package insert. Pfizer Inc; 2021.
Femara® (letrozole). Package insert. Novartis Pharmaceuticals Corp; 2018.
Fertility Preservation. Walgreens Specialty Pharmacy. Accessed October 31, 2022.
https://www.walgreens.com/topic/pharmacy/specialty-pharmacy/fertility-preservation.jsp.Fertility Preservation Safe for Young Women with Breast Cancer. National Cancer Institute. Published December 22, 2020. Accessed October 31, 2022.
https://www.cancer.gov/news-events/cancer-currents-blog/2020/breast-cancer-fertility-preservation-safe.Hormone Therapy for Breast Cancer. National Cancer Institute. Updated July 12, 2022. Accessed October 28, 2022.
https://www.cancer.gov/types/breast/breast-hormone-therapy-fact-sheet.Nolvadex® (tamoxifen). Package insert. AstraZeneca Pharmaceuticals LP; 2006.
About the Experts
Alex Cosimano, PharmD Walgreens Specialty Pharmacist Medical Advisor for Learn Look Locate
Alex Cosimano, PharmD, CSP, is a highly skilled and compassionate board-certified specialty pharmacist with over 15 years of experience in community and specialty pharmacy. Currently serving as a Manager for Clinical Program Development in the Walgreens Office of Clinical Integrity, Alex specializes in oncology medications, research, and providing exceptional care to cancer patients through innovative pharmacy services. In his prior role, Alex served as an oncology-specialized pharmacist, where he was dedicated to managing the complex needs of oncology patients. He provided personalized care by addressing symptoms, ensuring medication adherence, and overcoming access barriers.
Williams Audeh, MD, MS Medical Oncologist, Medical Advisor for Learn Look Locate
Dr. William Audeh is a compassionate medical oncologist with over 30 years of experience dedicated to improving the lives of breast cancer patients. He combines cutting-edge research with personalized patient care, focusing on precision oncology and genetic testing. Dr. Audeh’s expertise spans from leading clinical trials to developing innovative genomic tests for more accurate breast cancer diagnosis and treatment.
Authentic Insights on Aromatase Inhibitors:
An Open Educational Conversation with Dr. William Audeh and Survivor Kelly
This comprehensive discussion on aromatase inhibitors explores their role in preventing breast cancer recurrence by suppressing estrogen. Dr. William Audeh explains their benefits, challenges, and side effects like joint pain and menopausal symptoms. Kelly, a breast cancer survivor, shares her journey with various aromatase inhibitors, emphasizing perseverance and collaboration with oncologists and pharmacists. Highlighting the importance of informed decision-making and personalized care, this conversation offers hope and practical advice for navigating hormone-based breast cancer treatments.
Paid Collaboration with Walgreens Specialty Pharmacy
