Lupron plus AI

I was diagnosed right after my 39th birthday. I am 40 now. I have been getting Zoladex injections and taking arosmasin. I have had no periods. I got 3 monthly zoladex injections prior to starting aromasin.

Kathy, Tamoxifen is not just a preventive. It is an effective cancer treatment. I know, because I'm Stage IV, and I was treated with it. It worked well, and I had very few side effects.

If you are concerned about Lupron's efficacy, it might be worth re-considering Tamoxifen as a preventive. By taking an AI now, you are taking away a drug that could be used later, post-menopause, not just as a preventive, but as a treatment, should you have a recurrence.

I am aware of studies that weigh effectiveness of AI versus Tamoxifen as a preventive. The side effects of AI are much harder than Tamox. I frequently praise Tamoxifen in discussions here -- because I was so wrong about it in the beginning. I wasscared of it after my Stage I diagnosis and refused to take it. (I wish that I would have just tried it.)

I wish you the best of health.

I'm doing Zoladex and Aromasin. My side effects are negligible, and I'm pretty close to menopause anyways (diagnosed at 46, now 49 -- average age of menopause: 51). I guess I don't worry much about whether they are working. I was still getting my period during the first two months of chemo; I don't get it now.

TarheelMichelle,

There are three different AIs that work slightly differently from one another. Should I recur, I will still have options. (I'm also HER2+, so there's targeted therapies as well.) In fact, the goal is NOT to recur so that I don't have to worry about future options!

I tried Lupron in an effort to switch from Tamoxifen to Arimidex. I was struggling with tamoxifen side effects. Unfortunately, after 5 months of injections, my levels never dropped low enough to take an AI. My onc and I discussed this and felt, for me, the best option was to have a total hyster with ovary removal. I had this done in July and my levels were low enough to begin taking Arimidex by September 1st.

Best of luck to you!

I am also on Lupron plus AI (generic Arimidex). My MO checks my estradiol and FSH on a regular basis, about every other visit. My periods stopped right away with the first injection, but it took five months before my hormone levels dropped low enough to start the AI. I would not assume that no period means your estrogen level is low enough. I think you should be tested at least once to confirm that you are responding to the Lupron.

Hello,

I started my first round of Lupron Depot- the three month extended release- on 11/11/16. I haven't had a period and will be meeting with my MO to go over blood test results next week. However, I must add that while the hot flashes are frustrating, I am suffering from almost debilitating migraines. Headaches were never a problem for me throughout my life; nothing that a few Advil couldn't cure. Now I feel a constant pressure in my head and ringing in my ears. After doing some research I read that other OVF supppressors have fewer side effects. You may want to ask your MO. Hope you find the right treatment.

Hi Cubbie- how are you feeling on Lupron? Aside from the usual hot flashes, what else have you noticed

Thanks, Tarheel Michelle. I'd researched so much about all the other aspects of BC treatment that when it came time for the hormone therapy I just left it up to my MO (who, btw, has left the practice). Anyway, my new MO is sending me for an MRI this week to check up on the headache issue. I truly believe it's the Lupron and nothing else. I'm hoping that once it is out of my sys I will try Tam and will feel better! Thank you also for the link to the latest research. It

incomplete ovarian suppression is also my concern, but my MO doesn't believe that hormone levels are reliable for women who are on AI or tamoxifen and doesn't use them and uses lack of period and hot flash as indicator. I'm back on tamoxifen now (with Zoladex) as I had weird side effects on Aromasin. But when/if I go back to an AI again, I'd like to know that my hormone levels are, maybe I'll ask my family doctor.

Kathy, a clarification: I wished I had taken the Tamoxifen before making up my mind about side effects. I don't regret not taking Tamox after my Stage 1. I had almost 4 years of good living without any drug side effects, with a young son. I'm glad it was available to me as a treatment when the cancer spread was detected. I totally understand your POV about treatmen. I was not a patient at MSKCC from beginning. I was borderline menopausal when I started being seen there. I guess that's why they checked me.

Erento, your doctor might not know what to do with me. I had a uterine ablation, so no periods, and AIs gave me hot flashes, so those wouldn't be reliable indicators for me of menopausal status. Even on Tamoxifen, my hormone levels were clearly Menopausal range.

Falconer, thanks. I don't want early-stagers to feel hopeless or helpless. Some early-stagers will have a recurrence, that's a fact. Sometimes, it will happen despite making every effort to prevent it. Maybe, the hope lies in LESS treatment, not more. There are ways to manage breast cancer without removing the whole breast and without chemo.

I have only noticed hot flashes as side effects of the Lupron. So far I haven't had any other problems with it.

