Menopausal Symptoms in Breast Cancer Patients

Transcript

00:00 --> 00:21Announcer Funding for Yale Cancer answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:21 --> 00:48Eric Winer Tonight, we're going to be talking with Doctor Maryam Lustberg who's the director of the Center for Breast Cancer at Smilow Cancer Hospital and the chief of the Division of Breast Medical Oncology at Yale Cancer Center. Maryam is also a professor of medicine at the School of Medicine. We're going to be talking about menopause and menopausal symptoms in people who have breast cancer.
00:48 --> 01:18Eric Winer And depending on how the conversation goes, we may touch on some other aspects of breast cancer as well. So breast cancer is a disease that is often sensitive to the influences of female reproductive hormones. And we talk about estrogen and progesterone receptors on the cancer, about what percentage of breast cancer is sensitive to the influences of female hormones.
01:18 --> 01:34Maryam Lustberg Approximately two thirds of our breast tumors are considered hormonally driven, and we see this across all ages, whether patients are diagnosed at a younger age or later in their lifespan. So it is our most common type of breast cancer.
01:34 --> 01:42Eric Winer And for these patients we often consider different types of hormonal treatment. Is that correct?
01:42 --> 01:42Maryam Lustberg Yes.
01:42 --> 02:17Eric Winer I think one of the problems that many people have, both with treatment soon after a diagnosis and then for years following that diagnosis are symptoms of menopause. And of course, this is this is true both in women who have hormonally driven cancers, where sometimes our therapies induce menopause, but also in other women who have had breast cancer, where there may be a reluctance to treat menopausal symptoms, even if their cancer wasn't a cancer driven by by hormones.
02:17 --> 02:35Eric Winer So maybe we could start off and just talk a little bit about treatments for younger women who have hormonally driven cancers, and what are those treatments like these days, and how often are we are we finding that women are going through menopause early because of our treatment?
02:36 --> 03:12Maryam Lustberg Yes, it's it's a very important area to discuss. Breast cancer in younger women comes in many different flavors. There are younger women who present with very biologically favorable tumors at a very low stage that may need simply surgery, some type of local regional treatment, if they had lumpectomy coupled with radiation. And they can simply go on apple a day such as tamoxifen, which is a selective estrogen receptor modulator.
03:13 --> 03:23Maryam Lustberg And they may have menopausal symptoms as a consequence of taking tamoxifen. But but it's it's it's not often the most severe manifestation of menopause.
03:23 --> 03:36Eric Winer So with tamoxifen alone for the for the subset of women who choose to take to marksman alone on the recommendation of their physicians, what are the side effects with tamoxifen in young women?
03:36 --> 04:13Maryam Lustberg So many patients can tolerate tamoxifen very well. I think it's really important to say that, but it is very much an individualized experience of a drug. There can be basal motor symptoms that can present as hot flashes, sleep disturbances, night sweats. About a third of patients can have a kind of experience moderate to severe symptoms onto Marxian and other symptoms can include some vaginal secretion changes, some fatigue and changes.
04:13 --> 04:18Maryam Lustberg But the vasomotor symptoms tend to be the most common toxicity of tamoxifen.
04:18 --> 04:29Eric Winer And there's at least some number of women who, when they go into marksmen, just don't tolerate it at all, particularly younger women. Is that. Yeah, absolutely.
04:29 --> 04:47Maryam Lustberg And approximately 5 to 10% of patients are not able to tolerate tamoxifen, as reported in the literature. However, the numbers may be higher in that patients may not feel comfortable reporting to us that they're not taking the drug. So there are some interesting studies showing up.
04:47 --> 05:17Eric Winer And of course, we know that not everyone takes all pills in general, and that if you look at compliance, adherence with antihypertensive medication or with all sorts of different medications, it's far from 100%. We tend to think that it's better in the in the cancer arena, because people are often worried about having a recurrence of cancer. But still, we know for sure that not everyone takes medications.
05:17 --> 05:27Eric Winer And for that matter, the more expensive a drug is, the higher the co-pay. We've also learned that people may not take it in those situations either.
05:27 --> 05:50Maryam Lustberg We don't blame our patients for this. I think it's a very individualized decision in terms of why patients may not take their drug as prescribed. But we do know from the literature and just in taking care of patients that toxicity and side effects and concerns about how to Oxford or other drugs may be affecting them can influence how regularly they are taking these drugs.
