Jane is a 36-year-old mother of three just trying to make it through the day. She has children in three different schools, and the constant driving was taking a toll on her. One day, while putting on her seat belt, her left breast hurt. She thought nothing of it as she drove around town from school to ballet to soccer and to the grocery store. Then, one morning, in the shower, she noticed a lump in her breast. No one in her family, not her mother, not her sisters, not her aunts, had breast cancer. Still, she was scared. She called her physician who recommended a mammogram and ultrasound. Jane had breast cancer.
Thankfully, Jane’s breast cancer was caught early, and all she needed was a lumpectomy and radiation. Her oncologist then recommended tamoxifen-a pill to block or shut down the estrogen receptor that stimulates her breast cancer to grow. But she had heard that if she had her ovaries removed, she would not get ovarian cancer and that she would have a lower risk of her breast cancer returning. The risk of developing ovarian cancer when you have breast cancer is very low unless you have a genetic mutation of the BRCA gene – like Angelina Jolie.
Jane also heard, however, that the aromatase inhibitors, such as Arimidex (anastrozole), Femara (letrozole) or Aromasin (exemestane) are better than tamoxifen at reducing the risk of recurrence of breast cancer. They are better. However, pre-menopausal women cannot take the aromatase inhibitors, mainly because these medications are ineffectual in the premenopausal woman. The aromatase enzyme produces estrogen and in the premenopausal woman. The aromatase in the ovaries is so numerous that the aromatase inhibitors cannot shut down all production of estrogen.
So what about removing the ovaries, or what we medically call Ovarian Function Suppression (OFS)? They are three ways to remove, or better, ablate the ovaries. You can surgically remove the ovaries (oophorectomy), you can radiate the ovaries, or you can medically shut them down. If the ovaries no longer function, then the aromatase inhibitors become an option – perhaps leading to increased survival?
A study published in the Journal of Clinical Oncology addressed this very issue. In women at intermediate risk for recurrence of breast cancer, ovarian ablation may play a role. The first question to ask is whether chemotherapy is needed in the premenopausal woman with ER-positive, Her2-negative breast cancer. If chemotherapy is not needed, then the question can be asked as to whether tamoxifen alone is sufficient or whether an aromatase inhibitor with ovarian ablation is better. If the tumor is a low-risk tumor, as determined by the medical oncologist, then tamoxifen is just as effective as the aromatase inhibitors. If the tumor is a higher risk of recurrence, but not sufficiently high to require chemotherapy, then an aromatase inhibitor with ovarian ablation may be of benefit.
The medical oncologist and you must decide on the best treatment. First, you must decide if chemotherapy is necessary. Then, you must decide if the tumor, while a low-risk tumor, is very low risk to warrant tamoxifen only, or whether there are some high-risk features that you would want you to consider an aromatase inhibitor and ovarian ablation.
Jane’s tumor was small, measuring 1.7cm. Her tumor was low grade, and her lymph nodes were negative. She did not need chemotherapy. She and her oncologist decided that her tumor was low risk and that all she needed was tamoxifen.
After her surgery and radiation, Jane started taking tamoxifen and resumed her life as a mother. She really loves her children, and they are the most precious gifts to her. She is so happy that she paid attention to her body and found her cancer early. She will be with her babies as they grow up, graduate from high school, get married and have grandbabies that she can then spoil rotten.
