Chemoprevention for Women at High Risk Breast Canacer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Tamoxifen and raloxifene:
    • Reduce the risk of invasive breast cancer in high-risk women when compared to placebo:
      • But are associated with increased vasomotor symptoms
    • In the NSABP P-2 / STAR trial:
      • When compared to raloxifene:
        • Tamoxifen use resulted in higher rates of uterine cancer (2/1000 vs. 1.5/1000), deep vein thrombosis (2.29/1000 vs 1.69/1000), and pulmonary embolism (1.41/1000 vs. 0.96/1000)
  • Aromatase inhibitors:
    • Are not associated with a risk of thrombosis
  • Use of concomitant hormone replacement therapy with tamoxifen or raloxifene:
    • Was not allowed in the STAR trial and is discouraged in the 2013 American Society of Clinical Oncology chemoprevention guidelines
  • In the MAP.3 prevention trial:
    • Exemestane significantly reduced the incidence of invasive breast cancer
    • Was not associated with serious adverse effects, and resulted in only minimal changes in health-related quality of life:
      • However, it is not FDA-approved for chemoprevention of breast cancer but can be used in an off-label manner
    • Decision tables weighing the risks and benefits of chemoprevention agents:
      • Are available and can identify the most appropriate drug with the fewest side effects for each individual patient
  • Compliance with chemoprevention varies by the agent used:
    • In the MAP.3 trial:
      • 85% of enrolled women were compliant with exemestane
    • In the NSABP P-1 trial:
      • 76% of women with compliant with tamoxifen
    • In clinical practice, overall compliance with chemoprevention is even lower:
      • With a study by Flanagan and colleagues reporting a 61% rate of completion of planned chemoprevention in high-risk patients
  • References
    • Visvanathan K, Hurley P, Bantug E, Brown P, Col NF, Cuzick J, et al. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31(23):2942-2962.
    • Freedman AN, Yu B, Gail MH, Costantino JP, Graubard BI, Vogel VG, et al. Benefit/risk assessment for breast cancer chemoprevention with raloxifene or tamoxifen for women age 50 years or older. J Clin Oncol. 2011;29(17):2327-2333.
    • Goss PE, Ingle JN, Ales-Martinez JE, Cheung AM, Chlebowski RT, Wactawski-Wende J, et al. Exemestane for breast-cancer prevention in postmenopausal women. N Engl J Med. 2011;364(25):2381-2391.
    • Nelson HD, Fu R, Humphrey L, et al. Comparative Effectiveness of Medications To Reduce Risk of Primary Breast Cancer in Women [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Sep. (AHRQ Comparative Effectiveness Reviews, No. 17.)
    • Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90(18):1371-1388.
    • Flanagan MR, Zabor EC, Stempel M, Mangino DA, Morrow M, Pilewskie ML. Chemoprevention Uptake for Breast Cancer Risk Reduction Varies by Risk Factor. Ann Surg Oncol. 2019;26(7):2127-2135.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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