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Considerations When Treating With Hormone Therapy



Adam M. Brufsky, MD, PhD: One thing that we have talked about a lot, and we’ve done a lot of work in our clinic with this, is osteoporosis from these drugs. Generally, if the patient’s bone density is low enough, their T-score is less than —1.5, or –2, we’ll offer them some sort of resort to therapy, like zoledronic acid, re-classed, or denosumab, Xgeva or Prolia.

Lynn Acierno, BSN, RN, OCN, RN-BC: Right.

Adam M. Brufsky, MD, PhD: For nurses who are listening to this, and other doctors, the issue is that this has to be coded properly. We run into this a lot. This is for prevention of cancer therapy induced bone loss. It’s not for osteopenia. It’s not for osteoporosis. There are a strict set of criteria to get payment for these drugs. We’ve run into this problem, occasionally, in our practice.

Lynn Acierno, BSN, RN, OCN, RN-BC: And, of course for the patients who are on this family of drugs, we have them take a calcium with vitamin D, daily.

Adam M. Brufsky, MD, PhD: Exactly, that’s a big thing.

Lynn Acierno, BSN, RN, OCN, RN-BC: We also suggest weight-bearing exercises.

Adam M. Brufsky, MD, PhD: Weight-bearing exercises. Also, we tell them to wash their mouth because there’s a small incidence of osteonecrosis of the jaw. However, it’s very uncommon. When we put people on that, because they’ve either read about it or have seen it on television, the first thing they say is, “You put me on this drug. Is my jaw going to fall apart?” Have you had this conversation with people?

Lynn Acierno, BSN, RN, OCN, RN-BC: Perhaps, once or twice.

Adam M. Brufsky, MD, PhD: Yes, perhaps. She’s laughing because she actually has had that conversation. So, these are things that people worry about with receptor-positive breast cancer. But, the nice thing is, the vast majority of people with what’s called luminal A, low-risk hormone-receptor positive breast cancer will survive. We’re talking about a 97%, 5-year disease-free survival; or, a 95%, 10-year survival. I think the vast majority of people are going to be absolutely fine, which is great. This is really the cool part of our business.

Lynn Acierno, BSN, RN, OCN, RN-BC: How do you determine whether to keep a patient on 5 or 10 years of therapy?

Adam M. Brufsky, MD, PhD: That’s a great question. It’s a question that you get all the time. I think that the reflex was always for 10 years. Aromatase inhibitors, however, are another story. The data’s still very uncertain. We did a big trial where women got 5 years of aromatase therapy versus 10. Statistically, there was no difference between the 5- and 10-year arm in terms of disease-free survival. But there were numerically fewer recurrences in the 10-year arm. So, we’re kind of trying to figure out who should get what. That’s unknown. Right now, most people get 5 years of therapy, unless they don’t want to stop.

Lynn Acierno, BSN, RN, OCN, RN-BC: Right.

Adam M. Brufsky, MD, PhD: We talk about the risks and benefits. The risks are arthralgias, osteoporosis, and that sort of thing.

Lynn Acierno, BSN, RN, OCN, RN-BC: Right.

Adam M. Brufsky, MD, PhD: But the benefit is reduced recurrence. Most of those recurrences turn out to be in the breast. So, if a woman has had a bilateral mastectomy, I probably would tell her not to do it.

Tamoxifen is a different story. With tamoxifen, there seems to be benefit. In fact, there was a trial called ATLAS. This happened before you came into our practice. It must have been about 15 years ago. They came to us and asked us to participate in it. They had women who were on 5-year tamoxifen. It was not even a randomized trial. Then, they offered them another 5 years of therapy, and they recorded what happened to them.

It turns out, in that trial, there were fewer recurrences in the 10-year group. But the problem with that is you get more blood clots and endometrial cancer. So, I dialed back a little bit. I don’t give it to everybody, any more. Now, if someone is high risk for recurrence, someone who has a lot of lymph nodes, up front, and they had cancer when we first started, I may think very strongly of giving that. It’s the same for people who are premenopausal. I don’t give luteinizing hormone-releasing hormone agonists, like Lupron or Zoladex, to everybody. The side effect profile of those drugs tends to be a lot harsher for the benefit you get. And so, it’s really for someone who is at higher risk—someone who has a lot of lymph nodes, or had a big tumor. And those are the same people I tend to give 5, 10 years of therapy to.

Lynn Acierno, BSN, RN, OCN, RN-BC: Have you ever had a patient say, “Can I be on Arimidex forever?”

Adam M. Brufsky, MD, PhD: Absolutely. I have a lot of them. There is a trial which had women on tamoxifen for 5 years. Then, they got letrozole for another 5 years. Then, they randomized them to either nothing or another 5 years of letrozole. The people who got an extra 5 years of letrozole had fewer recurrences, mostly in the breast. But they had a lot more osteoporosis. I’ve had a woman, in my practice, for almost 13 years. She wanted to continue. Yes, they want to continue forever.

Lynn Acierno, BSN, RN, OCN, RN-BC: As the nurse, we make sure they get their DEXA scans every 2 years.

Adam M. Brufsky, MD, PhD: That’s an important thing to do, especially in this era where we’re pushing back DEXA scans to 2 years, 3 years, or 4 years. Insurance won’t pay for it. This is a big problem. This is very, very important. I think my colleagues around the country have differing opinions. But, for me, I tend to really reserve long-term therapy for people who are at a high risk for recurrence.

We have some genomic tests, like the BCI [Breast Cancer Index] and ENDOPredict, that help tell us who’s going to recur, between years 5 and 10. We are starting to use those tests to help us, but they’re not widespread. They’re expensive. Insurance doesn’t like to pay for them. It’s interesting to see how we’re going to do this.

Transcript Edited for Clarity

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