The management of endocrine therapy in young patients with breast cancer

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Published: 8 Oct 2020
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Dr Olivia Pagani - European School of Oncology, Milan, Italy

Dr Olivia Pagani speaks about her presentation at the EBCC virtual congress 2020 about how to manage endocrine therapy in women under 40 with breast cancer.

The main factor is that endocrine therapy requires ovarian function suppression, thus inducing a menopausal state.

Dr Pagani explains some of the changes that arise during this state, and how to help patients manage them.

At the recent EBCC meeting we had a session on breast cancer in young women where we addressed what are the specific issues in this population of patients. My task was discussing the endocrine therapy in these women, both in the early and in the advanced breast cancer setting. So the endocrine therapy is really the only medical therapy in these young women who are just different from other age groups. For young women we mean women less than 40, so it’s not just a broad population of premenopausal women but this is specifically women below the age of 40 when they had their diagnosis.

Why is this important? Because these women have specific issues and specific worries and in the session we also faced pregnancy-related breast cancer and fertility. Endocrine therapy in these women most of the time requires ovarian function suppression which means to suppress the ovaries and to put these women in a menopausal status. This is associated with a lot of side effects because these women suddenly develop side effects which are typical of postmenopausal women, which means body image issues, cognitive issues, sleep disturbances, sexual issues. So when we are discussing with our patients treatment to prevent relapses or to treat advanced breast cancer, we need to face the specific issues of induced menopause.

In the early setting we now have a lot of treatment possibilities and we are now able to risk adapt our treatment recommendations. So not all the women require ovarian function suppression, there are women who do just need Tamoxifen which is not associated with menopause. But then in higher risk women, and we have the tools to calculate this risk, we need to escalate endocrine therapy which means to induce premature menopause. So the difficult task for the health professionals is to try to identify best which are the women who need their ovaries to be suppressed and who are the women who do not need that. In high risk women ovarian suppression is associated with a significant improvement in disease relapse and also in distant metastasis recurrences which are, of course, linked to overall survival.

So this is very important. We have to take care of side effects; side effects can be addressed, can be managed. You need to talk with your patients because sometimes, for example for sexual problems, they tend to deny these kinds of problems, they are embarrassed, and we are not always used to face and to ask these questions, it can be embarrassing also for health professionals.

In the advanced setting we now have a lot of new drugs in ER positive disease, specifically the CDK4 and 6 inhibitors. There is only one trial which was run in premenopausal women and the results are the same as the trials run in postmenopausal women. One of the things that we really struggle for is that all the trials in the future should not be designed for premenopausal women and postmenopausal women but all premenopausal women should be enrolled in trials for new treatment options, provided the menopause is induced. So this is very important.

Of course, these new treatments are not available in all countries. We have issues about low and middle income countries where most of the patients with breast cancer are young, much younger than in the Western countries. So we need to make available these treatments also in these countries and we need to develop better strategies to allow every young woman with early or advanced breast cancer to be treated the best way it’s now possible.

Thanks for your attention.