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BC hormone treatment question

Marker67
Posted by

Is the combination exemestane with zoladex better for triple positive BC? I'm reading reports of early tamoxifen resistance and failure for triple positive BC, and that aromatase inhibitors with ovarian suppression is better, even when premenopausal, could you shed some light on this? thank you!

Ellen M-Macmillan
Posted by

Hi Marker67,

Thanks for getting in touch with us and welcome to our Online Community.

It’s natural to ask questions about treatments after you have been diagnosed with breast cancer.

Decisions about treatments for breast cancer are made by a group of experts(MDT.) They consider the type, grade, hormone and HER2 status as well as the stage of your cancer.

There have been studies that have compared exemestane plus ovarian function suppression compared with tamoxifen alone. They do show increased survival benefits in patients who have a higher chance of recurrence. On that basis alone, I suppose it’s right to say that this combination is “better” than tamoxifen in some situations. But MDTs also have to think about the impact that the treatment will have on quality of life.

Endocrine therapy is a mainstay of curative treatment for early stage breast cancer. Treatment decisions need to include estimates of how effective they will be, the potential side effects, and the individual patient's tolerance for each.

Taking all of these variables into account, tamoxifen on its own seems to be a reasonable option for low-risk premenopausal women that do not have sufficient risk to warrant adjuvant chemotherapy.

The standard duration of adjuvant endocrine therapy is at least 5 years, but 10 years of either tamoxifen or 5 years of tamoxifen, followed by a switch to 5 years of an AI (if confirmed as postmenopausal after 5 years of tamoxifen) can be considered.

For higher risk premenopausal patients, particularly those aged <35 years who are more likely to find their ovaries beginning to work again after chemotherapy, there seems to be meaningful additional disease-specific benefit to be gained from ovarian function suppression. The benefit appears greater when combined with exemestane compared with tamoxifen. Some oncologists suggest that this should be offered to young patients deemed at particularly high risk. However, it is also recommended individual patients will have to assess their tolerance for toxicities that can include many signs and symptoms of premature menopause (that quality of life issue again).

The recent updated NICE guidelines for the Management of early and locally advanced breast cancer section 1.7.4 and 1.7.5 recommend.

1.7.4 Consider ovarian function suppression in addition to endocrine therapy for premenopausal women with ER‑positive invasive breast cancer. [2018]

1.7.5 Discuss the benefits and risks of ovarian function suppression in addition to endocrine therapy with premenopausal women with ER‑positive invasive breast cancer. Explain to women that ovarian function suppression may be most beneficial for those women who are at sufficient risk of disease recurrence to have been offered chemotherapy. [2018]”

It would be a good idea to speak to your team about what is the best treatment option for you. They know all your individual pathology results and your individual circumstances. They should be able to discuss your options with you and the risk and benefits from each treatment.

Best wishes and take care.

Ellen-Macmillan Online Digital Nurse Specialist.