Letter to the Editor: Patients' Knowledge and Decisional Conflict Regarding Tamoxifen Use: Scientific Views

No abstract available.

The Author's Response: Assessment of Breast Cancer Patients' Knowledge and Decisional Conflict Regarding Tamoxifen Use

No abstract available.

Assessment of Breast Cancer Patients' Knowledge and Decisional Conflict Regarding Tamoxifen Use

Breast cancer is the most common type of female cancer. Tamoxifen, a selective estrogen receptor modulator, is widely used to decrease breast cancer recurrence and mortality among patients. However, it also increases the risk of endometrial cancer. This study aimed to assess knowledge and decisional conflict regarding tamoxifen use. Between June and October 2014, breast cancer patients using tamoxifen were consecutively screened and requested to complete a survey including the EQ-5D, Satisfaction with Decision Scale (SWD), Decisional Conflict Scale (DCS), and a self-developed, 15-item questionnaire measuring tamoxifen-related knowledge. The study sample comprised 299 patients. The mean total knowledge score was 63.4 of a possible 100.0 (range, 13.3-93.3). While 73.9% of the participants knew that tamoxifen reduces the risk of breast cancer recurrence, only 57.9% knew that the drug increases endometrial cancer risk. A higher education level (> or =college) was associated with a higher, total knowledge score (beta = 4.291; P = 0.017). A higher knowledge score was associated with a decreased DCS score (beta = -0.366; P < 0.001). A higher SWD score was also associated with decreased decisional conflict (beta = -0.178; P < 0.001). In conclusion, the breast cancer patients with higher levels of tamoxifen-related knowledge showed lower levels of decisional conflict regarding tamoxifen use. Clinicians should provide the exact information about tamoxifen treatment to patients, based on knowledge assessment results, so as to aid patients' decision-making with minimal conflict.

Terapia de reposição hormonal e o câncer do endométrio / Hormone replacement therapy and endometrial cancer

A reposição hormonal para alívio dos sintomas menopausais é amplamente utilizada em todo o mundo. A evolução do conhecimento sobre os riscos deste tratamento sempre foi mais lenta do que sua aplicação na prática clínica. Na década de 70, um aumento de incidência de câncer do endométrio ocorreu nos países desenvolvidos sendo que a terapia de estrógenos exógenos na menopausa foi o principal fator relacionado. Nas décadas de 80 e 90, a combinação entre estrógenos e progestínicos passou a ser largamente utilizada com base na premissa de que apresentava efeitos benéficos sobre os sistemas cardiovascular e osteoarticular, sem aumento no risco de câncer uterino. Entretanto, relatos recentes novamente questionam a segurança da reposição hormonal e, desta vez, apontam para o risco maior de câncer total e doença cardiovascular nos esquemas combinados. Concluímos neste trabalho que os riscos recentemente relacionados à terapia combinada têm grande potencial de impacto na Saúde Pública, e este esquema não é indicado para proteção do risco de carcinoma endometrial uma vez que seus riscos superam os benefícios.

Hormone replacement therapy (HRT) has been used worldwide to relieve menopausal symptoms. The evolution in clinical knowledge of its risks has lagged persistently behind its application in clinical practice. In the 1970s, endometrial cancer incidence increased in developed countries, and exogenous estrogen therapy in postmenopausal women was the most important factor. In the 1980s and 90s, combined estrogen-progesterone therapy was prescribed on a large scale, based on its potential beneficial effects on the musculoskeletal and cardiovascular systems without increasing the risk of endometrial carcinoma. However, once again, recent reports argue against the safety of HRT, and the most important issues are now the increased risk of cardiovascular disease and total cancer in combined formulations. We conclude that the recently reported risks on combined HRT may have a significant public health impact, and that this treatment regimen should not be prescribed to protect postmenopausal women from endometrial carcinoma, since the risks outweigh the benefits.

