Extending AI Treatment Beyond 5 yrs - Discussion w/my Onc

[Becky]

I had my normal check up on Wed. Sept 17. My onc is great and we will always have a conversation on one or two topics (usually of my choice). This time I brought up 2 things. One being the breast specific gamma imaging - aka Gammogram. The other was his thoughts and any concensus out there on continuing AI therapy beyond the prescribed 5 yrs (I am at 3 yrs on Arimidex now).

First, he told me there is a trial right now. The women on the trial are women who were taking Arimidex for 5 yrs instead of taking tamoxifen 5 yrs. Some of those women were randomized to continue Arimidex another 5 yrs. The other trial are women who took Tamoxifen 5 yrs and then took 5 yrs of Femara. Some of those Femara women were randomized to take another 5 yrs of Femara. He told me the results won't be ready for another 2-4 yrs. However, he will be continuing some of his patients on an AI (remember they were just approved for use in non-metastatic women in October, 2004 so some patients are almost at 4 yrs of use). Anyway, he plans on keeping me on an AI and switching me to Aromosin at 5 yrs (due to the Efects trial). He told me if for some reason I can't tolerate Aromosin (as I have no joint pain etc from Arimidex), he will just switch me back. He said if the trials show no added benefit (even though I would be on an extra 2 yrs or so), then we would just stop. His criteria for continuation will be age of woman (if younger than 50 when diagnosed there is a long anticipated life span to consider), does the woman currently have severe issues that one must consider the potential good of continuing is less than the potential bad of continuing - meaning - is joint pain debiliating? Bad cholestrol side effect, severe and uncontrollable bone loss? He said that some Her2 negative women who are highly ER+/PR+ but have alot of issues with AI but never took tamoxifen he might put them on tamoxifen or Evista after the 5 yrs of AI. It is a case by case basis.

So, have that discussion with your oncs and see what their thoughts are. His (or mine) might change in the 2 yrs I have left to be on Arimidex but that is what we discussed this time.

[Sheila]

Becky
I think this way be the new wave for ER+ women
I have always felt that my Mom is a pioneer in this field...she was on Tamoxifen 17 years....she is almost to 21 years as a survivor and never had a recurrence, she probably was not Her2+ as they did not test for it back then....and she had no chemo, even with 13 positive nodes...just a RADICAL (and I mean that) mastectomy and Tamoxifen
so kudos to you for taking charge and looking into it!

[Margerie]

Way back when I first met my oncologist, he recommended an ooph and Arimidex for 5 years. He also said that after 5 years, he would probably recommend switching to another AI for another 5 years depending on what studies are showing. We will cross that bridge when we get there. I am 2.5 years into my 5 years of Arimidex. Thankfully, I do not have too many problems with the Arimidex (the new blister pack not withstanding) and my bone density and cholesterol are still good.

I was thinking that since ER+ seems to like to recur 7 years+ it makes sense to stay on AI's longer than 5. I am just glad that they are trying to figure out what to do with all the women who are 5+years out NED.

Thanks for taking the time to post your discussion Becky. Your onc sounds like a gem!

[tricia keegan]

Thanks for the info Becky, I won't be seeing my onc until December but do intend discussing this then. I do have some minor bone loss and stiffness/joint pain but nothing I can't handle at this point. Looking on the bright side if I'm still NED at five years I'd really like to stay on arimidex despite any side effcts!

[Donna]

Hi Becky,

Your post made me wonder about the weight and age of the woman as well since, well, here's a quote from PubMed on it:

"Adipose tissue is the principal site of estrogen formation in postmenopausal women; with advancing age as well as with increased body weight, there is an increase in the fractional conversion of circulating androstenedione to estrone."

So I would think not only is the weight going to be a factor, but age seems to step up the production, too. If mere aging increases aromatase conversion, and if a person is overweight - I read that as a "yikes!"

It will be interesting to see what these new trials bring to the table.

Thanks for the information and the thoughts.

Donna

[Barbara2]

(I'm not sure how this little face appeared in the heading, but I can't make it go away!)

I reached 5 years of Arimidex this past March 2008. My onc said he would prefer that I continue the Arimidex (rather than not taking it anymore). He felt that it was important to keep knocking down the ER+.

We had been discussing hypothyroidism, and I mentioned the ongoing battle of trying to lose weight, and he agreed that excess weight and ER+ is another reason to continue with the Arimidex.

He had his nurse look into trials for people who had been on Arimidex for 5 years. She found one that uses a placebo with 1/2 of the participants, the other half get letrozole. We didn't discuss the details because we knew that I would not be interested in taking a chance of getting the placebo. That was the only trial she mentioned.

I thought that maybe at my next 3 month visit, I may ask what he thinks about changing to Letrozole (Femara). There is probably little or no difference between Arimidex and Letrozole, so I'm not sure why one would want to switch.

Becky, could you please elaborate on the discussion you had with your onc concerning Aromasin and the Efects trial. What did the trail show?

I understand that Aromasin contains 25 mg of exemestane, an irreversible, steroidal aromatase inactivator, but what exactly that means, I'm not sure.
"Steroidal" would probably pack on more pounds!....?

[Becky]

The Efects trial used hormone positive metastatic women who failed on Arimidex. Half were give Faslodex shots and the other half were given Aromosin. Astro Zeneca was probably hopeful that Faslodex would "win" since it not only makes Faslodex but the "failed" Arimidex (thereby keeping the business). The trial showed Faslodex and Aromosin to be equal in effect. What the trial showed was metastatic women who fail Arimidex can switch to another pill form of anti-hormonal (as Faslodex is a shot).

Aromosin works in a different way (biochemically) to suppress the action of aromatase than Arimidex and Femara work (they are different drugs but work the same way). I don't know if one or another causes more weight gain or not.

[Cheryl E]

This month is my 5th anniversary on Femara. Last year, when I asked what would happen after 5 years, he replied that MD Anderson was keeping women on femara 7 years without any complications and they were looking into 10 years. I will see my onc in a few weeks for my regular check up and see what he says. I was dx in 3/03 and therefore never recieved herceptin. Aside from mild osteopenia, I have no complications from the femara.

Cheryl

[Mgarr]

My mom (though a diff. age bracket) was on Tamoxifen for 5 yrs. and is taking Femara for 5 more she is about 2 1/2 yrs. in. She did have some initial joint pain and she backed off then her onc. cut the dose for some time and the pain subsided she has since gone back on the full dose and has not complained of any side effects. The one concern with the Femara has been loss of bone she is screened regulary and this last one showed some loss.

Best of luck with your decisions.

Mar

[PatS]

I've been on Arimidex for 5 years and my onc is having my continue.

Pat

[Soccermom2006]

Was on tamoxifen for 6 months then switched to Arimidex and its been 3 years (just starting my 4th). Becky, your query is timely for me as my 6 mo visit w my Onc is soon and since my best friend recurred 5 years after finishing Tamoxifen its been weighing heavily on my mind, Thanks
Marcia

[Barbara2]

I came across this today:

"Results from head-to-head trials comparing steroidal and nonsteroidal AIs will determine whether meaningful clinical differences in efficacy or adverse events exist between the classes of AI. This review summarizes the available evidence regarding known differences and evaluates their potential clinical impact."
http://theoncologist.alphamedpress.o.../full/13/8/829

[Becky]

Nice article.