The impact of endocrine therapy on patients with breast cancer: a review of the literature

Partner status moderates the relationships between sexual problems and self-efficacy for managing sexual problems and psychosocial quality-of-life for postmenopausal breast cancer survivors taking adjuvant endocrine therapy

OBJECTIVE

Past studies indicate that >90% of breast cancer survivors taking adjuvant endocrine therapy (AET) experience menopausal symptoms including sexual problems (eg, vaginal dryness, dyspareunia); however, research examining the impact of these problems on quality-of-life is limited. This cross-sectional study examined (1) the impact of sexual problems and self-efficacy for coping with sexual problems (sexual self-efficacy) on quality-of-life (ie, psychosocial quality-of-life and sexual satisfaction), and (2) partner status as a moderator of these relationships.

METHODS

Postmenopausal breast cancer survivors taking AET completed measures of sexual problems (Menopause-Specific Quality-of-Life [MENQOL] sexual subscale], sexual self-efficacy, psychosocial quality-of-life (MENQOL psychosocial subscale), and sexual satisfaction (Functional Assessment of Cancer Therapy-General item).

RESULTS

Bivariate analyses showed that women reporting greater sexual problems and lower sexual self-efficacy had poorer quality-of-life and less sexual satisfaction (all P-values < 0.05). Partner status moderated the relationship between sexual problems and psychosocial quality-of-life (P = 0.02); at high levels of sexual problems, unpartnered women experienced poorer psychosocial quality-of-life than partnered women. Partner status also moderated the relationship between self-efficacy and psychosocial quality-of-life (P = 0.01). Self-efficacy was unrelated to psychosocial quality-of-life for partnered women; for unpartnered women, low self-efficacy was associated with poorer quality-of-life. Partner status did not moderate the relationships between sexual problems or self-efficacy with sexual satisfaction.

CONCLUSIONS

Greater sexual problems and lower sexual self-efficacy were associated with poorer psychosocial quality-of-life and sexual satisfaction among postmenopausal breast cancer survivors taking AET. Interventions to address sexual problems and sexual self-efficacy, particularly among unpartnered women, may be beneficial for improving the well-being of postmenopausal breast cancer survivors on AET.

Predictors of distress and quality of life in patients undergoing cancer therapy: impact of treatment type and decisional role

PURPOSE

The purpose of this secondary investigation was to examine the impact of the type of treatment received and the perceived role in treatment decision making in predicting distress and cancer-specific quality of life in patients newly diagnosed with breast or prostate cancer.

METHOD

Participants included 1057 newly diagnosed breast and prostate cancer patients from four Canadian cancer centers who partook in a randomized controlled trial examining the utility of providing patients with an audio-recording of their treatment planning consultation. A MANCOVA was performed to predict distress and cancer-specific quality of life at 12 weeks post-consultation based on control variables (patient age, education, residence, tumor size (breast sample), gleason score (prostate sample), and receipt of an initial treatment consultation recording), predictor variables (treatment type--chemotherapy, hormone therapy, radiation therapy; decisional role--active, collaborative, passive), and interactions between these predictors.

RESULTS

Women who received chemotherapy and reported having played a more passive role in treatment decision making had significantly greater distress and lower cancer-specific quality of life at 12-week post-consultation. There were no statistically significant predictors of these outcomes identified for men with prostate cancer.

CONCLUSION

Receipt of chemotherapy places women with breast cancer at risk for distress and reduced quality of life, but only for the subset of women who report playing a passive role in treatment decision making. Prospective, longitudinal studies are needed to confirm the present findings and to explicate the antecedents, composition, and consequences of the 'passive' decisional role during the treatment phase of the cancer trajectory.

The influence of endocrine treatments for breast cancer on health-related quality of life

Many hormonal modalities are available for breast cancer treatment, such as selective oestrogen receptor modulators (SERMs), aromatase inhibitors, progestins and luteinising hormone-releasing hormone (LHRH) agonists. The long-term impact of these endocrine manipulations is an issue, because the duration of adjuvant treatment is still increasing, as is the number of breast cancer survivors. Premature menopause is induced at a young age, and may often be permanent after chemotherapy. The purpose of this review is to provide a literature-based overview of the side effects of endocrine treatment in pre- and postmenopausal breast cancer patients and the influence on HRQoL, especially on sexual functioning. The collection of health-related quality of life (HRQoL) data can result in better treatment recommendations during endocrine therapy.

METHODS

This review was limited to prospective randomised studies in English literature from between 1977 and 2007 and provides an overview of the effects on HRQoL and sexuality of various hormonal treatment in pre- and postmenopausal breast cancer patients, both in the adjuvant and palliative setting. Relevant clinical studies were identified by using the Medline database.

RESULTS

HRQoL mostly is severely influenced by chemotherapy and part of these symptoms may be lasting, especially when associated with the induction of premature menopause. Similar symptoms may be encountered during ovarian suppression therapy by LHRH analogs, but they will usually prove to be reversible. The varying side effect profiles of tamoxifen and aromatase inhibitors did not lead to significant difference in overall HRQoL. HRQoL during progestins and the SERM fulvestrant has been compared to this during aromatase inhibitors, and a large number of studies on HRQoL during endocrine therapy will be discussed.

