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October is not only a time when the wind picks up a chill, leaves change colors or when goblins and ghosts appear at your doorstep, looking for a treat. October is also Breast Cancer Awareness month, the only month when pink ribbons are peppered around your work place, schools, parks, and even on packaged cookies and snacks. What is the significance of the pink ribbon? The pink ribbon is to remind the public, especially women to be aware of breast cancer. Here are 5 breast cancer facts women should know.
How common is breast cancer?
Among women, breast cancer is the most common (non-skin) cancer and it is the second leading cause of death from cancer. In one lifetime, approximately one out of every eight women will be diagnosed with breast cancer. Breast cancer can present itself as invasive (cancer has spread to other tissues) and noninvasive (cancer has not spread). If the cancer is untreated, a noninvasive breast cancer can evolve into an invasive cancer. Invasive cancers are more aggressive (can result in fatality), causing more symptoms, and requiring more treatments such as chemotherapy, radiation, and surgery.
Who is at risk for breast cancer?
Patients at high risk include women ages 50 or older, those with a family history of breast, ovarian, uterine, and colon cancer, those with inherited genes responsible for breast cancer, early puberty (before age 12), and late menopause (after age 55). Men can also get breast cancer but their risk is 100 times less than women.
Other risk factors include women who drink alcohol (more than 2 servings per day); have not given birth; had a first pregnancy after age 30; used diethylstilbestrol (DES), a drug used to prevent miscarriages up to 1960s; are using hormonal replacement therapy; are obese; and have previous exposure to radiation therapy to the chest as a child.
Who should ask for a mammogram?
Detection is the first step in cancer treatment. Women should ask their physician if a mammogram is due. According to the United States Preventive Task Force 2009 guidelines, the current criteria for mammograms are for women ages 50 to 74 and women ages 40 to 49 with high risk factors such as family history for breast, ovarian, uterine, and colon cancer, the defective gene responsible for breast cancer, early menarche and late menopause. Your physician will also consider other factors to assess your risk level for breast cancer which include race or ethnicity, breast density, smoking, alcohol use, physical activity, and diet. If the initial mammogram is granted, subsequent mammograms will be performed every other year.
A mammogram is an x-ray of the breasts, revealing any masses, cysts, and calcifications within the tissue. If the mammogram returns with findings, it doesn’t necessarily mean that breast cancer has been detected. Your physician will order further testing such as a breast biopsy, to help make a definitive diagnosis.
What if my mammogram is negative (no cancer found) but I’m still at high risk for breast cancer?
The latest recommendation indicates that asymptomatic women, ages 35 or older and have a high risk for breast cancer (has a family history, has the genotype for the cancer, etc.) can benefit from taking selective estrogen-receptor modulators (SERMs). Currently, there are two selective estrogen-receptor modulators available, tamoxifen (Nolvadex) and raloxifene (Evista). The recommendation is based on several studies that concluded that SERMs significantly reduces the incidence of invasive estrogen-receptor breast cancer in high risk patients. Majority of breast cancers are estrogen-receptor positive, which means that the cancer cells have estrogen-receptors on them. In the presence of estrogen, the receptors are stimulated, fueling growth to the cancer.
Which SERM should I consider using?
Tamoxifen competes with estrogen at the estrogen-receptors on cancer cells. By occupying the receptors, tamoxifen blocks estrogen from binding to them which will inhibit cancer growth. The normal dose is 20 mg orally daily and the duration is 5 years. It is indicated to prevent estrogen-receptor positive breast cancer in asymptomatic women, ages 35 or older. Common side effects include hot flashes, irregular menses, skin changes, weight gain or loss, and white or brownish vaginal discharge. Serious adverse effects and complications include thromboembolic events (i.e. clots in the leg, lungs, and brain), increased risk for cataracts, and an increased risk for endometrial cancer (if the uterus is still present). The advantages of tamoxifen are having fewer non-vertebral fractures than placebo and being more effective than raloxifene in reducing the risk of invasive breast cancer. Notify your physician or pharmacist if you are taking bupropion, fluoxetine, and paroxetine. These antidepressants can interact with tamoxifen, reducing tamoxifen’s efficacy.
Raloxifene acts similarly to tamoxifen in the breast tissue. However, raloxifene exerts more estrogenic properties on non-breast tissue. The normal dose is 60 mg orally daily for 5 years. It is indicated to prevent estrogen-receptor positive breast cancer in postmenopausal women. Common side effects include hot flashes, joint or muscle pain, swollen joints, white vaginal discharge, mental depression, gas, upset stomach, vomiting, weight gain, and insomnia. Like tamoxifen, the risk of thromboembolic events exists with raloxifene. Notify your physician immediately if you develop a thromboembolic event (e.g., clots in the legs, lungs, and brain). Studies have shown that raloxifene treated patients had fewer vertebral fractures compared to placebo, making raloxifene preferred in patients with osteoporosis. Compared to tamoxifen, raloxifene has a lower risk of thromboembolic events and endometrial cancer.
Apart from skin cancer, breast cancer is the most common cancer among women. By familiarizing yourself with the latest guidelines on breast cancer screenings (mammograms) and drug options, you are taking the first step in protecting yourself, preventing cancer, and prolonging your life. Next time you see a pink ribbon, remind yourself and loved ones about the risks of breasts cancer and recommendations for breast cancer check up. Help raise awareness about an important health issue.
USPSTF 2009 Guidelines (accessed on 10/28/13)
Moyer VA. Medications for Risk Reduction of Primary Breast Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. Published online 9/24/13.
About the Author
Dr. Karine Wong has a 10 year history of working in hospital management and 2 years as a hospital pharmacist and outpatient pharmacist. She recently published a children's book called Don't Sit on Her.
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