Terapia hormonal na menopausa: quando não usar: [revisão] / Hormone therapy in menopause: when not to use: [review]

A menopausa corresponde à cessação permanente da menstruação, conseqüente à perda da função folicular ovariana ou à remoção cirúrgica dos ovários. A idade média para ocorrência da menopausa natural gira em torno de 50 anos. A deficiência estrogênica decorrente da menopausa está associada com sintomas vasomotores, atrofia urogenital, declínio cognitivo, assim como a um aumento no risco de doenças crônico-degenerativas, aterosclerose e doença cardiovascular, osteoporose e doença de Alzheimer. A estrogenioterapia permanece sendo o tratamento mais efetivo para o manejo dos sintomas vasomotores e atrofia urogenital. Em mulheres com útero presente, a progesterona natural ou os progestogênios devem ser associados ao tratamento com estradiol para antagonizar os efeitos proliferativos deste hormônio sobre o endométrio e anular o risco de hiperplasia/carcinoma endometrial. Por outro lado, em determinadas condições clínicas, a terapia hormonal não é recomendada ou é mesmo contra-indicada. Neste artigo, focalizamos criticamente essas situações clínicas em que não se deve indicar a terapia hormonal na menopausa.

Menopause is defined as the permanent cessation of menses, as a result of the loss of ovarian follicular function or of surgical removal of ovaries. The mean age for occurrence of natural menopause is around 50 years. Estrogen deficiency has been associated with vasomotor symptoms, urogenital atrophy, and cognitive impairment, as well as increased risk of chronic degenerative diseases such as osteoporosis and Alzheimer’s disease. Estrogen therapy remains the most effective treatment for the management of vasomotor symptoms and urogenital atrophy. Progesterone or progestins should be added to estrogen treatment in women with uterus, in order to antagonize the estrogen-induced endometrial proliferation. In turn, in specific clinical conditions hormone therapy is not recommended. In the present article, the authors critically focus these clinical conditions in which hormone therapy should not be used.

In vivo and in vitro estrogenic and progestagenic actions of Tibolone

Estrogen and progestin combination in hormone replacement therapy (HRT) increases the incidence of breast cancer, but decreases the endometrial cancer risk of unopposed estrogen. Therefore, a SERM such as Tibolone, that delivers the beneficial, but not the adverse side effects, of steroid hormones would be clinically advantageous. However, data from the Million Women Study suggests that Tibolone increases the risk of both breast and endometrial cancer. Herein, we assessed the estrogenic and progestagenic actions of Tibolone using transvaginal sonography studies and an in vitro model of breast (ZR-75, MCF7) and endometrial cancer (Ishikawa). The known cancer associated proteins (ER, EGFR, STAT5, tissue factor and Bcl-xL) were selected for study. Transvaginal sonography demonstrated that postmenopausal women treated with Tibolone displayed a thinner endometrium than in the late proliferative phase, but had a phenotype characteristic of the secretory phase, thus demonstrating the estrogenic and progestagenic actions of this SERM. In vitro, Tibolone acted as an estrogen in downregulating ER and upregulating Bcl-xL, yet as progesterone, increasing STAT5 and tissue factor in breast cancer cells. The increase in tissue factor by Tibolone correlated with its coagulative potential. Interestingly, EGFR was up-regulated by progesterone in the breast and by estrogen in endometrial cells, while Tibolone increased protein levels in both cell types. In conclusion, this study further demonstrates the estrogenic and progestagenic nature of Tibolone. The pattern of regulation of known oncogenes in cells of breast and endometrial origin dictates caution and vigilance in the prescription of Tibolone and subsequent patient monitoring.

Surveillance for endometrial cancer in postmenopausal breast cancer patients taking tamoxifen.

OBJECTIVES: To determine the prevalence of endometrial thickening and endometrial pathologies in postmenopausal breast cancer patients taking tamoxifen. MATERIALS AND METHODS: A total of 37 postmenopausal breast cancer patients receiving 20 microg/day of tamoxifen treatment for at least 6 months at Srinagarind hospital were included in the study. Thorough history taking and physical examination as well as transvaginal ultrasonography were conducted for all patients. Fractional curettage was carried out in those whose endometrial thickness was found to be greater than 5 mm. RESULTS: Among 37 patients included in this study, the mean age was 56.35 years. The mean body weight and mean body mass index was 60.88 kg and 26.03 kg/m(2), respectively. The majority of patients (75.68%) had stage II disease. The mean + SD of endometrial thickness found in this study was 7.53 + 5.16 mm. The prevalence of thickened endometrium (defined as ET > 5mm from TVS) was 59.46%. Among the 19 patients for whom fractional curettage was conducted, the majority (73.69%) exhibited inadequate endometrium for evaluation. Atrophic endometrium and other unremarkable changes were found in 21.05% of patients and it is important to note that endometrial adenocarcinoma was detected in 1 case (5.26%). CONCLUSIONS: The prevalence of thickened endometrium in postmenopausal breast cancer patients taking tamoxifen found in this study was extraordinarily high. These is, however, a discrepancy between the value and that for endometrial abnormalities detected histologically.

