Aromatase Inhibitors

In post-menopausal women, the ovaries are no longer functional and cannot produce oestrogen. Their main source of oestrogen comes from the adrenal glands and from special proteins, called enzymes that act on areas of the body such as fatty tissue. One of the most important of these enzymes is called aromatase. A new group of drugs called aromatase inhibitors reduce oestrogen production in post-menopausal women by blocking the action of the aromatase enzymes. Examples of these drugs are letrozole (Femara), anastrozole (Arimidex) and exemestane (Aromasin).
These drugs are prescribed for post-menopausal women with advanced or early breast cancer containing oestrogen receptors (ER positive) . Post-menopausal women with advanced breast cancer or whose breast cancer progresses or relapses while on tamoxifen are also suitable for treatment with this type of drug, provided that the cancer contains oestrogen receptors. These drugs are less likely than tamoxifen to cause weight gain, womb cancer or deep-vein thrombosis.
The final results of a study comparing Arimidex with tamoxifen in postmenopausal women with early breast cancer that contains hormone receptors, suggests that Arimidex is better than tamoxifen in preventing breast cancer recurrence and has less-frequent side-effects. Recent research has also shown that the use of aromatase inhibitors such as Aromasin or Arimidex (for 3 years) in sequence after tamoxifen (for 2 years) for early breast cancer in postmenopausal women improves outcome. Women completing 5 years of tamoxifen seem to benefit further if they take Femara for 2 years. However, bone mineral density scans (known as Dexa scans) may be required to identify women at risk of brittle bone disease. In such cases, other drugs to protect the bone can be given in conjunction with aromatase inhibitors. Further research in this area is urgently required. It is also likely that these drugs may be used to prevent breast cancer in high-risk women.

The author believes that for postmenopausal women diagnosed with low risk (node negative, smaller than 2 cm) early invasive breast cancer that contains hormone receptors, the best approach would be to take tamoxifen for 2 years and then to switch from tamoxifen to an aromatase inhibitor such as Aromasin or Arimidex for 3 years. For postmenopausal women diagnosed with high risk (node positive, larger than 2 cm) early invasive breast cancer that contains hormone receptors, the best approach would be to take Femara for 5 years. For women completing 5 years of tamoxifen, Femara should be considered for further two years especially in node positive patients. Vitamin D and calcium supplements and monitoring of bone density are recommended whenever aromatase inhibitors are used.

Breast Reconstruction

Approximately 1 in 5 patients with breast cancer will require a mastectomy rather than a lumpectomy. As mastectomy results in the distortion of the body image, it is natural for some patients to seek reconstructive surgery. However, some women are just relieved to have had the cancer removed and are not keen on having breast reconstruction. Although an external implant is available that can be put inside the brassiere, it may be adequate for some women. Other women will require surgical breast reconstruction to give them a satisfactory appearance. All patients undergoing mastectomy should be offered the possibility of breast reconstruction, either performed immediately at the time of mastectomy, or as a later procedure. Mastectomy combined with immediate reconstruction is preferred and seems to cost less than mastectomy with subsequent delayed reconstruction. There is no evidence that immediate reconstruction at the time of mastectomy worsens the breast cancer outlook. Frail patients with other medical problems are not advised to undergo breast reconstruction surgery as they have an increased risk of complications.
There are various methods of reconstruction and the choice should be made after discussion with the breast surgeon, specialist breast nurse and other patients who have had breast reconstruction. You should request pictures showing the outcome of the various methods. The choice of reconstruction depends upon the woman's build, shape and size of her breasts, previous scars, and her own preferences. The author prefers the type of mastectomy that preserves most of the natural skin envelope of the breast (called a skin-sparing mastectomy) when performing immediate breast reconstruction in view of the superior cosmetic result:

 Steps of standard skin-saving mastectomy (SSM)

The various methods of reconstruction include:

A. Breast implants (saline-filled tissue expanders or silicone implants)
B. Flap reconstruction (from back, tummy or buttocks)

The LD flap (back) reconstruction:

This 52 year old lady had right skin-saving mastectomy and immediate breast reconstruction using a skin and muscle flap from the back for early breast cancer. She also had nipple reconstruction and enlargement of the opposite breast in order to achieve symmetry. (The procedure was performed by the author KM in 2003)

Breast Implants

An implant is inserted under a muscle in the chest wall at the mastectomy site. Implant reconstruction can be performed immediately at the time of skin-sparing mastectomy or as a delayed procedure through the original mastectomy scar. There has been a recent concern regarding the safety of silicone implants. In fact, there is no evidence that silicone implants increase the incidence of breast cancer or other diseases, such as arthritis. The main problems with implants are infection (occurring in 2% of patients) and scarring around the implant. Scarring makes the breast feel hard and painful, and it is more common if the prosthesis is very smooth.


 

Next >          < Back