Balancing quality-of-life concerns with treatment goals is complicated for young patients with hormone-sensitive breast cancers.
Balancing quality-of-life concerns with treatment goals is complicated for young patients with hormone-sensitive breast cancers. Shared decision-making, ongoing two-way communication between patient and providers, and consistently addressing symptoms are critical to optimizing management, encouraging adherence, and having good survival outcomes.
The 8-year follow-up data from the ASTRRAtrial (NCT00912548) is exciting to see, because the more long-term outcome information we have in these specific age-stratified cohorts, the better we can help individualize care for patients and empower them in their decision-making about treatment. The findings from this trial suggest that for patients with estrogen-receptor positive breast cancer who remain in a premenopausal state—or resume ovarian function—following chemotherapy, 2 years of ovarian suppression may be a good approach. I see these findings as good news to reassure those women who have difficulty with the adverse effects (AEs) of ovarian suppression, and for whom the idea of 5 years of therapy is intolerable. Perhaps it is too early for a sweeping change to practice, but for a lower-risk patients who is miserable on treatment, it may be reasonable to consider a shorter duration of therapy to balance her need for better symptom management and quality of life.1
Tolerating ovarian function suppression (OFS) is a challenge for nearly all premenopausal patients: AEs like hot flashes, sleep disturbances, mood swings, vaginal dryness, and impact on libido are some of the most problematic changes. Some women also have the long-term effects of fertility loss, and others experience bone loss and joint pain that can be debilitating. Treatment-related AEs vary widely since each person has a different threshold for what they can tolerate. Because symptoms are individual and seem to depend where along the estrogen deprivation continuum the patient is, individualized conversations are imperative. Without ongoing communication, it is impossible to predict how a specific patient will handle their regimen. Some very young patients cope with the sudden loss of circulating estrogen very well, where others who have been in the throes of perimenopause for some time experience intolerable effects that lead them to discontinue therapy prematurely. Preparing patients for expected symptoms is important and can be decisive in terms of their long-term adherence.
Continuity of care is also critical. Ongoing check-ins and symptom-monitoring conversations between patient and their trusted provider are important. Too many patients over the years have reported that their oncology team emphasized adherence but did not do a good job addressing the impacts on their quality of life. We must normalize ongoing conversations about sexual AEs, pain, fatigue, joint pain, and insomnia so that our patients are comfortable and feel empowered to discuss all aspects of their quality of life, whether we bring it up or not (we should try to always bring it up!).
Aggressive symptom management is key, letting patients know what the expected side effects are, but also that we have strategies to address each one. For example, tell them that you have experience managing the initial vasomotor effects that bother many early on in treatment and explain that these symptoms may improve over time, or become more manageable with prescription medications and other interventions. It is often a matter of trying various strategies until something works. Patients and their partners need to feel comfortable communicating their concerns with the team, and that open communicating starts with the initial consult and treatment discussion. I try to reassure patients that while we list many possible AEs, most people do not experience all—or even most of them—and certainly not at the same time.
When providers address sexual AEs and fertility concerns especially, it is best to assume nothing and keep open communication so that the patient can share freely. When it comes to a patient inquiring about issues related to sexuality, fertility, and early menopause, it is the questions they do not ask that concern me the most!
Sometimes this lack of communication is because of shyness or embarrassment, a perception that symptom concerns are frivolous, and that the oncology team is not interested in the patient’s personal life. This, of course, could not be further from truth; oncology providers are committed to keeping patients functioning in every area of their life and on optimal treatment for as long as they can to have best chance at cure. The conversations about treatment, particularly in younger women with more concerning or high-risk prognostic features, occur so quickly. The urgency to get started often means that truly informed decision-making is impacted. Too often treatment plans initiate without the patient and partner fully understanding what is at stake long term, and without the team clearly understanding the patient’s priorities. The time to preserve fertility, for example, is prior to starting any potentially gonadotoxic treatment. Directly asking a patient about their family building plan, even if they already have a child or children, or have a partner, is key. I ask if there is a possibility that they would want to have a biological child in the future and let the conversation proceed from there. Fertility preservation has challenges and barriers like timing, cost, and availability of a provider, but the conversation for a patient considering endocrine therapy, including ovarian function suppression, should not be overlooked.
I will never forget a brave patient in her early 30s, who, in frustration and sadness, talked about the impact side effects of endocrine therapy were having on her intimate relationship, spoke to her oncologist in a shaky tearful voice, “What good is it to prolong my life if I don’t have quality of life?” It was a powerful moment of realization for me as part of this patient’s team. I recognized my unique role and opportunity as a navigator and advocate in her care. As we navigate today’s cancer treatment landscape with constantly evolving evidence and information about best practices, we must include our patients in the conversation.
Baek SY, Noh WC, Ahn SH, et al. Adding ovarian suppression to tamoxifen for premenopausal women with hormone receptor-positive breast cancer after chemotherapy: an 8-Year Follow-Up of the ASTRRA Trial. J Clin Oncol. 2023;JCO2300557. doi:10.1200/JCO.23.00557