Gabriel Miller; Clifford Hudis, MD


June 26, 2014

In This Article

Survivor Care

Less Frequent Bisphosphonates

Zoledronic acid is often given to women with bone metastases from breast cancer to reduce the risk for skeletal fractures and osteoporosis, though the drug has a number of side effects, including nausea, fatigue, anemia, bone pain, constipation, and fever, and can lead to renal toxicity.

Oral abstract LBA9500 demonstrated that after 1 year of routine monthly treatment, zoledronic acid given every 12 weeks was as effective, and safer than, continuing with an every-4-week schedule. The prospective, randomized, double-blind, multicenter trial included 403 patients. There was a nonsignificant 1.2% difference in skeletal events between the groups; patients who received the drug every 4 weeks had a slightly higher rate of kidney-related adverse events (9.6% vs 7.9%); however, overall adverse event rates were similar between the 2 groups.

Dr. Hudis: "This one is very relevant, and this really addresses something that's narrow for people with metastases but might actually relate to people with just osteoporosis who are getting these drugs for prevention and fracture. Basically, it says that you don't have to keep giving the drug every month once you get past the first year. This is something that we bet was true years ago. But this is the first hard evidence that that's the case, and that's helpful because, of course, everyone remains worried about the long-term consequences of using these drugs -- and notably the osteonecrosis of the drug. This doesn't answer whether this really protects against that, but it does tell you that we can at least consider giving less frequent dosing after the first year in people with metastases."

Targeted Breast Cancer Therapy and Heart Failure Risk

Heart problems are a well-established long-term side effect of many chemotherapies, and more recently studies have linked the HER2-positive breast cancer drug trastuzumab to cardiac dysfunction.

Oral abstract 9504 assessed the risk for heart failure among 3371 breast cancer patients who were treated with adjuvant chemotherapy and trastuzumab. Compared with women who were treated with chemotherapy alone, patients who were also given trastuzumab had double the estimated risk of developing heart failure (5.3% vs 2.6%; P < .0001).

Importantly, however, after adjusting for potential confounding variables, trastuzumab was independently associated with heart failure within the first 1.5 years (P = .0004) but not thereafter (P = .53).

Dr. Hudis: "I have mixed feeling about [this study]. On the one hand it's not prospective clinical trials data; on the other it's very reassuring. It reminds everybody that while there's a lot of concern about heart failure in the long term, there is really no evidence that you can or should screen for it in people who have survived cancer and done well. This is a bit of an issue because cardiologists and others believe that finding changes in ejection fraction can be useful. They may be right, but this particular study says that basically the risk is mostly during treatment, not after."

Sex After Surviving Cancer

As many as half of women who survive breast cancer report some form of long-term sexual dysfunction as a result of treatment.[1,2]

In oral abstract 9507, investigators found that a daily vaginal moisturizer compounded with the steroid hormone DHEA lessens pain and improves sexual desire, arousal, and overall sexual function, compared with a vaginal moisturizer alone. The improvements were seen after 12 weeks of use.

Dr. Hudis: "This is really important because we have a large number of women with sexual dysfunction related to their treatment for cancer, and we're struggling to find safe ways to manage that. This is another example of something that some people were concerned about but that appears to be safe and in fact does improve sexual function. I think that this might have relevance beyond cancer because people who have low estrogen and dyspareunia -- painful intercourse or sexual dysfunction -- are all looking for ways to feel better and to be more comfortable with sex. That's what was achieved here in a group of people who had breast cancer."

Cancer Treatment and Cognitive Decline

Among older women treated for localized breast cancer, there is no significant difference in cognitive deficits for those treated with chemotherapy and those treated with only radiotherapy, oral abstract 9509 demonstrated.

Among all women treated for breast cancer with chemotherapy or radiotherapy, 49% had objective cognitive decline compared with a group of healthy women. However, the study did not find a deleterious impact of chemotherapy specifically on objective cognitive functions when compared with radiotherapy.

Dr. Hudis: "This is really important because there's been a long simmering belief that chemotherapy causes some sort of cognitive decline. There have been studies suggesting that it's really treatment, aging, stress, posttraumatic stress disorder, and anxiety that contribute, and this is consistent with that because this says that there were declines in cognition, but they were really similar with or without chemotherapy. It isn't the drug per se, but the experience of having and being treated for cancer that leads to cognitive decline. Clinicians should be aware of this, and general practitioners as well, because they have all these people who've been treated... But what is clear is that it's not specifically from chemotherapy. That's important because when chemotherapy is needed for cure, it's a shame that people perceive it as a risky intervention."


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