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Suggest treatment plan when suffering with breast cancer

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Posted on Mon, 15 Sep 2014
Question: Dear Doctor,
 
I am a 38 year old female Chinese, married with no children. I was diagnosed with Breast Cancer in early April 2014. My surgeon did a double mastectomy (with skin and nipples) for me in mid April 2014, followed by 4 cycles of Chemotherapy from 29 May 2014 to 31 July 2014 which I have completed. I will be seeing my Medical Oncologist in September to discuss next treatment, i.e. Hormonal Therapy using drug, 'Tamoxifen' for 5 years.
 
The diagnosis of my right breast is at Stage 2A (lymph nodes not affected) with details as follows:
In situ carcinoma: present
Subtype: Ductal
DCIS nuclear grade: Intermediate
DCIS growth pattern: Solid and cribriform
Necrosis: Focal
Size: DCIS is noted around the cavity. The tumour is 5-7mm in depth around the cavity.
Lobular: LCIS is present
Paget's disease: Absent
Invasive carcinoma: Present
Size invasive tumour size-5 x 3mm
Whole tumour size: The tumour is seen 5-7mm in depth around a cavity of 35 x 25 x 7mm
Histologic Grade: Grade 2 using modified bloom and XXXXXXX criteria
Tumour extent - localised
Vascular invasion - not seen
Axillary nodes present: Total number - 5 (sentinel lymph node 1-4 and one non sentinel node), number positive: 0
Calcifications: Present in non-neoplastic tissue
 
Immunohistochemistry: The invasive carcinoma cell shows the following staining characteristics:
Intensity of staining (1+ to 3+): ER - 2+
Percentage of cells stained: > 90%
Conclusion: Positive
 
Intensity of staining (1+ to 3+): PR - 2+
Percentage of cells stained: > 90%
Conclusion: Positive
 
Intensity of staining (1+ to 3+): c-erb-B2 - 1+
Percentage of cells stained: > 20 - 30%
Conclusion: Negative
 
 
 
The diagnosis of my left breast is at Stage 0 (lymph nodes not affected) with details as follows:
Lymph node sampling - Sentinel nodes 1 through to 3
In situ carcinoma: present
Subtype: Ductal
DCIS nuclear grade: Intermediate
DCIS growth pattern: Solid and cribriform with involvement of adjacent sclerosing adenosis
Necrosis: Not present
Size: 30 x 16 x 5mm (ductal only)
Lobular: Absent
Paget's disease: Present
Vascular invasion: Not seen
Axillary nodes present: Total number - 3, number positive: 0
Excision margins: Margins are negative. The closest margin is superior.
Base: not transected
Microcalcifications: Present in DCIS and present in invasive carcinoma
 
Immunohistochemistry: The invasive carcinoma cell shows the following staining characteristics:
Intensity of staining (1+ to 3+): ER - 3+
Percentage of cells stained: 80%
Conclusion: Positive
 
Intensity of staining (1+ to 3+): PR - 3+
Percentage of cells stained: 80%
Conclusion: Positive
 
Intensity of staining (1+ to 3+): c-erb-B2
Percentage of cells stained: > 20 - 30%
Conclusion: Negative stain
 
My Medical Oncologist has prescribed for me chemotherapy treatment consisting of drug name - Docetaxel (TAXOTERE) and Cyclophosphamide, and hormonal therapy through consumption of 'Tamoxifen' pills for 5 years. His prescription was based on my medical condition as per the diagram attached.
 
As I have read up about 'Tamoxifen' from the web and have many concerns about using this medicine, I am contemplating not to take it on, which my Medical Oncologist strongly advised against. I have questions on how this medicine can do for me as well as other questions relating to my condition and prognosis. I am hoping to hear a second opinion and what I should and should not do to lead a normal cancer-free life again. My questions are as follows:
 
1) From the diagram, can I assume my survival increases by 6%, i.e. from 82% (completion of chemotherapy after surgery) to 88% with hormonal therapy? If so, is it advisable to take on hormonal therapy since it also increases the risk of uterine cancer?
 
2) I am considering to seek 'Traditional Chinese Medicine (TCM)' help instead of consuming Tamoxifen. Is this advisable?
 
3) If I decided to consume Tamoxifen as part of the treatment, can TCM be used in conjunction with Tamoxifen?
 
4) Tamoxifen causes hair thinning. As I have lost all my hair due to chemotherapy, does this mean that I will not have full hair growth as before, with the consumption of Tamoxifen?
 
5) Will Tamoxifen affect bodily organs such as liver, kidneys etc? How can one minimise damage to health through consuming Tamoxifen? Will drinking plenty of water help?
 
6) Is it advisable for patients with my condition to conceive during Tamoxifen treatment? As my cancer is estrogen receptor positive, how will pregnancy affect my medical condition?
 
