When is active monitoring of a tumor appropriate?

TO YOUR GOOD HEALTH

DEAR DR. ROACH: In a recent column, you addressed breast cancer in an older woman. She expressed concern about overtreatment of small tumors and if just keeping an eye on the tumor (active surveillance) might be a way to go.

Do you think active surveillance might be an option at any age in a woman’s life, rather than chemo and radiation for some tumors? Is that form of treatment appropriate, and could it be a better option for a better quality of life for the patient? — G.C.

ANSWER: “Active surveillance” refers to not treating a lower-risk condition initially, but actively monitoring it to look for signs that it might be changing to a condition with greater risk. This is a preferred means for many men with very-low-risk or low-risk prostate cancer. A recent trial has been started and is recruiting women with DCIS (ductal carcinoma in situ) to see whether active surveillance might be reasonable for this condition as well. I think this is an important study, with the potential to affect many women who otherwise are recommended for lumpectomy, sometimes with radiation. Many women, in fact, opt for a total mastectomy for this condition, and if we can identify women who might not need such invasive procedures, that would be a major benefit.

However, for a woman with invasive intraductal breast cancer (which is a much more aggressive tumor than DCIS, usually), I can’t recommend active surveillance. Older women with this diagnosis, or those with one of many other medical conditions, still can receive medication, like an anti-estrogen, which has far fewer side effects than surgery or traditional chemotherapy.

Women who would not consider treatment of an invasive breast cancer should reconsider getting a mammogram in the first place.

DEAR DR. ROACH: I have been taking hormone treatments for 10 years. I’m 60 years old. I have concerns about long-term usage.

I tried getting off them slowly. The results are always the same: I end up with 10 to 15 hot flashes a day. I can’t sleep, because I get five to six at night. I end up going back on my Divigel and progesterone. My doctor says to stay on them if it makes my life easier, rather than being miserable. Do you have any thoughts on how I can eventually get off them without going through the hot flashes again? — Anon.

ANSWER: Put simply, you have three options: go off the hormone (Divigel is an absorbable gel form of estradiol, the bioidentical human estrogen) and likely be miserable; continue the treatment and have a risk of side effects; or try a different treatment.

I don’t recommend being miserable. The other options are both better, in my opinion.

Continuing estrogen treatment has risks. Combined treatment with estrogen and progesterone increases risk of blood clotting, coronary artery disease and breast cancer. It decreases the risk of bone fracture and of colon and lung cancers. The risk of coronary disease probably is lower for women who began treatment right at menopause (which it sounds like might be the case with you). The overall risk of mortality due to combined treatment is roughly 8 women per thousand in five years’ time. That degree of risk is worth it for some women.

Other options to reduce hot flashes without the risk of hormone treatment include medications like venlafaxine or citalopram. A new treatment, called a neurokinin 3 receptor antagonist, shows promise for the future.

It doesn’t sound like you have tried alternatives to hormones: I’d recommend speaking to your doctor about them before deciding whether to accept the long-term risk of continued hormones.