Tamoxifen Underused for Early Breast Cancer

Drug's benefits outweigh risks, study says

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HealthDay Reporter

TUESDAY, Jan. 20, 2004 (HealthDayNews) -- Despite its strong track record against breast cancer, many women with the earliest form of the disease are not turning to tamoxifen as a treatment.

A study in the March 1 issue of Cancer finds women with ductal carcinoma in situ (DCIS) and their physicians appear reluctant to use the breast cancer drug, perhaps because of some of its side effects.

This is despite evidence that the drug has a proven benefit in women with DCIS: The 1999 National Surgical Adjuvant Breast and Bowel Project found it reduced the absolute risk of cancer recurrence by about 5 percent for these women.

"Despite a well-published, randomized trial, the adoption of what the trial stated has not been as universally accepted as thought," says Dr. Jay Brooks, chief of hematology/oncology at the Ochsner Clinic Foundation in New Orleans.

Dr. Henry M. Kuerer is the new study's senior author and director of the Breast Surgical Oncology Training Program at the University of Texas M.D. Anderson Cancer Center. "As part of giving any patient a treatment we have an informed consent process," he explains. "But in this particular situation, it's more appropriate to call it informed refusal."

Kuerer and his colleagues analyzed data on almost 300 women with DCIS who were treated at M.D. Anderson between July 1999 and June 2002.

Only 60 percent of the patients were offered tamoxifen and, of those, only 54 percent opted to take the drug.

In general, doctors were less likely to recommend the drug to women who had had a total mastectomy, and more likely to recommend it to women who had smaller tumors and who had undergone a lumpectomy.

Twenty of the 94 patients who received tamoxifen (21 percent) discontinued it because of side effects or complications.

The main reason women refused treatment with tamoxifen was for its potential side effects, which can include endometrial cancer and hot flashes. These same side effects also led a number of women to stop using the medication, the study found.

"In most cases, the benefits of tamoxifen outweigh the risk for patients with invasive breast cancer," says Dr. Susan K. Boolbol, an attending physician in the department of surgery and at the cancer center of Beth Israel Medical Center in New York City.

Reducing the risk of recurrence, for many women, is reason enough to go on tamoxifen. "We cannot underestimate the emotional impact of a local recurrence in a breast cancer patient," Boolbol adds. Also, a recurrence could be invasive [outside the milk duct], which is that much more dangerous.

Kuerer says: "It's such a personal decision. The patient needs to hear the potential benefits as well as the risks. Although it is a complex decision-making process, the patients are making their own decision. They're not universally taking a pill just because on the surface it sounds like they are going to decrease their chance of getting cancer again."

The study results caused physicians at M.D. Anderson, where the research was conducted, to reassess their practices.

"We saw that about 40 percent of us were not offering it [tamoxifen], and now we have made a conscious decision that we owe it to our patients to discuss the potential of this medication," Kuerer says. "Even though we perceive the risk [of side effects] might be very tiny for individual patients, we have to let them know that there are these drugs that they might want to take."

More information

The National Cancer Institute has more information on tamoxifen and on ductal carcinoma in situ.

SOURCES: Henry M. Kuerer, M.D., Ph.D., director, Breast Surgical Oncology Training Program, University of Texas M. D. Anderson Cancer Center, Houston; Susan K. Boolbol, M.D., attending physician, department of surgery and cancer center, Beth Israel Medical Center, New York City; Jay Brooks, M.D., chief, hematology/oncology, Ochsner Clinic, New Orleans; March 1, 2004, Cancer, available online Jan. 19, 2004

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