05:50 --> 06:21Eric Winer Well, if you're taking a drug to prevent something and you feel bad taking the drug, on some level, it's pretty hard to keep taking it, you know, why do you want to keep feeling bad every day? Okay, so those are that covers, you know, the people who are going on tamoxifen alone. But oftentimes, particularly as a result of recent studies, we're giving somewhat more intensive hormonal therapies to younger women.
06:21 --> 06:24Eric Winer And what do those look like?
06:24 --> 06:57Maryam Lustberg So they come in different varieties, including, you know, for for hormonal, hormonally driven breast cancers that may have higher proliferation or more signs of aggressive potential. We may add a drug to tamoxifen known as O'Brien suppression. These are injections that are essentially chemically inducing early menopause. So so we're essentially.
06:57 --> 07:32Maryam Lustberg Slowing down estrogen production from the ovaries and combining this with tamoxifen, or even with another set of drugs known as aromatase inhibitors, has been shown in this higher risk, hormonally driven tumor population to be associated with better outcomes. Cancer wise, however, because we're inducing this more rapid menopause in a young woman who otherwise would would be far from initiation of menopause, the symptoms can be quite severe.
07:32 --> 07:42Maryam Lustberg And so this is this is this is something that we actively manage in medical oncology, is supporting these individuals who are experiencing these early symptoms of monopolies.
07:43 --> 08:12Eric Winer And this is based on large randomized trials where not everyone, but particularly for some of our younger patients, meaning women who are in their 30s with with breast cancer, that's hormonally driven. And people who may have a higher burden of, of of their cancer in that there's lymph node involvement or a larger tumor, that these treatments really do work somewhat better, but at at a cost.
08:12 --> 08:41Eric Winer You know, I often say to patients that menopause is something that most women are supposed to wade into. It's like walking out in a shallow beach and having the water rise up slowly. Whereas when we give people treatments like ovarian suppression and we suddenly and abruptly turn off their ovarian function, it's a little bit like jumping into a pool from the high dive.
08:41 --> 09:15Maryam Lustberg Yes, yes it can. And it's important to again emphasize, just like there are different types of breast cancer, there are different types of how women experience menopause as a consequence of our treatments. I still have younger women who do quite well, but then I would say a higher proportion of patients on ovarian suppression or younger women who have initially received chemotherapy, which can also further accelerate entry into matapos, followed by ovarian suppression that we use subsequently.
09:15 --> 09:38Maryam Lustberg These are the women who tend to have more of the moderate to severe symptoms, which can include vasomotor symptoms the half lashes, the night sweats, increased weight gain, libido changes, vaginal dryness, bone loss. So these are the things that we most commonly encounter in this patient population.
09:38 --> 10:09Eric Winer Yeah. No. By no means did I intend to scare people by using the high dive analogy. But, you know, for some people it's really tough. And for some people it's really very easy. And it's almost shocking the way some people can just stop having periods and go on these treatments and do completely fine with almost no symptoms. But what are the other health consequences of going through menopause early?
10:09 --> 10:27Eric Winer So most 35, 36, 38, 42 year old women aren't going through menopause and most women, in fact go through menopause in their early 50s. So are there other health problems that arise from going through menopause so early?
10:27 --> 10:53Maryam Lustberg We are concerned about bone loss, accelerated bone loss that can happen due to early menopause. This is something that we actively manage in medical oncology through the use of bone modifier therapy, an area that perhaps we don't focus as much on as medical oncologist is all the metabolic changes and cardiovascular risk factors that could be impacted by this earlier menopause.
10:53 --> 11:16Maryam Lustberg And this is something that is actively, certainly being researched and looked at. But in a 20 minute medical oncology visit, I think sometimes we are most focusing on those more acute symptoms of menopause and less on those long term later effects that we see. But I do think the cardiovascular effects are certainly a significant one.
11:16 --> 11:32Eric Winer I mean, that's concerning, I think, for many of our patients. On the other hand, if someone is at significant risk of having a recurrence in these drugs can reduce that risk, it's it's a set of side effects that many people are willing to put up with.
11:32 --> 11:58Maryam Lustberg And that is such an important point. And not all of these discussions really need to be a balancing act, taking into account the actual known risk of early and late recurrence from breast cancer, while taking into account potential late health effects as well as quality of life issues. So I'm sure we'll get into this a little bit more.