Detection of endometrial cancer in asymptomatic postmenopausal breast cancer patient treated with tamoxifen: a case report.

Breast cancer is among the commonest malignancies in women and tamoxifen has been widely used for more than two decades for treatment of breast cancer. It has been known that long term use of tamoxifen significantly increases the risk of endometrial cancer but there is no generally accepted recommendation regarding the surveillance of endometrial pathologies in breast cancer patients taking tamoxifen. Although the incidence of endometrial cancer associated with tamoxifen use is not high, the risk is true and these patients could be helped by screening methods such as transvaginal ultrasonogrphy. We report here a case of endometrial cancer detected by transvaginal 2D scan in an asymptomatic postmenopausal woman taking tamoxifen.

Müllerian adenosarcoma of the uterus with sarcomatous overgrowth following tamoxifen treatment for breast cancer

Müllerian adenosarcoma with sarcomatous overgrowth presented by a 52-year-old female patient after adjuvant tamoxifen treatment for breast carcinoma is described. The diagnosis was made on histological basis after curettage and complementary total hysterectomy with bilateral salpingo-oophorectomy. The immunohistochemical study showed high expression of estrogen receptors in the epithelial component of the lesion and irregularly positive findings in the stroma. The proliferative activity evaluated by Ki-67 immunoexpression was higher in the stroma than the epithelium. Some of the stromal cells showed rhabdomyoblastic differentiation. The association of tamoxifen use and development of mesenchymal neoplasms is discussed.

Utero y tamoxifeno / Uterus and tamoxifen

Por sus indiscutibles beneficios, el tamoxifeno es una droga ampliamente utilizada en el tratamiento del cáncer de mama. Sin embargo, algunos de sus efectos secundarios inconvenientes ocurren a nivel del tracto genital femenino, siendo particularmente importante el aumento de la incidencia del cáncer endometrial. Se analizan en este artículo dichos efectos y la racionalización del empleo de los diversos medios de evaluación del endometrio

Efeito da terapêutica de reposiçäo hormonal sobre o endométrio: revisäo da literatura / Effect of hormonal replacement therapy upon endometrium: literature review

Os autores apresentam uma revisäo da literatura sobre os efeitos da hormonioterapia sobre o endométrio utilizada sob diversos esquemas na terapêutica de reposiçäo hormonal do climatério. A estrogenioterapia isolada, embora aumente a incidência de câncer endometrial, estas neoplasias parecem ser de melhor prognóstico e maior sobrevida, quando comparadas áquelas das näo usuárias da TRH. A incidência de hiperplasia endometrial se reduz a 0 por cento, quando se utiliza progestogênio por 12 dias. Os progestogênios mais utilizados tem sido o acetato de medroxiprogesterona e a noretindrona e as principais vias de administraçäo säo a oral e, mais recentemente, a transdérmica. O esquema de administraçäo conhecido como combinado seqüencial, provoca um padräo de sangramento que auxilia a avaliaçäo do estado endometrial, triando os casos para a avaliaçäo histopatológica. O esquema de reposiçäo estroprogestativo contínuo freqüentemente provoca atrofia endometrial, e as mulheres permanecem, na grande maioria das vezes em amenorréia, após os 6 primeiros meses de uso. Essa evoluçäo dos padröes menstruais e histológicos do endométrio sugerem que, durante o processo de atrofia endometrial, algum grau de sangramento pode ser gerado. Recentemente, tem-se avaliado o emprego dos progestogênios a cada 3 meses, alegando-se menor incidência de efeitos colaterais e de sangramento.

Asymptomatic carcinoma of the endometrium in a patient on adjunctive tamoxifen therapy for carcinoma of the breast

A case report of a 70 years old female, on tamoxifen for over five (5) years after a left mastectomy and with lymphadenectomy and radiotherapy in whom an asymptomatic adenocarcinoma of the endometrium is reported. Review of the literature suggests this association, however, definitive proof that tamoxifen causes cancer of endometrium has not been fully accepted. The best study in this regards is the one from Radiohemmet Oncologic Centre from Stockholm, Sweden. Patients with cancer of the breast that have been over two (2) years on tamoxifen should be screened with endovaginal sonograms for thickness of endometrium, thickness over 9mm and possibly over 5mm should be investigated with hysteroscopy and fractional uterine curetage