7) Another option provided to me by my Medical Oncologist was to remove ovaries and uterus, goes straight into menopause, and take medicine - aromatase for 5 years. Is this a better option for patients like me?
 
In a nutshell, I would like to know if I should take on hormonal therapy through consuming Tamoxifen for 5 years, and what I should do during the 5-year period to lead a life as normal and healthy as possible.
 
Thank you for your valuable time.
 
 
doctor
Answered by Dr. Monish De (13 hours later)
Brief Answer:
5 years of tamoxifen therapy highly advised

Detailed Answer:
Hi

It is highly advisable to take hormonal therapy after chemotherapy is completed for 5 years in your case. The risk of uterine cancer with tamoxifen is very rare. Hormonal therapy will prevent recurrences.

Traditional Chinese Medicine (TCM) is not scientifically proven.So hormonal therapy is highly advised after surgery and chemotherapy.

Yes TCM can be used in conjunction with Tamoxifen.

Tamoxifen does not cause causes hair thinning.

Tamoxifen does not affect kidneys.It may occasionally cause liver function test abnormality.

Yes u can conceive during Tamoxifen treatment.Though your cancer is estrogen receptor positive, it will not affect pregnancy.


As u are only 38 year old removal of ovaries and uterus and taking medicine aromatase is not a good option for you as you will not be able to conceive.

You should take on hormonal therapy through consuming Tamoxifen for 5 years.

The drug may cause a brief feeling of intense warmth and sweating called hot flashes.

It can be prevented by drinking a glass of cool water at the beginning of a hot flash. Also, be sure to drink enough water, usually six to eight glasses per day.

Avoid drinking beverages that contain caffeine or alcohol, since these can make hot flashes more uncomfortable.

Cut down on red wine, chocolate, and aged cheeses. They contain a chemical that can trigger hot flashes by affecting the brain's temperature control center.

Don't smoke. Smoking can make hot flashes worse.

Wear loose, comfortable clothing made of cotton to help absorb perspiration.

Hope i have answered your query

Regards

DR De



Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Monish De (2 days later)
Dear Dr. Monish De,

Thank you for taking time to answer my doubts. I'm more certain now on taking Tamoxifen. Nevertheless, I have more queries seeking your advice:

1. Given my generally young age, what could be the reason of me being inflicted with breast cancer? I have always been cautious with my diet, and i measure 165cm in height and weigh 49kg. I have been a HR Practitioner for more than 15 years. In the past 7 years, i was under tremendous work stress where most of the time, i was angry at work. Could stress be the main culprit of my illness?

2. Since i have double mastectomy, what does a recurrence means to me, and where are the common locations for recurrence? Is recurrence usually very serious (as in Stage 4) and does it mean that there is no cure for a the patient with a recurrence?

3. Other than Tamoxifen, is there no other medicine or treatment that is equivalent that can be used to prevent breast cancer recurrence, while offering similar, if not more, effectiveness while causing lesser side effects?

4. Other than hot flashes,  what other harm, if any, does Tamoxifen cause to the body, such as liver, bones etc?

5. I understand that Medicine, Rogaine (chemical name: minoxidil) or generic versions of Rogaine which are less expensive but just as effective, can be consumed to inhibit hair loss due to taking Tamoxifen. My i know if these medicines are safe for consumption?

6. Is it true that Doctors now recommend 5 years + 5 years for breast cancer patients taking Tamoxifen?

7. A breast cancer survivor advised me against pregnancy as my body will become very 'hormonal', especially that mine is estrogen receptor positive. I also read from XXXXXXX Cancer Society webite warning against pregnancy while on Tamoxifen. May i know if this is true and if so, why?

8. I have heard of more 'don'ts' involved with taking Tamoxifen. I would like to know if they are myths or with scientific evidents:

a) avoid taking chinese herbs as it may interfere with Tamoxifen.

b) i have been introduced to 'eexcel' health supplement product'. The founder, Dr Jau-Fei Chen, is a cancer research scientist. Eexcel offers 'whole food' which are manufactured into powder or capsule forms. My pharmacist (who prepared the chemo drugs)advised me against taking eexcel product with Tamoxifen, since it is in capsule form and may be high in concentration and may interfere with Tamoxifen (hence causing it to lose its effectiveness) since both go through the liver. Is he right? More information on eexcel can be found following this link: www.eexcelasia.com

c) avoid using cosmetics including perfumes, anti-perspirant/deodorant etc? I perspire alot, especially under-arms. I have a scar in each armpit due to earlier mastectomy surgery. Can i use anti-perspirant and cosmetic now?

d) avoid soya products as it is well-known for its estrogen properties similar to women hormones and commonly used to replace hormones for women who have menopaused. As my cancer is estrogen receptor positive, should i avoid soya products? I used to make soya beverage that comes in packet powder form blended with water and i like soya bean drinks very much. Should i avoid taking them? If i can continue to consume soya products, can i consume on daily basis and how much in terms of quantity that wil be suitable or safe in my case?

