Hormonal therapy

Modem cancer therapy has been primarily dependent upon surgery, radiotherapy, chemotherapy, and hormonal therapy (72) (see Chemotherapeutics,anticancer Hormones Radiopharmaceuticals). Chemotherapeutic agents maybe able to retard the rate of growth, but are unable to eradicate the entire population of neoplastic cells without significant destmction of normal host tissue. This serious side effect limits general use. More recentiy, the immunotherapeutic approach to cancer has involved modification and exploitation of the cellular and molecular mechanisms in host defense, regulation of tissue proliferation, tissue differentiation, and tissue survival. The results have been more than encouraging. 

Therapeutic Function Estrogen used in hormone therapy for prostate cancer Chemical Name 4,4 -(1,2-Diethyl-1,1-ethenediyl)bisphenol-bis(dihydrogen phosphate) Common Name Fosfestrol Structural Formula ... 

Turgeon JL, McDonnell DP, Martin KA et al (2004) Hormone therapy physiological complexity belies therapeutic simplicity. Science 304 1269-1273... 

The measurement of ER has become a standard assay in the clinical management of breast cancer. The presence of ERa identifies those breast cancer patients with a lower risk of relapse and better clinical outcome. Receptor status also provides a guideline for those tumors that may be responsive to hormonal intervention. But only about half of ER-positive patients respond to hormonal therapies. Of those who respond initially, most will eventually develop an estrogen unresponsive disease following a period of treatment even though ERa is often still present. Mutant receptors and constitutively active r eceptors as well as hormone-independent activation of the ERa are discussed. The involvement of ER 3 isoforms is under investigation. 

Besides the hormone therapy, the notion of targeted cancer therapy is not so new and can be traced back to the 1940 s [2]. Early approaches included the largely unsuccessful use of antibodies, often conjugated with radioisotopes or toxins, directed against tumor-associated antigens. 

MANAGING SODIUM AND WATER RETENTION. Sodium and water retention may occur during female hormone therapy, hi addition to reporting any swelling of die hands, ankles, or feet to the primary health care provider, die nurse weighs the hospitalized patient daily, keeps an accurate record of die intake and output, encourages ambulation (if not on bed rest), and helps the patient to eat a diet low in sodium (if prescribed by the primary health care provider). 

List the monitoring parameters necessary to assess therapeutic outcomes and adverse effects in patients receiving growth hormone therapy. 

Recombinant growth hormone therapy is the main pharmacologic treatment for growth hormone deficiency in both children and adults. 

Recognize that alternative, non-hormonal therapies for menopausal symptoms exist and should be considered in some circumstances for women unable to take hormone-... 

CD Since the publication of the Women s Health Initiative study, there has been an increase in the use of non-hormonal therapies for the management of menopausal symptoms. Particularly for women with CHD and breast cancer risk factors, non-hormonal therapies may offer an alternative to assist with symptom management. A wide range of therapies, both prescription and herbal, have been studied with varying degrees of success. In choosing a particular therapy, it is important to match patient symptoms with a therapy that is not only effective but also safe. 

HRT, but they are less efficacious than hormonal therapies. Alternative treatments should be chosen based on the efficacy and safety profile of the treatment and the patient s past medical history and current medications. 

For women who cannot tolerate even a very slow taper, the benefits must be weighed against the risks of HRT, and often women choose to continue HRT. Alternative, non-hormonal therapies are available and may be beneficial in some women however, the literature suggests that these therapies are less effective than HRT. 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

SSRIs are theorized to reduce the frequency of hot flashes by increasing serotonin in the central nervous system and by decreasing LH. Of the SSRIs, citalopram, paroxetine, and sertraline all have been studied and have demonstrated a reduction in hot flashes while treating other symptomatic complaints such as depression and anxiety.33 Venlafaxine, which blocks the reuptake of serotonin and norepinephrine, has demonstrated a reduction in hot flashes primarily in the oncology population.34 Overall, these antidepressant medications offer a reasonable option for women who are unwilling or cannot take hormonal therapies, particularly those who suffer from depression or anxiety. These agents should be prescribed at the lowest effective dose to treat symptoms and may be titrated based on individual response. 