Quality of life and adjuvant systemic therapy for early-stage breast cancer

Adjuvant chemotherapy and hormonal therapy reduce the risk of recurrence and death due to breast cancer, but often at considerable cost to the health-related quality of life (HRQL) of patients. The short-term effects of chemotherapy on HRQL are well known and are accepted by most patients for modest gains in survival. The long-term effects of chemotherapy-induced menopause and hormonal therapy on HRQL are poorly recognized. Vasomotor symptoms and altered sexual function are common, distressing and inadequately treated. HRQL information is helpful in describing likely effects of adjuvant treatment, facilitating informed decision-making, identifying health problems to guide research into potential solutions, guiding treatment strategies for interventions with equivalent survival and guiding resource allocation. New technologies will make HRQL information increasingly available for individual patient care.

Endocrine symptom assessment in women with breast cancer: what a simple “yes” means

GOALS OF WORK

To investigate the self-reported symptoms related to endocrine therapy in women with early or advanced breast cancer and the impact of these symptoms on quality of life (QL) indicators.

MATERIALS AND METHODS

Symptom occurrence was assessed by the Checklist for Patients on Endocrine Therapy (C-PET) and symptom intensity was assessed by linear analogue self-assessment (LASA) indicators. Patients also responded to global LASA indicators for physical well-being, mood, coping effort and treatment burden. Associations between symptoms and these indicators were analysed by linear regression models.

MAIN RESULTS

Among 373 women, the distribution of symptom intensity showed considerable variation in patients reporting a symptom as present. Even though patients recorded a symptom as absent, some patients reported having experienced that symptom when responding to symptom intensity, as seen for decreased sex drive, tiredness and vaginal dryness. Six of 13 symptoms and lower age had a detrimental impact on the global indicators, particularly tiredness and irritability.

CONCLUSIONS

Patients' experience of endocrine symptoms needs to be considered both in patient care and research, when interpreting the association between symptoms and QL.

Evolution of breast cancer treatments: current options and quality-of-life considerations

Data from patient self-report questionnaires provide valuable information about side effects that patients may view as having a significantly detrimental impact on their quality of life and yet are not always recognised as important by healthcare professionals. Such information is very important in enabling patients to make informed choices regarding treatment options. Despite this, formal data collection from patient self-report assessments still fails to influence management decisions as much as traditional outcome measures such as disease-free survival, or clinician-recorded symptoms. There are now a number of different options for the treatment of patients with breast cancer. These include antioestrogens, aromatase inhibitors and oestrogen receptor antagonists for postmenopausal women, and chemotherapy and ovarian ablation (via oophorectomy, irradiation or with luteinising hormone-releasing hormone agonists) for premenopausal women. However, there are still surprisingly few published reports from comprehensive quality-of-life studies comparing such treatments and thus little is known about the relative impacts of each of these on quality of life. Here, the evolution of hormonal therapies for breast cancer is reviewed and the differences between the tolerability profiles of currently available treatment options are highlighted.

Breast cancer patients' experiences on endocrine therapy: monitoring with a checklist for patients on endocrine therapy (C-PET)

Women with hormone responsive breast cancer routinely receive endocrine therapy. There is growing evidence that patients experience significant side effects. Between 1996 and 1998, all patients on endocrine therapy for adjuvant or advanced breast cancer, attending the Edinburgh Breast Unit, were invited to complete a checklist for patients on endocrine therapy. This simple form, designed as a communication aid, was completed by patients before their consultation. 708 patients (age 28-93) completed 1060 forms. These forms were analysed in order to gain a better understanding of the side effects experienced. Most patients were on tamoxifen (n = 524), with 103 on anastrazole and 35 on megestrol acetate. Common symptoms experienced were hot flushes, sweats and weight gain. Symptoms varied according to the patients' ages and the setting in which they received endocrine treatment. Pre-menopausal women were more likely to experience problems with flushes, sweats, weight gain and reduced libido.

Counting the costs of treatment: the reproductive and gynaecological consequences of adjuvant therapy in young women with breast cancer

As the mortality rate from breast cancer decreases, the issues facing breast cancer survivors are becoming increasingly important. Survivors of all ages may face physical and psychosocial consequences of their diagnosis and treatments. However, the long-term fertility and menopause-related side-effects of adjuvant therapy uniquely affect younger premenopausal breast cancer survivors. This article provides an evidence-based overview of the reproductive and gynaecological impact of breast cancer therapy for premenopausal women diagnosed with breast cancer. The physical and psychosocial implications of premature menopause are presented. Strategies for preserving fertility in selected patients are also discussed. Recent clinical trials strongly indicate that premenopausal women with oestrogen receptor positive tumours should receive endocrine therapy. The increased use of endocrine therapies in younger women raises important questions regarding patient information needs and treatment decision-making.