Aromatase inhibitor or tamoxfien??

[dng]

My wife is 46 years old, and was diagnosed with Breast cancer last
summer.
Her 1.3cm cancer was nonpalpable and was picked up on a screening
mammogram as a 1 year interval cancer.
She underwent a lumpectomy at a NY hospital and there were 2/22 nodes
positive.
The tumor was found to be
Estrogen receptor >80% positive,
Progesterone receptor >80% positive and
Her2/Neu+ as well.
The rest of her workup was unremarkable for distant disease.

She has undergone a course of chemotherapy :
Dose Dense Adriamycin and Cytoxan chemotherapy 4 cycles (every 2 weeks)
then Taxol and Herceptin weekly for 12 weeks
then Herceptin was switched to every 3 weeks for 40 weeks and
she began radiation to the lumpectomy site 33 sessions over 6.5 weeks
when the Taxol stopped.

Now the issue is the direction of her hormonal therapy :
AI vs Tamoxifen.

Her current lab values show:

estradiol is 7 postmenopausal <10-50pg/ml
FSH is 65.3 prepuberty <5.0mIU/ml
postpuberty <15.0
postmenopausal > 20.0
LH is 29.0 prepuberty <2.0

My wifes onc. wants to give her an AI and monitor her blood values over time to see if she is still menopause. He feels that an AI is appropriate because:
1. An AI is more effective in postmenopausal women
2. An AI may be more effective in Her2 breast cancer.

However I have read in two papers that there is a possibility that menses may resume after using AI:
Inadvertent use of aromatase inhibitors in patients with breast cancer with residual ovarian function: cases and lessons.

Burstein HJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Burstein+HJ%22%5BAuthor%5D),Mayer E (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Mayer+E%22%5BAuthor%5D), Patridge AH (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Patridge+AH%22%5BAuthor%5D), O'Kane H (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22O%27Kane+H%22%5BAuthor%5D), Litsas G (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Litsas+G%22%5BAuthor%5D), Come SE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Come+SE%22%5BAuthor%5D), Hudis CA (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Hudis+CA%22%5BAuthor%5D), Goldstein DF (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Goldstein+DF%22%5BAuthor%5D), Muss HB (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Muss+HB%22%5BAuthor%5D), Winter EP (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Winter+EP%22%5BAuthor%5D), Garber JE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Garber+JE%22%5BAuthor%5D).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16800976&dopt=Abstract (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16800976&dopt=Abstract)

Adjuvant aromatase inhibitors for early breast cancer after chemotherapy-induced amenorrhoea: caution and suggested guidelines.

Smith IE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Smith+IE%22%5BAuthor%5D), Dowsett M (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Dowsett+M%22%5BAuthor%5D), Yap YS (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Yap+YS%22%5BAuthor%5D), Walsh G (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Walsh+G%22%5BAuthor%5D), Lonning PE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Lonning+PE%22%5BAuthor%5D), Santen RJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Santen+RJ%22%5BAuthor%5D), Hayes D (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Hayes+D%22%5BAuthor%5D).

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16735701

We are not sure what the best way is to proceed.

The options seem to be:
1 Tamox
2. AI and monitor blood values
3. Remove the ovaries and take an AI
4. ovarian suppression and take an AI

Thank you very much for your help.

[CPA]

If her periods had stopped prior to chemo, I would guess that there is a good chance that she is really in menopause. If they stopped during chemo, then there is a chance that she could re-start her period. We were told that in addition to checking labs, our onc wanted to wait 2 years after Jill's last period before switching to an AI.

At 46, your wife is nearing natural menopause, so ovarian suppression or removal might not be a bad option. It sounds like many docs don't like to stop ovarian function in younger women, especially if there are no mets because of the other protective qualities of the hormones (bones, heart, etc.). Our oncologist seemed to think it was a no-brainer for Jill to go on Tamoxifen, but she is node negative and younger.

In a situation like this you might not find the right answer, rather several good answers with differing risks and benefits.

[sassy]

DNG

I too was diagnosed at 45, triple positive with 5 of 14 positive nodes and followed basically the same treatment path as your wife. My onc started me on Arimidex following rads, adding Lupron at the same time for ovary suppression. This was in November 05. I continued on the Lupron shots every three months until December of 06, when my Estrodiol (sp) levels began to rise. We have switched to monthly Lupron to see if that will maintain suppression.

For several reasons, neither my surgeon nor my onc wanted me to have my ovaries removed initially. My surgeon is now OK with it, but my onc feels remaining on Lupron would be more beneficial. He reported to me that he had learned at San Antonio that there were some studies underway that indicate Lupron may have added benefits for HER2+ women in terms of recurrence. This is a subject I will discuss with him again at my next visit and hope to have more information.

Neither my onc nor I ever considered tamoxifen as a alternative, and I would urge you to research the benefits of AI's for HER2+ women. You should be able to find information using the Search function on this site.

I hope your wife is doing well and I wish you both the best. You will find much information and support from the members of this site.
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[dng]

Thanks for the quick replies. I would be very interested in any info you have about the possible added benefits of lupron. I have not seen anything about that. My wife's onc is not reccomending the removal of her ovaries.

[Becky]

The added benefit of Lupron is for young premenopausal women as ovarian suppression benefits survival survival short term and when 5 years is done, they still need their hormones as they are too young to remain postmenopausal. For those 45 and older, there is no benefit of Lupron over oophorectomy as natural menopause is right around the corner anyway (where it is not in a 35 year old). This is what was reported in San Antonio - that ovarian suppression in the young with Lupron is beneficial over oophorectomy as they are too young to be put into menopause permanently.

[panicked911]

I too am a strong triple positive and was 43 at diagnosis- Luckily it was stage 1 and I am neing treated at a major NY cancer center. With that said - my surgeon intitally put me on tamoxifen but when I saw the Onc who is the head of breast cancer trials , she said no way - Arimidex w/lupron. Tamoxifen is not even on the table for at least 5 years. The monthly lupron shots suck, for lack of a bettr way to describe it. You can also administer very 3 months but side effects are worse. I have opted for the 1x a month.
Hope this helps.

S