Overall, non-hormonal therapies are less effective in treating vasomotor symptoms than HRT but do offer an important option for women experiencing menopausal symptoms who cannot or are unwilling to take HRT. The antidepressants gabapentin and clonidine have the best evidence for efficacy of all the non-hormonal options and should be considered first as an alternative to HRT. The most important considerations in choosing an alternative therapy are the patient s comorbidities and the efficacy and safety of the medication. 

Graft-versus-host disease Hormone therapy... 

Hormonal therapies have shown activity in the treatment of cancers whose growth is affected by gonadal hormonal control. Hormonal treatments either block or decrease the production of endogenous hormones. 

Initial therapy of metastatic breast cancer in women with hormone-receptor-positive tumors should consist of hormonal therapy. 

An NIH Consensus Development Conference Statement22 advises that adjuvant hormonal therapy should be recommended to women whose tumors contain hormone-receptor protein regardless of age, menopausal status, involvement of axillary lymph nodes, or tumor size. They also support a benefit of adjuvant chemotherapy for most women with lymph node metastases or with primary breast cancers larger than 1 cm in diameter (both node-negative and node-positive).22... 

The use of preoperative systemic therapy is gaining favor in both early-stage and locally advanced breast cancers. This approach to therapy, referred to as neoadjuvant or primary systemic therapy, most often consists of chemotherapy but in special circumstances also may include hormonal therapy (e.g., in inoperable patients with significant comorbidities). The advantages of preoperative systemic therapy include... 

Hormonal therapies that have been studied in the treatment of primary or early breast cancer include antiestrogens, oophorectomy, ovarian irradiation, luteinizing hormone-releasing hormone (LHRH) agonists, and aromatase inhibitors. 

In postmenopausal women, recently reported evidence supporting the use of aromatase inhibitors in the adjuvant setting is intriguing and may usurp the role of tamoxifen. Three different approaches to therapy have been undertaken with these new agents (1) direct comparison with tamoxifen for adjuvant hormonal therapy, (2) sequential use after 5 years of adjuvant tamoxifen therapy, and (3) sequential use after 2 to 3 years of adjuvant tamoxifen. Based on results of several studies, it has been concluded that therapy for postmenopausal women with ER-positive breast cancer should include an aromatase inhibitor.27,47 It is still unclear if the aromatase inhibitor should be used instead of tamoxifen or sequentially after receiving tamoxifen for 2 to 5 years.27 Concerns surrounding loss of bone density, changes in blood lipids, and cardiac and vascular disease require further study.27... 

The choice of therapy for metastatic disease is based on the site of disease involvement and presence or absence of certain characteristics (i.e., hormonal status of the primary tumor and disease location). For example, patients who experience a long DFS following local-regional therapy or have disease that is located primarily in the bone or soft tissue likely will respond to endocrine therapy. Patients with asymptomatic visceral involvement (e.g., liver or lung) may be candidates for hormonal therapy depending on the clinical circumstance (generally... 

There are no well-defined clinical characteristics or established tests to identify patients likely to benefit from chemotherapy. Factors associated with an increased probability of response that have been identified include a good performance status, a limited number (one to two) of disease sites, and patients who respond to chemotherapy or hormonal therapy with a long disease-free interval. Patients who have progressive disease during chemotherapy have a lower probability of response to a different type of chemotherapy. However, this is not necessarily true for patients who are given chemotherapy after some interval during which they have received no chemotherapy. Patients who do not respond to endocrine therapy are as likely to respond to chemotherapy as patients who are treated with chemotherapy as their initial treatment modality. Age, menopausal status, and receptor status have not been associated with favorable or unfavorable response to chemotherapy. 

Early breast cancer is resected completely with curative intent, and adjuvant chemotherapy and hormonal therapy are initiated to prevent recurrence. During adjuvant chemotherapy, laboratory values to monitor chemotherapy toxicity are obtained prior to each cycle of chemotherapy. After completion of adjuvant therapy, patients are monitored every 3 months for the first few years after diagnosis, with intervals between exams extended as time from diagnosis lengthens. 

Metastatic breast cancer is not curable, and therapy is intended to palliate symptoms. In most cases, hormonal therapy is the mainstay. While on therapy, patients are monitored monthly for signs of disease progression or metastasis to common sites, such as the bones, brain, or liver. 

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