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The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
symptoms but evidence of effectiveness
has only been anecdotal.54 For urogential
symptoms, vaginal lubricants for mild
symptoms and vaginal oestrogen for
severe symptoms have been used with
various degrees of success.55--57
Is tamoxifen the only hormonal drug
used for breast cancer?
Since the 1990s, tamoxifen has been
widely used as adjuvant therapy in
breast cancer. Survival rates can be
increased by around 15% after five years
of treatment. However, of late and due to
its side effects, newer drugs have been
Aromatase inhibitors such as anastrozole,
exemestane and letrozole can be used
as an alternative to tamoxifen.59,60 In
some studies, these drugs were initiated
after tamoxifen had been taken for five
years by post-menopausal breast cancer
patients.61 In postmenopausal women,
aromatase inhibitors (AI) improve
survival rate and are used either after
surgical removal of cancerous tissue, or
after approximately two to three years'
standard tamoxifen treatment, or after
five years' tamoxifen treatment to prevent
relapse, or if there are contraindications
to tamoxifen such as a history of
thrombotic events or embolism.40,62--64 In
pre-menopausal women, however, high
oestrogen levels render AI ineffective.65
As a result, pre-menopausal women with
hormone receptor-positive breast cancer
are usually prescribed tamoxifen. 65,66
Case study continued
In this scenario, the patient has neglected
to fill her prescription for two out of
six months, indicating a compliance
issue as a result of the persistent
symptoms of early menopause caused
by tamoxifen.47 Confirm that she does
have an adherence problem, and possible
reasons. Then establish whether the
patient is premenopausal and explain
how this influences the choice and
duration of treatment.67,68 Recommend
that she continue to take the tamoxifen
daily. Counsel the patient regarding
the five years' treatment benefits
versus 1--3 years' treatment seen with
tamoxifen as adjuvant therapy for breast
cancer.47 If side effects are a concern,
collaboratively (in consultation with her
prescriber, and considering the patient's
preferences) explore options, which may
include continuation, cessation with no
substitute, or cessation with introduction
of a substitute treatment. Furthermore,
educate the patient regarding the
benefits of compliance and consistency
to ensure optimal effectiveness.42
Then consider non-hormonal natural
alternatives, including lifestyle
Key learning points
Tamoxifen needs to be taken regularly
to prevent fluctuation of tamoxifen
serum levels. Tamoxifen has been shown
to result in greater long-term survival
when used for five years versus one to
three years. Tamoxifen precipitates early
menopause. Medicines such as citalopram
and venlafaxine may provide relief of
vasomotor adverse effects, alongside
alternative treatments including
breathing techniques or acupuncture
and lifestyle changes such as avoiding
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