11:58 --> 12:11Maryam Lustberg But but I think having these very nuanced, rich discussions, taking into account this balancing act, I think is a really key part of menopausal management and rest cancer survivors.
12:11 --> 12:32Eric Winer Yeah. Now, in fact, just today I was talking to someone about hormonal therapy for for breast cancer. And the first thing that that person said is I don't want to take a pill. And I think that a lot of people have this reaction that they just don't want to go on a medication. Or for some people, it's another medication in addition to their others.
12:32 --> 12:42Eric Winer On the other hand, the potential risks and the potential benefits are things that we have to think about very, very seriously. And these are, of course, medications that are used very commonly.
12:43 --> 13:13Maryam Lustberg Correct, correct. There are absolutely like saving I think, you know, we talk so much about precision medicine and personalized medicine. I think it's really important to remind the audience that targeting the estrogen receptor was one of our key precision medicine, early initiatives that has shown tremendous success in breast cancer. However, at the same time, I do think we need to balance out the toxicities and really give our patients the tools and the knowledge to to continue to make the most informed decision that's right for them.
13:13 --> 13:24Eric Winer These medications overall have saved hundreds of thousands of lives around the world, and each and every year save thousands upon thousands of lives.
13:24 --> 13:53Maryam Lustberg Absolutely. I say Microsoft has saved more lives than any other cancer drug, and I think there is a lot of misinformation currently in social media and online. And I think it's so important for oncologists to be also out there kind of kind of kind of really sharing kind of kind of kind of this more kind of balanced, evidence based review of what our cancer therapies can do and what they can't do.
13:53 --> 13:56Maryam Lustberg So, so that I do feel very passionately about that.
13:56 --> 14:18Eric Winer All right. Well, we're going to have to wrap up this first half and do a brief break. I will return in just a minute or so with Doctor Maryam Lustberg, chief of breast oncology at Yale Cancer Center and Smilow Cancer Hospital. We'll be right back.
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15:38 --> 16:07Eric Winer Hello again. This is Eric Winer. I'm the director of the All Cancer Center. And here with our guest, Doctor Maryam Lustberg, a breast cancer expert. We're talking about menopause and breast cancer. Treatment is something that is directly caused by many of our treatments. And for some women with breast cancer, it's actually beneficial in terms of reducing the risk that the cancer can ever show up again.
16:07 --> 16:37Eric Winer Maybe we can just shift gears just a bit and talk about something that may be related to these menopausal symptoms and may not be, but something that our patients frequently complain about, which is cognitive fog. It's also for those people who have had chemotherapy, which is by no means everyone, but for those who have had chemotherapy, people also talk about chemo brain.
16:37 --> 16:41Eric Winer What do we know about the cognitive effects of these therapies?
16:41 --> 17:17Maryam Lustberg Yeah, it's a it's a fascinating area that's being actively researched. The broad umbrella term for it is cancer related cognitive impairment, which acknowledges that it's not only chemotherapy that can cause cognitive changes. It can be chemotherapy immunotherapy and or crime therapy as we call things chemo brain. There is actually a colloquial term called calling endocrine therapy. Associated cognitive changes and or brain and patients describe foggy ness like you describe.
17:17 --> 17:43Maryam Lustberg They describe a little bit more difficulty multitasking. Ward finding. Sometimes face recognition can also change. In menopause, where you used to just recognize people very instantly, it can become harder and it's most noticeable to the individual. So if these patients actually, you know, are able to function very similarly in their jobs at home, but they notice that they have to work harder.
17:43 --> 18:05Maryam Lustberg That and when we study the brain after cancer treatment, they're very interesting imaging studies that actually saw our connections, our connectivity in the brain. It takes more areas of our brain to essentially complete the same task. So we're working harder to to arrive at the same answer.
18:05 --> 18:24Eric Winer Is this similar to what happens to people in general when they get older? I can tell you that I have to, you know, work hard to come up with names from time to time. So is this perhaps an exaggeration of something that happens to many, many people as they age?
