Cancer: endure hormone therapy

Prescribed to prevent relapses of certain breast cancers, hormone therapy is accompanied by side effects that are often difficult to live with, without help to endure them.

Most breast cancers are hormone-sensitive or hormone-dependent. Biopsy analysis of the tumor reveals the presence of estrogen (ER +), progesterone (PR +) or both receptors. These proteins located on the surface of the cancer cell pick up female hormones in the blood. Once bound to receptors, they stimulate cancer growth. Since the 1970s, research has shown that survival is significantly improved if they are deprived of this fuel by so-called hormone therapy treatments, but these are unfortunately often accompanied by side effects.

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What benefit?

Hormone therapy can be administered to stabilize the progression of metastatic breast cancer but, most often, it is prescribed for 5 to 10 years, in addition to surgery for localized cancers (after possible radio and chemotherapy) to avoid the risk of relapse (local or in the other breast). But when we are in remission, once the heavy treatments are over, we only aspire to rebuild ourselves and, if possible, to relive as before, forgetting the cancer. “When we no longer feel sick, we accept less easily to suffer for preventive treatment,” agrees Dr. Mahasti Saghatchian, medical oncologist at the American Hospital in Paris. The first essential step to endure it is to understand why it is given and what to expect from it.

It’s hard to accept, but even cured, cancer remains a sword of Damocles. “He can relapse for up to 15 years from the initial cancer,” says the doctor. Even if we removed everything while operating, even if we had chemotherapy, the cancer cells are sneaky. It can remain hidden in other organs and wait there for years before developing metastases or a second breast cancer. ” Clinical studies have, on the other hand, proved that the antihormonal treatment administered in secondary prevention of hormone-sensitive cancers is an effective shield. At 5 years, antiestrogens, such as tamoxifen, reduce the relative risk of relapse by half, and by a third between 5 and 10 years. Anti-aromatases, which appeared in the 1990s and prescribed to already menopausal women, reduce the risk of recurrence by 65%.

What side effects?

“Removing estrogen is not trivial,” explains Dr Delphine Wehrer, gynecologist at the Gustave-Roussy Institute in Villejuif. They manage many processes in the body: from hair growth during puberty to bone density, through menstrual cycles, the thickness of the skin and mucous membranes, including that of the vagina, and its lubrication. They also help regulate body temperature, cholesterol. “Their disappearance disrupts everything, triggering a menopause all the more brutally felt as, unlike the natural menopause which comes gradually, the body does not have time to get used to it”, underlines Dr. Barbara Pistilli, oncologist at the Gustave-Roussy Institute.

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If you are already through menopause, hormone therapy reduces estrogen levels to zero, which makes menopause more drastic and aggravates its symptoms. Hot flashes, joint pain, weight gain, memory problems, low libido: the list of effects that women complain about is long and much more disabling than cancerologists imagine. A study, conducted at the Institut Gustave-Roussy on 4,262 women with localized breast cancer, and published in 2019 (1), has shown for the first time that hormone therapy has more deleterious and lasting effects on quality of life than chemotherapy, 2 years after diagnosis. An accentuated degradation in postmenopausal women.

Can we escape it?

“30 to 50% of patients tolerate hormone therapy fairly well, and some even don’t want to stop after 5 years. But one in two, which is huge, actually has side effects. And for a third of them, they are important, ”notes Dr Saghatchian. But “not all women feel them all, or at their maximum intensity,” reassures Dr. Wehrer. Their occurrence depends on many factors, including the type of medication prescribed and for how long. “Age, sequelae of the disease and previous treatments also play a role for 10 to 20% of patients. In addition, studies and MRIs have legitimized a direct effect on the joints. They are really damaged and inflammatory in women taking anti-aromatases.

Tamoxifen, on the other hand, does not have a significant biological effect on the articular sphere, ”says Dr Saghatchian. The stiffness then owes more to the induced menopause all at once, “in women who still have very active lives and who have never experienced joint stiffness before”, underlines Dr Pistilli. Persistent fatigue, the symptom most frequently highlighted in patient discussion forums, cannot entirely be attributed to hormone therapy either. “Real and burdensome, fatigue is also linked to cancer itself, to cancer. psychological shock, chemotherapy, life change and age, ”lists Dr Saghatchian.

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Weight gain is also favored by the preceding journey: between muscle wasting linked to postoperative convalescence and corticosteroids associated with chemotherapy, the body reacts by making reserves. Then comes hormone therapy. “Therefore, the gradual weight gain directly linked to anti-aromatases is inexorably manifested,” confirms Dr. Wehrer. “The other side effects, which occur mainly during the first 2 years, can subside over time,” reassures Dr. Saghatchian.

What solutions?

Whatever effects are felt, you should talk to your doctor and oncologists, even if they admit sometimes feeling powerless to respond correctly in a follow-up consultation due to lack of time. “Although they are not magic, recalls Dr. Wehrer, there are solutions to help support the treatment, and prevent it from stopping.”

Hot flashes

Appearing in the first months, they fade over time, but are favored by coffee, alcohol, spicy foods, overweight and especially stress. “Yoga, sophrology, relaxation or meditation can help reduce them,” says the gynecologist. “A meta-analysis of acupuncture studies in breast cancer survivors showed a reduction in hot flashes (2)Adds Dr Saghatchian. Antidepressants (serotonin reuptake inhibitors), such as venlafaxine, have been shown to be effective and safe (3).

Weight gain

This is the most ungrateful side effect, because it is linked to the change in metabolism, induced by hormonal suppression. The only solution: to adhere to an exemplary hygiene of life, with regular and sustained physical activity associated with a balanced diet, avoiding improvised and drastic diets, which would instead install a yo-yo effect. To stick to it in the long term, it is better to get help from a dietitian to change your eating habits and be prescribed adapted physical activity sessions (APA).

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Joint pain

Here again, “regular physical activity is proving, as against fatigue, the best remedy”, underlines Dr Saghatchian. Anti-inflammatory drugs (NSAIDs) should be taken punctually, in the event of an acute attack. On the other hand, “duloxetine, an antidepressant from the class of serotonin reuptake inhibitors (SRIs) has demonstrated its effectiveness on these osteo-articular pain induced by hormonal suppression. (4)Says Dr Pistilli.

Vaginal dryness and sexual difficulties

“Luckily, libido is not just linked to hormones,” recalls Dr Wehrer. Sexuality suffers, however, from the effect of the treatment on the vulvovaginal mucosa, which is thinner and less vascular. Even if it seems delicate, it is not incidental; it is important to broach the subject with the patients. “We recommend that you limit yourself to an external intimate toilet with a surgras product, and to resort to vaginal creams based on hyaluronic acid, sold in drugstores and without contraindication”, explains Dr. Wehrer. More effective, the vaginal laser (Mona-Lisa Touch) restores atrophied walls for 18 months to 2 years, in three sessions. But few hospitals are still equipped with it and, in the private sector, it remains expensive and not reimbursed.

Maisons Roses Reception centers in Paris and Bordeaux for the RoseUp patient association.

The League Against Cancer

Cami sport et cancer is an association offering adapted sports sessions

Unicancer Network of cancer centers

(1) Ann Oncol. 2019; 30: 1784-1795.

(2) Cancer Nurs. May-Jun 2016; 39 (3): 228-37.

(3) Clin J Onco Nurs. 2011; 15: 149-57.

(4) J Clin Oncol. 2018; 36: 326-332.

(5) J Clin Oncol. 2020; 38 (24): 2762-2772.


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