Hi:

I posted some information and articles that discuss "incomplete ovarian suppression" in another one of KathyL624's threads back in August. Here is a link to the original post, along with an updated version (edited to update the link to Dowsett, add the title of Dowsett, update information re PDF access, and add links to Bellet and Krekow).

Prior Post: https://community.breastcancer.org/forum/78/topics/847590?page=1#post_4792588

Updated Version:

As a layperson with no medical training, I have no idea what the best approach to endocrine therapy or particular drug selection in any specific case should be. This is a highly specialized area with a very large body of literature. The materials below should not be used by anyone to make treatment decisions, but should be used to inform discussions with one's MO. There may be additional and/or conflicting studies that alter understanding or the findings may not apply in the individual case.

The differing adverse effect profiles may play into the recommendations received. For some other considerations, see this Medscape article/interview discussing the recent 2016 ASCO guideline re ovarian suppression. The entirety of the text on page 2 of the article may be of particular interest to you, with two caveats regarding AI's: (1) the first, based on conflicting results from the ABCSG12 trial, POSSIBLY due to a different (slightly lower) risk profile of the study group or other factors (but see, Dowsett below); and (2) the second concerning "incomplete ovarian suppression". Dr. Burstein also comments on how he addresses this in his practice.

Medscape (2016): "Ovarian Suppression in Breast Cancer Patients: Right or Wrong, Depending"

http://www.medscape.com/viewarticle/860383#vp_1

Registration for Medscape is free, but if you prefer, you can access the full-text without registration by googling the title of the article (above).

This recent article discusses the concept of "incomplete ovarian suppression" in much greater detail:

Dowsett (2016),"Incomplete Estrogen Suppression With Gonadotropin-Releasing Hormone Agonists May Reduce Clinical Efficacy in Premenopausal Women With Early Breast Cancer"

Full-text page: http://ascopubs.org/doi/full/10.1200/JCO.2015.62.3728

- A pdf version is available under the PDF tab.

Dowsett has a somewhat different view regarding the results of the ABCSG12 trial.

Here is a link to the SOFT-EST study discussed in Dowsett:

Bellet (2016): http://ascopubs.org/doi/full/10.1200/jco.2015.61.2259

Here is a link to Krekow discussed in Dowsett:

Krekow (2016): http://ascopubs.org/doi/full/10.1200/jco.2015.62.2985

The 2016 ASCO guideline update that addressed the question of ovarian suppression mentions the concept of "incomplete ovarian suppression" in a number of places, including this quote:

2016 ASCO Update: http://jco.ascopubs.org/content/early/2016/02/11/JCO.2015.65.9573.full.pdf

"The Panel cautioned clinicians that AI-based therapy is only effective in the setting of ovarian suppression or ablation. There are situations in which there may be ambiguity regarding the status of ovarian function, such as in women with chemotherapy-induced amenorrhea, after hysterectomy, with incomplete ovarian suppression, with incomplete compliance with GnRH agonist treatment, or with other pathophysiological conditions. In such instances, tamoxifen is the treatment of choice, as it remains effective regardless of ovarian reserve."

The usual caveats about guidelines not mandating individual treatments, and being snap-shots in time that may not reflect the latest studies, etc. apply.

You may wish to discuss your question with your MO, to gain a better understand his thinking behind the selection of tamoxifen in your specific case, in light of your risk profile and overall presentation.

Regarding the questions in this thread, I do not know what the recommendation is regarding testing hormone levels. In the literature, different views have been presented. [EDITED to add: Dowsett (2016) above notes:

"Incomplete suppression of ovarian estrogen synthesis may be achieved with GnRHa as a result of recovery of FSH levels, and this appears to reduce the impact of added aromatase inhibition in at least some women. The possibility that this leads to suboptimal efficacy merits detailed study. Particular attention should be paid toward this problem in overweight patients.9 Monitoring endocrine changes in individual patients to manage their OFS with or without AI or tamoxifen cannot be recommended because the basis of our understanding is incomplete and sufficiently sensitive estradiol assays are not widely available. In circumstances where there is gross evidence of incomplete estrogen suppression, the clinician and patient may wish to consider oophorectomy."

But see] this Grand Rounds feature authored by a Swedish group and related correspondence:

Papakonstantinou (2016): Is Estradiol Monitoring Necessary in Women Receiving Ovarian Suppression for Breast Cancer?

http://ascopubs.org/doi/full/10.1200/JCO.2015.65.3493

Lin (2016): "Estradiol Level and Menopause"

http://ascopubs.org/doi/full/10.1200/JCO.2016.69.2251

Papakonstantinou (2016): Reply to A.Y. Lin

http://ascopubs.org/doi/full/10.1200/JCO.2016.69.5866?trendmd-shared=0

There can be challenges in determining estradiol levels in this setting.

BarredOwl