ASCO Guidelines and Case Study

00:01 Breast cancer unfortunately causes ovarian insufficiency.

00:05 I should say breast cancer treatment typically causes ovarian insufficiency.

00:09 So in the course of the chemotherapy regimen, most women will receive a combination of alkylating agents likely cyclophosphamide which results in ovarian toxicity or ovarian gonadotoxicity.

00:25 And so that can impact the overall health of the patient, Their bone health can be deleteriously affected and it's recommended that primary care clinicians refer postmenopausal breast cancer survivors for a baseline DEXA scan.

00:43 You should repeat the DEXA every 2 years for women who are taking aromatase inhibitors or premenopausal women who were taking Tamoxifen and/or a GnRH agonist Unfortunately, infertility can be a result of chemotherapeutic agents and it's advisable that you refer patients to a reproductive endocrinologist and infertility specialist as soon as possible prior to treatment ideally.

01:12 It's recommended that when attempting to concieve, stop their Tamoxifen, 1-2 months prior to attempting conception.

01:20 Breast cancer survivors should be advised that although cyclophosphamide and other alkylating chemotherapeutic agents can cause ovarian insufficiency or ovarian failure, they still could become pregnant.

01:32 They should be advised to use non-hormonal methods of contraception including barrier methods such as condoms and diaphragms or the copper intaruterine device and sterilization.

01:45 Hormonal methods can actually propagate tumor cells.

01:50 There are guidlines that are published regarding menopausal symptoms and sexual health.

01:55 Primary care physicians should assess sexual dysfunction or problems with sexual intimacy.

02:01 There could be other contributing factors for sexual dysfunction and patients should be offered non-hormonal water-based lubricants for vaginal dryness.

02:11 Patients who suffer from other issues should also be referred for psychoeducational support, group therapy, sexual counselling, marital counselling and potentially intensive psychotherapy.

02:24 So there are other guidelines for premature menopause or hot flashes.

02:29 SNRIs or Selective Serotonin Norepinephrine Reuptake Inhibtors, SSRIs which is Selective Serotonin Reuptake Inhibitors, Gabapentin, lifetyle modifications and environmental modifications.

02:43 An example of an environmental modification would be to keep your room cool at night and to sleep in less clothing to keep yourself cool, to not have hot flashes.

02:53 and...

02:54 Let's go over a case.

02:56 This scenario is a 37 year old G0 or woman who's never been pregnant, with ductal carcinoma in-situ with lobular features who will have a bilateral mastectomy and be treated with cyclophosphamide and she's currently now taking Tamoxifen.

03:11 How would you counsel this patient? What type of anticipatory guidance would you give her? Well, one - she's actually had a bilateral mastectomy.

03:19 That could be a very disfiguring for a woman and you may want to address some psychological concerns that she may have that may affect her body image.

03:28 In addition, she's actually had cyclophosphamide.

03:31 Cyclophosphamide as we've reviewed is kinetic toxic and she's not producing the estrogen that she normally would.

03:38 So she may be experienceing these motor symptoms, such as hot flushes and hot flashes, she may be experiencing vaginal dryness and you know that bones are affected by not having estrogen present.

03:50 and so when should she have a DEXA scan? Normally if this patient has actually already had cyclophosphamide, she should have a baseline DEXA scan.

04:00 What about her fertility concerns? As we've addressed previously, the ovaries may not be functioning normally and she can have either ovarian insufficiency or ovarian failure.

04:11 So ideally, this patient should be counselled before she undergoes any kind of treatment to preserve her fertility either through oocyte cropreservation or embryo cryopreservation.

04:22 If her treatment has already happened and she's taking Tamoxifen, she should stop Tamoxifen 1-2 months before planning to concieve.

04:32 What about her sexual health? So we've talked about the fact that she is hypoestrogenic, meaning her estrogen is low because her ovaries have been affected by cyclophosphamide This can make sex very painful - this is called dyspareunia.

04:46 So unfortunately, these women cannot receive hormonal treatment and so water-based lubricants are ideal for treating this type of sexual dysfunction Routine screening for other cancers should occur.

05:01 We also encourage patients to undergo colonoscopy at age 45 and if the findings are normal at the time of colonoscopy, then every 10 years.

05:10 She should still have cervical screening and she's over 21 which this case is, she should continue to have pap smears.

05:19 Thank you.