Postmenopausal patients

Toremifene is another commercially available SERM for the treatment of breast cancer. It exhibits similar efficacy and tolerability to tamoxifen in the metastatic setting. Cross-resistance to toremifene has been demonstrated in patients with tamoxifen-refractory disease.51 Therefore, toremifene appears to be an alternative to tamoxifen in postmenopausal patients with positive or unknown hormone-receptor status with metastatic breast cancer. 

Toremifene has similar efficacy and tolerability as tamoxifen and is an alternative to tamoxifen in postmenopausal patients. Fulvestrant is a second-line intramuscular agent with similar efficacy and safety when compared to anastrozole in patients who progressed on tamoxifen. 

Dowsett M, Bundred NJ, Decensi A, Sainsbury RC, Lu Y, Hills MJ, et al. (2001) Effect of raloxifene on breast cancer cell Ki67 and apoptosis a double-blind, lacebo-controlled, randomized clinical trial in postmenopausal patients. Can Epidemiol Biomar Prev 10 961-966... 

Love RR, Newcomb PA, Wiebe DA, Surawicz TS, Jordan VC, Carbone PP, DeMets DL (1990) Effects of tamoxifen therapy on lipid and lipoprotein levels in postmenopausal patients with node-negative breast cancer. J Natl Cancer Inst 82 1327-1332... 

The effects of tamoxifen on uterine leiomyomas have been studied also in postmenopausal patients with breast cancer (Schwartz et al. 1998). After an average treatment of about 1 year, uterine and leiomyoma volumes increased significantly, confirming an agonistic effect of tamoxifen on the uterus. No significant difference in agonist effect on the uterus has been detected between tamoxifen and toremifene (Tomas et al. 1995). 

Optimal management of the postmenopausal patient requires careful assessment of her symptoms as well as consideration of her age and the presence of (or risks for) cardiovascular disease, osteoporosis, breast cancer, and endometrial cancer. Bearing in mind the effects of the gonadal hormones on each of these disorders, the goals of therapy can then be defined and the risks of therapy assessed and discussed with the patient. 

In 122 postmenopausal patients with metastatic breast cancer who were randomized to exemestane 25 mg/day (n = 62) or tamoxifen 20 mg/day (n = 60), neither exemestane nor tamoxifen had adverse effects at 8, 24 or 48 weeks on concentrations of total cholesterol, HDL cholesterol, apolipoproteins A1 or B, or lipoprotein a (15). Exemestane lowered triglyceride concentrations while tamoxifen increased them. 

Atalay G, Dirix L, Biganzoli L, Beex L, Nooij M, Cameron D, Lohrisch C, Cufer T, Lobelle JP, Mattiaci MR, Piccart M, Paridaens R. The effect of exemestane on serum lipid profile in postmenopausal women with metastatic breast cancer a companion study to EORTC Trial 10951, Randomized phase II study in first line hormonal treatment for metastatic breast cancer with exemestane or tamoxifen in postmenopausal patients . Ann Oncol 2004 15(2) 211—7. 

When breast cancers occur in women taking estrogen replacement therapy they are sometimes claimed to be less aggressive than in other women. The effect of the duration or type of replacement therapy on the aggressiveness of such tumors has been studied in 1105 consecutive postmenopausal patients treated for operable breast cancer at the European Institute of Oncology (183). Tumors in women who had been exposed to... 

Persico N, Mancini F, Artini PG, Regnani G, Volpe A, de Aloysio D, Battaglia C. Transdermal hormone replacement therapy and Doppler findings in normal and overweight postmenopausal patients. Gynecol Endocrinol 2004 19(5) 274-81. 

Arpino G, Krishnan MN, Dinesh CD, Bardou VJ, Clark GM, Elledge RM. Idoxifene versus tamoxifen a randomized comparison in postmenopausal patients with metastatic breast cancer. Ann Oncol 2003 14 233 11. 

Maia H Jr, Maltez A, Oliveira M, Almeida M, Coutinho EM. Growth of an endometrial polyp in a postmenopausal patient using raloxifene. Gynaecol Endosc 2000 9 117-21. 