18:24 --> 19:03Maryam Lustberg I believe so. I think there's definitely a strong component of aging. And if we're not carefully, it's been very hard to adjust for it as we study survivors for cognitive dysfunction. I think definitely it's one of the contributors. And back to our discussion about vasomotor symptoms. Cognitive function doesn't exist in a vacuum. So if you're having a lot of hot flashes and night sweats and not sleeping through the night and you're foggy in the morning, the principle of symptom clusters where kind of your other symptoms, such as your menopausal symptoms, can further feed the cognitive changes.
19:03 --> 19:13Maryam Lustberg So yeah, it's it's quite complex. It's quite common. And many oncologists and patients don't know what to do with it. Like how do I support my patients through it.
19:13 --> 19:20Eric Winer Yeah. No. And are there any established treatments for these types of difficulties.
19:20 --> 19:47Maryam Lustberg So looking for contributors to that symptom toxicity. So if you're not sleeping well due to basal motor symptoms making sure that we're addressing it, improving quality of sleep, very good data that exercise is truly medicine. So so if we can get our patients to be more physically active, that can absolutely help. We want to screen for depression, anxiety and other contributors and metabolic health.
19:47 --> 20:22Maryam Lustberg I think it's a huge computer contributor. We know that there is inflammation happening and inflammation in the body due to, you know, our sedentary lifestyle and poor diets. And so addressing all of these can help for patients who have more moderate symptoms. A careful neuropsychiatric evaluation to rule out adult onset attention deficit disorder and other things that can be further addressed, I think is also important, but I think assurance also helps.
20:22 --> 20:48Maryam Lustberg I think one of the biggest fear is that patients have is, does this mean I'm going to progressively get worse and essentially get them then shot? That's the most common fear if you go to the root cause and really reassuring them that these tend to be relatively mild and their compensatory mechanisms that patients can do, making less, reducing stress, improving sleep and all of those can be helpful.
20:48 --> 20:58Eric Winer And there's also some evidence that these kinds of symptoms seem to be most prominent in people who are particularly high functioning.
20:58 --> 21:20Maryam Lustberg They notice that more they will. Part of the challenge. And studying cancer related cognitive impairment is that if we do our standard psychological Neurosci testing patients perform quite well. We can't really capture this on a test, but they know internally that they're having to work a little bit harder than they used to. So we tend to see that, yes, in more high functioning adults.
21:20 --> 21:34Eric Winer Talk to us now about hot flashes. Hot flashes can be surprisingly debilitating. What's what's going on with that? And our hot flashes and night sweats really essentially the same thing.
21:34 --> 22:25Maryam Lustberg It's all part of our exquisite thermal regulatory centers in our brain that are meant to regulate our body temperatures, and they're very responsive to feedback from our hormone levels, be it as Jen or even testosterone in men, because men can also get hot flashes through cancer treatment. And so kind of when when these hormone levels decline, these thermal regulatory centers kind of can get dysregulated and kind of kind of this balance, this equilibrium can, can absolutely get disrupted presenting and kind of these more kind of the, the sweating and the heat and the so it it can be disruptive and bothersome to some patients who are having a more severe form of it.
22:25 --> 22:46Eric Winer And sometimes triggered by caffeine and alcohol, a little bit of anxiety, and suddenly someone feels like the temperature has just risen to an uncontrollable level, as if they're in the hottest steam room. And of course, the night sweats aren't easy either, because it wakes people up.
22:46 --> 23:10Maryam Lustberg And it kind of feeds that symptom cluster of fatigue and mood changes. If you're not sleeping and waking up 7 to 10 times in the night. Even you may not be even aware of it that you're waking up. Your sleep is disrupted. So really seeing vasomotor symptoms not as just hot flashes, but that they can be part of this whole syndrome of toxicity that can make our patients feel quite poorly.
23:10 --> 23:14Eric Winer So what kind of treatments do we have for these symptoms.
23:15 --> 23:47Maryam Lustberg So lots of treatments. We have a number of options for managing hot flashes, including two very new targeted drugs that specifically are are are are targeting these receptors. And our thermal regulatory centers. These are this is the New York and pathway in the hypothalamus. And we actually have two FDA approved drugs that are precisely targeting this pathway. And they can be quite effective.
23:47 --> 23:52Maryam Lustberg Insurance can be prohibitive. So that they may not be the first drugs that we start with.
23:52 --> 23:54Eric Winer Meaning insurance may prohibit.
