This episode of Curbside Consult on Breast Cancer with Dr Lise Alschuler tackles issues around managing drug toxicity and side-effects and the changing science around estrogen therapy and the risk of breast cancer. Dr Alschuler also shares her strategies to help patients with pain management.
Managing drug toxicity and side-effects
Managing side-effects of hormone therapy is complex, and it depends on a lot of factors: the type of hormonal therapy, the age of the woman, the health condition of the woman, the symptoms that she's experiencing.
First, don’t anticipate that a woman will get every side effect from their hormone therapy. Rather, see how she does and then as symptoms begin to occur, address those individually.
However, there are some toxicities from certain drugs that should be anticipated. For example, Tamoxifen, which is commonly used for premenopausal women that can cause fatty liver in about a third of the women.
It can be a mitochondrial toxin. So support mitochondria and make sure their liver is well supported as they go into Tamoxifen.
Aromatase inhibitors lower estrogen levels but are hard on the bone, so over time they might decrease bone density. Patients should get a baseline bone density scan. If the oncologist has not recommended a pharmaceutical option for preserving bone density, I want to really focus on exercise and calcium, vitamin D and the bone nutrients.
Aromatase inhibitors can cause cardiotoxicity in about 10% of people. So make sure they're on Ubiquinol, an electron-rich form of coenzyme Q, to give them some cardiac support.
Mitochondrial toxicity isn't typically an issue with aromatase inhibitors, but of course mitochondrial support can be useful for women in general who are tired.
Aromatase inhibitors can cause some pretty significant joint pain. So think about how we can support her joints, so that she can exercise, which in turn will reduce the risk of recurrence further.
Approach symptom relief as you would a menopausal woman, except these women are not candidates for hormone replacement therapy.
Some women may benefit from vaginal estradiol for vaginal dryness, but like systemic estrogen, progesterone for menopausal symptoms is not possible.
Exercise is really important. Consider adding phyto-estrogenic foods like soybeans, tofu, tempeh, soy beverages, linseed (flax), sesame seeds, wheat, berries, oats, barley, dried beans, lentils, rice, alfalfa, mung beans, apples, carrots, wheat germ, rice bran and soy linseed bread.
Also, herbal therapies address symptoms like hot flashes.
Evolving links between hormone replacement and breast cancer
New science points to a little more leeway in our understanding of the connection between hormone replacement therapy and the initial incidence of breast cancer, it appears to be not as conclusively tied as we thought perhaps five years ago.
However, a woman with a history of estrogen receptor-positive cancer will be hard-pressed to find a gynecologist or an oncologist who will be willing to endorse systemic estrogen therapy. The risk is just too great because now we have an established disease which feeds off of estrogen.
There is more leeway around local applications such as vaginal estrogen.
Surprisingly, women with lumpectomies often do not experience very much pain, unless complications like a hematoma develop. Mastectomies can be a little bit more painful post-op because there's obviously more surgery.
As an approach, focus on this idea of pain centralization, which is part of the pain pathway. If the brain interprets signals that come from the body that are overlaid with anxiety, it can accentuate those signals.
Refer them to a medical hypnotherapist. Medical hypnotherapy is really good at helping women access their subconscious to soothe sensitization pathways.
Mindfulness practice in general can do that as well.
Aromatherapy and infused aromatherapy can be used. Peppermint or lavender aromatherapy can be quite useful.
Contrast bath therapy is a series of brief, repeated water immersions, alternating between warm and cold temperatures which can be quite helpful.
Physical therapy as early as possible in the healing process can resolve some of the issues that are contributing to pain, too.
There are supplements that can be used for pain, but for this kind of acute surgical-related pain, don't go to supplements first.
“I think now there's a little bit more leeway in terms of the link in our understanding and the connection between hormone replacement therapy and the initial incidence of breast cancer, where that appears to not be as conclusively tied as we thought perhaps five years ago. That being said, once a woman has a history of estrogen receptor-positive cancer, you're going to be hard-pressed to find a gynecologist or an oncologist who will be willing to endorse systemic estrogen therapy.” Dr Lise Alschuler, ND FABNO
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