Pandya KJ, Raubertas RF, Flynn PJ, Hynes HE, Rosenbluth RJ, Kirshner JJ, Pierce HI, Dragalin V, Morrow GR. Oral clonidine in postmenopausal patients with breast cancer experiencing tamoxifen-induced hot flashes a University of Rochester Cancer Center Community Clinical Oncology Program study. Ann Intern Med 2000 132(10) 788-93. 

Cohen I, Azaria R, Bernheim J, Shapira J, Beyth Y. Risk factors of endometrial polyps resected from postmenopausal patients with breast carcinoma treated with tamoxifen. Cancer 2001 92(5) 1151-5. 

Maia H Jr, Maltez A, Calmon LC, Moreira K, Coutinho EM. Endometrial carcinoma in postmenopausal patients using hormone replacement therapy a report on four cases. Gynaecol Endosc I999 8 235 1I. 

Nuovo MA, Nuovo GJ, McCaffrey RM, Levine RU, Barron B, Winkler B. Endometrial polyps in postmenopausal patients receiving tamoxifen. Int J Gynecol Pathol 1989 8(2) 125—31. 

Wegman P et al (2007) Genetic variants of CYP3A5, CYP2D6, SULT1A1, UGT2B15 and tamoxifen response in postmenopausal patients with breast cancer. Breast Cancer Res 9 R7... 

Therapeutic efficacy in the treatment and prevention of bone loss in postmenopausal patients has been defined in terms of changes in bone mineral density (BMD) as well as fracture incidence. Although the occurrence of fracture is the clinical manifestation of osteoporosis, this disease is operationally defined by the WHO as a BMD equal or greater than 2.5 standard deviations below the young adult reference mean. In this regard, BMD has been shown to be an accurate predictor of some fractures, and it can be used as a diagnostic tool for at-risk individuals.4... 

Mrs TY is an elderly woman with a fractured hip. NICE (2005) recommends that postmenopausal patients who have experienced a fracture should receive bisphosphonates as treatment for secondary prevention of fractures. 

Bastholt L, Dalmark M, Gjedde SB, Pfeiffer P, Pedersen D, Sandberg E, Kjaer M, Mouridsen HT, Rose C, Nielsen OS, Jakobsen P, Bentzen SM. Dose-response relationship of epirubicin in the treatment of postmenopausal patients with metastatic breast cancer a randomized study of epirubicin at four different dose levels performed by the Danish Breast Cancer Cooperative Group. J Clin Oncol 1996 14(4) 1146-55. 

Wils JA, Bliss JM, Marty M, Coombes G, Fontaine C, Morvan F, Olmos T, Perez-Lopez FR, Vassilopoulos P, Woods E, Coombes RC. Epirubicin plus tamoxifen versus tamoxifen alone in node-positive postmenopausal patients with breast cancer a randomized trial of the International Collaborative Cancer Group. J Clin Oncol 1999 17(7) 1988-98. 

Hayes DF, Van Zyl JA, Hacking A, et al. Randomized comparison of tamoxifen and two separate doses of toremifene in postmenopausal patients with metastatic breast cancer. J CUn Oncol 1995 13 2556-2566. 

Idoxifene has been evaluated as a breast cancer treatment for postmenopausal patients [296, 297]. In one study, 321 postmenopausal patients with unknown receptor status or hormone receptor-positive metastatic breast cancer were randomized to receive either tamoxifen or idoxifene as first-line endocrine therapy for their advanced disease. Complete plus partial response rates were 9 and 13% for tamoxifen and idoxifene, respectively. The median time to progression was slightly higher for idoxifene (140 versus 166 days), but these differences were not statistically significant. Morbidity was similar for both groups. The authors concluded that in postmenopausal women with metastatic breast cancer idoxifene had similar efficacy and toxicity to tamoxifen [298]. However, idoxifene has not been developed further because of concerns about uterine prolapse [299]. This side-effect is not seen with tamoxifen. 

Holli, K., Valavaara, R Blanco, G., Kataja, V., Hietanen, P., Flander, M., Pukkala, E. and Joensuu, H. (2000) Safety and efficacy results of a randomized trial comparing adjuvant toremifene and tamoxifen in postmenopausal patients with node-positive breast cancer. Finnish Breast Cancer Group. Journal of Clinical Oncology, 18, 3487-3494. 

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