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Done skin sparing mastectomy. By how much does Zoladex reduce chances of recurrence when taken with Tamoxifen?

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Practicing since : 2002
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Hi Doc,

I got a Skin Sparing Mastectomy done on my right breast on March 30th, 2011 as the tumour was malignant. Post that i completed my 8 cycles of Dose-Dense Chemotherapy followed by 28 fractions of radiation therapy. My ER & PR are 90% positive & hence now i am on hormone therapy taking 1x20mg tablet of "Tamoxifen" daily & will have to do so for the next 5 years. I have attached my post surgical report. My Onco yesterday also advised that i get Injection Zoladex for 2 years (@ 3.6 mg monthly or 10.8 mg quarterly). I am 36 years unmarried. I do understand that zoladex will suppress the function of the ovaries for 2 years. My ques:
1)     By how much does Zoladex reduce chances of recurrence when taken with tamoxifen in comparison to only Tamoxifen ?
2)     Basis my report is it advisable to get Zoladex shots ? and why is 2 years considered ideal & not less or more ?
3)     Cancer cells don’t have the ability to die, like other cells. So what happens after 2 yrs, once the shots are complete ?
4)     Honestly I am nervous about the side effects of stopping production of estrogen. Right from mood swings, depression, to weak bones, putting on weight, facial hair growth etc. I have handled my entire treatment so far in a very positive manner but am confused about taking Zoladex shots as no one is able to tell me just how much “more” will it benefit me.
5)     Also very importantly, I purchased a : Zoladex 10.6 mg LA Depot (quarterly) manufactured by Astra Zeneca but in the printed literature it said clearly “Not for use in Women”. Why would a reputed company write something like that, while docs in India are recommending the shots ?
6)      How much time will it take for my body to recover & start normal functioning after the Shots are complete ?
7)     In how much time after completion of Chemotherapies & Radiation Therapy, should the Zoldaex shots be started ?
8)     And kindly advise the follow up treatments in my case with the periodicity.
Posted Wed, 2 May 2012 in Breast Cancer
Answered by Dr. Robert Galamaga 1 hour later
Hello and thank you for submitting your question.

Your question is a very good one and I will work on providing you with some good information recommendations regarding what is going on.

The Zoladex is something I would highly recommend. There are no firm statistics but most professionals agree that taking this with Tamoxifen may reduce the risk of recurrence as much as 25 percent more than using Tamoxifen alone. I have to say that if you were my mother or my sister or my wife, I would recommend that you take this medication along with the tamoxifen to further decrease the chances that this tumor may recur.

Cancer cells actually do have the ability to die especially if you starve them of the stimulatory factors which keep them alive. For example with your breast cancer the tumor cells need estrogen and progesterone to continue to survive them proliferate. You are now in the process of removing any residual stimulatory factors in the form of the progesterone and estrogen which will cause the remaining cells to die. These cells are really unable to survive in the absence of the hormones.

Regarding side effects every patient is different as far as how the medication will affect the body. Most women asked to do very very well without any significant side effects that cause problems. Some women do have some side effects which are manageable and very few women have side effects which cause us to have to discontinue the medication. I recommended to continue to maintain a positive attitude and I'm sure you will do fine.

Here is a link to a website which gives more information on how this medication is used in the setting of breast cancer. I realize the label which you are reading indicates that this medication is not for use in winning and typically it is not. In your case however you're dealing with the cancer and this medication does have a labeling indication for treatment of some breast cancers.

It generally takes 3 to 6 months for the bodies hormone production to return back to a baseline after taking these types of medication. However some women do enter early menopause with the use of these medications and this is something you should be prepared to possibly have to deal with. Regarding timing of this medication, I think it can be started within a month after completion of chemotherapy and radiation.

You should see your oncologist as scheduled every one to two months after completion of therapy. Beyond that your oncologist will likely see you every 3 to 6 months for continued clinical follow-ups. In addition, you should have annual mammogram performed as well for surveillance. some physicians also may advise a mammogram to be done six months after completion of chemotherapy and radiation. This is up to the discretion of your doctor.

I thank you very much for submitting your question. I hope you find my response to be helpful and informative. If you have any additional concerns I would be happy to address them.


Dr. Robert

Above answer was peer-reviewed by
Follow-up: Done skin sparing mastectomy. By how much does Zoladex reduce chances of recurrence when taken with Tamoxifen? 13 hours later
Thanks for your detailed reply Doc. First & foremost I was thrilled to see that my question somehow got on-passed to you after a long 8 months or so :) I find your explanations informative & detailed. So that’s a Great Start in my books. I have a few follow up questions:

1)     W.R.T. timing of the shot- My Med Onco in Delhi did not recommend Zoladex. I was told about it just last week in Mumbai, after which I started my research on the drug. I completed my Chemotherapy on Aug 03rd 2011 & my Radiation therapy start-end was Aug30th -07th Oct, 2011. I started Tamoxifen from November 03rd , 2011. And assuming I start Zoladex from Dec 30th onwards. How late am I in starting with Zoladex ? I know there may not be precise percentages you can tell me, but given my dates, how late am I?
2)     What type of tests, scans (DEXA Scan?) vitamins et al, will I need to take once I start zoladex ? to monitor & also perhaps minimize impact of side effects ?
3)     I also read up that a small pct of women are resistant to Tamoxifen if they do not have CYP2D6 enzyme in their DNA. Should I get myself tested for that ?
4)     I was also told that the body could develop resistance to Tamoxifen after 2-3 years of taking it.. I have been advised to take Tamoxifen for 5 years which I reckon is a standard timeline for Hormone therapy. How would I know if & when my body develops this resistance ? Are there any symptoms or tests ?
5)     I am on 1x20 mg of Tamoxifen once a day. Is that sufficient or should I increase that to a 40 mg potency ?

