Dr Goldstein comments on NY Times article on preventing breast cancer

To my patients,

In last week’s Science Times, the weekly column on personal health by Jane Brody was entitled, “A New Focus Turns to Preventing Breast Cancer.” I have tremendous respect for Jane Brody and almost always agree with what she writes and the thoroughness with which she presents information. There are, however, some points in that article that I feel I must comment on. 

She does mention, and rightly so, that if breast cancer is confined to the breast with no spread to regional lymph nodes, five-year survival rates are as high as 99%. Many of you have heard me extoll the virtues of quality breast cancer surveillance with imaging (3D mammograms with ultrasound as well). Even with spread to regional lymph nodes, the five-year survival is still 85%. Clearly, breast cancer is not the same disease it was one or two generations ago. When caught early, it need not be lethal.

There are and have been, however, a number of medications that are approved for breast cancer risk reduction. In her article, Jane Brody, in fact, quotes the United States Preventative Services Task Force, whose recommendations are that women who have more than a 3% chance of developing invasive breast cancer within the next five years be offered such risk reducing drugs. My concern with her article is that she mentions tamoxifen, raloxifene (also known as Evista) and the category of drugs known as aromatase inhibitors. Although all these drugs have been shown to reduce breast cancer risk, they’re very different in their side effect profile, in terms of both serious adverse events as well as nuisance side effects. The only one approved for use in premenopausal women is tamoxifen. Many of you are aware, however, that it results in formation of benign uterine polyps in 10-17% of women as well as a small but real number of uterine cancers in postmenopausal women. Evista, which is now generically available as raloxifene, has similar breast cancer prevention results as tamoxifen but does not have cancer or polyp producing potential in the uterus. In addition, however, both tamoxifen and raloxifene prevent bone loss because of their selectivity in which they act like estrogen in bone, while being estrogen blockers in breast. Both of these drugs may exacerbate hot flashes and night sweats making their use in younger, more recently menopausal women less desirable. The aromatase inhibitors are pure anti-estrogens (unlike the first two drugs, which are selective for the breast but not in all aspects of the body) these drugs contribute to osteoporosis, joint pain, vaginal atrophy, etc. Thus, in my opinion, while the aromatase inhibitors are excellent drugs for women with advanced breast cancers and can be lifesaving in such cases, their use for prevention of breast cancer, in women who don’t already have that disease, is inappropriate and unnecessary, especially in light of the high treatability when breast cancers are detected early. Furthermore, bone health, in my opinion, is as, if not more, important of an issue for long term healthy aging and quality of life as breast health. Allow me to expand on this:  since early detection of breast cancer will almost always result in a favorable outcome, and since women are routinely living much longer lives than previous generations, a fracture, especially of the hip, of a woman can be a much more life threatening and devastating event than an early breast cancer. A woman who suffers a hip fracture has a 20-30% chance of being dead within one year, and a 25% chance of never living independently again. Thus, drugs to prevent breast cancer that actually cause bone loss, like the aromatase inhibitors, in my opinion, make no sense for this purpose. Since its introduction in 1997, many of my patients have been excellent candidates for Evista (raloxifene) because of its dual effect of reducing breast cancer risk and preventing and treating osteoporosis. Thus, for certain patients, it is an excellent choice and remains thus so. 

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