23:55 --> 24:18Maryam Lustberg It's they're expensive because they're new drugs. And so they may not be the first drug that we can start with. But we have a number of antidepressants that have been shown to be helpful in reducing hot flashes. We have agents such as gabapentin that have been shown to be helpful. We have even we tend to reuse drugs for other purposes for basal motor symptoms.
24:18 --> 24:45Maryam Lustberg For example, a drug for overactive bladder has been shown to be really helpful for basal motor symptoms. But until recently we did not have a drug specifically for vasomotor symptoms till these two drugs were approved. So I think I think reporting your symptoms to your oncologist or women's health specialist or primary care clinician, I think is important. And then the two of you can decide together which one is the best agent to start with.
24:45 --> 25:06Eric Winer And then there is some over-the-counter remedies, the kinds of medicines you might find in a natural food store that actually that are phytoestrogens and have the potential to be converted to estrogens that we may not want to have around. Those are those are drugs that in general, we don't recommend, to.
25:06 --> 25:39Maryam Lustberg Be sure. So I think in well constructed studies, a few supplements have been looked at for vasomotor symptoms. And what these studies have shown is that there are no better than placebo. There's a strong placebo effect in symptom management studies. And then apart from limited efficacy, I do worry about that. Supplements are not very well regulated and plus potential for kind of hidden phytoestrogens and other things that we generally don't advise.
25:39 --> 25:51Maryam Lustberg So don't want to be the supplement police with my patients, but I do advise them to at least bring whatever they want to take to us, so we can check for interactions that kind of advise them properly.
25:51 --> 25:54Eric Winer I like the the concept of the supplements police.
25:54 --> 26:03Maryam Lustberg I think the more we scare our patients about. I think that open conversation is so key, because otherwise they may choose not to tell us what they're doing.
26:03 --> 26:33Eric Winer Let's go to the other extreme, which is estrogen replacement therapy in people who have had breast cancer for years now, we've tended to limit the use of hormone replacement therapy. And of course, when we talk about hormone replacement therapy, there's both the possibility of using estrogen alone and people who don't have a uterus or its combination therapy with estrogens and progestins.
26:33 --> 26:57Eric Winer But for years now, we've tended to avoid hormone replacement therapy. And a lot of women, not just people with breast cancer, other than for, you know, a couple of years around the time of menopause. But now there's even talk about revisiting this in women who have had a diagnosis of breast cancer. So what's what's all this talk about?
26:57 --> 27:29Maryam Lustberg Estrogen is not one thing. Just like breast cancer is not one type of cancer. So there are many formulations of estrogen. And when we dissect the data, actually conjugated estrogen may actually have certain properties similar to tamoxifen. So when used by itself it it it may. It's actually in large epidemiological studies, conjugated estrogen by itself was actually associated with lower risk of breast cancer.
27:29 --> 27:36Maryam Lustberg And this is in a population without a prior history of breast cancer. But I think it raises these intriguing, intriguing questions.
27:37 --> 27:48Eric Winer And this is in contrast, to be clear, with combination therapy of estrogen and progesterone. And progestins, in fact, do result in proliferation in breast tissue.
27:48 --> 28:15Maryam Lustberg Correct. So when conjugated estrogen was used in combination with synthetic progesterone, medroxyprogesterone in a large study known as the Women's Health Initiative, there was there was an increase in breast cancer. So so I think I think knowing that there are different types of estrogen, there are different types of progesterone and different risk levels to to breast cancer, I think is part of this conversation.
28:15 --> 28:38Eric Winer Well, I think that's a great way to end. Maryam, thank you so much for joining us here on Yale Cancer Answers. Again. I've been speaking with Maryam Lustberg, professor of medicine at Yale School of Medicine and a breast cancer expert. This is Eric Winer. I'm going to sign off for the evening. Be back again next week. Thank you all for listening so much.
28:38 --> 28:57Announcer If you have questions, the addresses CancerAnswers@Yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you'll join us next time to learn more about the fight against cancer. Funding for Yale Cancer answers is provided by Smilow Cancer Hospital.

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Dr. Maryam Lustberg talks with host Dr. Eric Winer about treating many types of breast cancers. Some treatments for hormonally driven cancers can induce early menopause. Helping women navigate symptoms including a lack of sleep and brain fog is part of their breast cancer treatment.

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Maryam Lustberg, MD, MPH

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