On a personal note, Hope things are well with you. I had taken an 8 month sabbatical from work in Mumbai and was with my Family in New Delhi getting my treatment. Since Dec 01st, I am back at work & currently taking tamoxifen & now I guess will start Zoladex soon too. Truly very happy about getting in touch with you.

Look forward to your revert.

Answered by Dr. Robert Galamaga 8 hours later
Hello again and thank you for the follow up question.

Regarding the medication, I would not consider you to be significantly delayed or late in starting this. As I stated earlier, this is a medication which will help to augment the likelihood that you will not have to deal with any recurrence of your cancer. You are extremely well-informed and obviously very intelligent and I appreciate that about you in our discussion. Again, let me reassure you that starting the medication at the end of this month is not going to be any significant detriment and I would not regard you as starting this late.

Regarding the bone mineral density testing, I would recommend that you have this done basically on an annual basis. Otherwise, I would recommend that you take a multivitamin on a daily basis with a calcium supplement which contains vitamin D.

There are some women on a very rare occasion who have abnormalities of the liver enzyme that you mentioned. This is rare however. Right now there are really no clear recommendations or guidelines regarding testing for this particular enzyme. There have been conflicting studies in the past which have shown that women who have mutations of this enzyme have more problems with recurrent cancer. However other studies have shown that even women with this mutation have no increased risk of breast cancer with using Tamoxifen. Again if this is a curiosity of yours you can certainly request that the testing be done. It may come at a significant cost to you however. Again I'm not sure what your physician would really do with the results since there are no clear indications or guidelines.

Regarding the Tamoxifen, I have never seen a case of tamoxifen resistance actually. I know this has been reported and suggested in the literature but we really do not have good data on how to test for this. One indication would be that if for some reason you encountered a recurrence of the cancer which is very unlikely we might consider you to have some degree of Tamoxifen resistance. If I remember correctly. However your tumor was strongly positive for the estrogen and progesterone receptors. This makes the likelihood that you will respond to Tamoxifen very very high. I would not worry about Tamoxifen resistance at all for you. Continuing the Tamoxifen for five years is the certain standard which we have established in medicine. Right now you are on a optimal dose and I would not change the dose at all.

I thank you again for submitting your question. I hope you found my responses to be helpful and informative. If you have any additional concerns I would be happy to address them with you.

Wish you good health.


Dr. Robert
Above answer was peer-reviewed by
Follow-up: Done skin sparing mastectomy. By how much does Zoladex reduce chances of recurrence when taken with Tamoxifen? 14 hours later
Thanks Doc ! Great to know that the high pct of ER/PR +ve makes my chances of Tam resistance minimal if not lesser. As always your detailed explanations have been very instrumental in helping me finalise my decision. I will go ahead with Zoladex then.

- Since i purchased (in all my zest) the 10.8 mg quarterly one, should i just start with that instead of purchasing the monthly one first ? Or should prudence prevail & i keep the quarterly one for later ?
- Typically within how many days of injection do the symptoms start to set in ?

i am a touch nervous this time in comparison to what i was during my Chemo & radiation therapy, since now i have to be at my Best in teh workplace. Cant afford mood swings & other side effects. So is there something (& i might sound repetitive) that you recommend i should do/eat/(perhaps even) read to offset the side effects as far as possible ?

thanks so very much again ! I might come back with some more queries as time passes & i have more of Zoladex in my body than Oestrogen :)

Answered by Dr. Robert Galamaga 23 hours later
Thank you again for submitting your follow up question.

I really see no problem with you starting out with the quarterly injection. I think this is a reasonable approach and the formulation of the medication is essentially equivalent to the monthly injection. Regarding possible side effects again, every patient is going to be a little bit different. One might expect some degree of side effects to occur within the first few days. These might peak within the first three or four days and then slowly level off over the next couple of weeks.

I completely understand your concern regarding wanting to perform at your highest degree of potential while taking this medication. A couple of things which I would recommend that might help you in particular would be very regular exercise. This does not have to be vigorous long distance run type of exercise but a brisk walk for 30 min. or so four or five days per week is certainly a good start. Also if you have the ability to do some very light weight training this would also provide you a good benefit. As with most stressful situations, I really do advocate for patients to participate in meditation or yoga. This certainly helps balance the mind and body.

As far as supplements or special foods I really don't think there is anything in particular that is going to help you other than maintaining a good and well balanced diet. Adequate sleep of course is also a priority. If you drink any type of tea or coffee I would suggest a decaffeinated version.

Again I thank you for submitting your questions and follow-ups. If you have any additional concerns please know that I am always here. Thank you again.

Wish you good health.


Dr. Robert
Above answer was peer-reviewed by
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