I would really appreciate it very much if you could enlighten me on my doubts above. Wishing you a pleasant day.

Regards
doctor
Answered by Dr. Monish De (3 hours later)
Brief Answer:
Avoiding pregnancy during tamoxifen therapy

Detailed Answer:
Hi

Young women like you can develop breast cancer if you have been taking birth control pills and has been using cosmetics such as shampoo, lotion, deodorant, shaving gel and cosmetics.

These personal care products contain contain parabens which are chemicals with estrogen like properties and estrogen is one of the hormones involved in the development of breast cancer.

Stress has nothing to do regarding development of breast cancer.

Tamoxifen may cause liver function test abnormalities. It may also cause increased bone pain.

Recurrence in breast cancer may occur months or years after your initial treatment. The cancer may come back in the same place as the original cancer which is called local recurrence or it may spread to nearby lymph nodes called regional recurrence or it may spread to other areas of your body which is called distant recurrence.

Sites of local recurrence include new lump in your breast or irregular area of firmness, one or more painless nodules on or under the skin of your chest wall, a new area of thickening along or near the mastectomy scar.

Sites of regional recurrence are lump or swelling in lymph nodes located under your arm, near your collarbone and in your neck.

Sites of distance recurrence are bones, liver and lungs

But having recurrent breast cancer is far from hopeless. Treatment may eliminate local, regional or distant recurrent breast cancer. Even if a cure isn't possible, treatment may control the disease for long periods of time.

There are no medicines other than Tamoxifen that can be used to prevent breast cancer recurrence.


Tamoxifen does not cause hair loss. Rogaine is not scientifically approved medication.

Optimal duration of therapy with tamoxifen is for 5 years.

Tamoxifen can hurt fertilized eggs so do not take it if you are already pregnant. It has caused birth defects, miscarriage, and prevented fertilized eggs from attaching to the wall of the uterus.

Avoid becoming pregnant while you are taking Tamoxifen but use non hormonal methods. Tamoxifen and the birth control pill should never be taken together because the pill will prevent Tamoxifen from working properly. Try condoms, spermicide, or a diaphragm to prevent a pregnancy. Don't attempt conception until you have been off of Tamoxifen for at least two months. This allows time for the drug to pass out of your system.

Chinese herbs interferes with the functioning of tamoxifen and it may reduce its positive effects.


Eexcel health supplement product should not be taken with tamoxifen as both go through the liver and it may damage liver functions.

Avoid using cosmetics including perfumes, anti-perspirant and deodorant because they contain parabens which are chemicals with estrogen-like properties and is involved in the development of breast cancer.

Soya products contain isoflavones which have chemical structures that look a bit like the estrogen found in a woman’s body. It is not the same thing as female estrogens. Soya foods do not contain estrogen and it can be safely be consumed.

Moderate amounts of soya foods as part of a balanced diet can be taken.

One to 3 servings of soya that is about half cup can be taken in a day.

If you have no more clarifications then please rate the answer and close the thread.

Warm Regards

DR De


Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Answered by
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Dr. Monish De

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Practicing since :2004

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Suggest treatment plan when suffering with breast cancer

Brief Answer: 5 years of tamoxifen therapy highly advised Detailed Answer: Hi It is highly advisable to take hormonal therapy after chemotherapy is completed for 5 years in your case. The risk of uterine cancer with tamoxifen is very rare. Hormonal therapy will prevent recurrences. Traditional Chinese Medicine (TCM) is not scientifically proven.So hormonal therapy is highly advised after surgery and chemotherapy. Yes TCM can be used in conjunction with Tamoxifen. Tamoxifen does not cause causes hair thinning. Tamoxifen does not affect kidneys.It may occasionally cause liver function test abnormality. Yes u can conceive during Tamoxifen treatment.Though your cancer is estrogen receptor positive, it will not affect pregnancy. As u are only 38 year old removal of ovaries and uterus and taking medicine aromatase is not a good option for you as you will not be able to conceive. You should take on hormonal therapy through consuming Tamoxifen for 5 years. The drug may cause a brief feeling of intense warmth and sweating called hot flashes. It can be prevented by drinking a glass of cool water at the beginning of a hot flash. Also, be sure to drink enough water, usually six to eight glasses per day. Avoid drinking beverages that contain caffeine or alcohol, since these can make hot flashes more uncomfortable. Cut down on red wine, chocolate, and aged cheeses. They contain a chemical that can trigger hot flashes by affecting the brain's temperature control center. Don't smoke. Smoking can make hot flashes worse. Wear loose, comfortable clothing made of cotton to help absorb perspiration. Hope i have answered your query Regards DR De