Hormones and the endocrine system

The role of Hormonal / Endocrine therapies in breast cancer

Approximately two thirds of breast cancers are oestrogen positive which means they have oestrogen receptors on the surface of the cells and therefore depend on the hormone oestrogen for growth.

This has meant that a range of treatments could be developed with the aim of decreasing the cancer growth or stopping the cancer from coming back by preventing oestrogen action on the cells.

These treatments include: Tamoxifen, Aromatase inhibitors, and Zoladex injections.

But what are they, and how do they work?

Tamoxifen

How it works

This is a synthetic hormone that binds to the oestrogen receptors on the breast cells in place of the woman’s own oestrogen. Unlike natural oestrogen, it does not stimulate breast cell growth and therefore has the effect of “blocking” the receptors.

It can be used in both pre-menopausal and post-menopausal women.

Trials have confirmed that tamoxifen significantly reduces the incidence of local recurrence, metastases (spread of breast cancer to distant organs) and breast cancer in the opposite breast.

It is taken as a single tablet daily.

The benefits have shown to be optimal if taken for a period of 5-10 years.

Side effects

Tamoxifen is in the group of Selective oEstrogen Receptor Modulators (SERMS) which means that it has different effects on different tissues in the body. While it blocks the action of oestrogen in breast tissue, it also has partial estrogen activity in other tissues.

This is the basis for its possible side effects such as hot flushes, vaginal dryness/bleeding and endometrial thickening or polyps.

Other side effects have been associated with its use such as thromboembolism, nausea/diarrhoea, weight gain,headaches or dizziness, and low mood.

It is important to realise that not all patients experience these side effects and some may experience them to a very mild and completely tolerable extent.

Aromatase inhibitors (AIs)

How they work

Aromatase inhibitors are another way of reducing oestrogen effect in post menopausal women. In this group of women, oestrogen is no longer produced by the ovaries, but smaller amounts of oestrogen are still circulating. This oestrogen is derived from androgens which are converted into oestrogen by the aromatase enzyme in peripheral tissues such as fat. The AIs block this enzyme and, in so doing, reduce oestrogen production.

There are 3 main AIs: Letrozole (Femara), Anastrozole (Arimidex), and exemestane (Aromasin).

They are prescribed as a single tablet every day for or at least 5 years.

Sometimes they can be used in sequence with tamoxifen where the patient will switch to an AI after 2-3 years of tamoxifen, or as an extended adjuvant therapy where an AI may be started after 5 years of tamoxifen.

Side effects:

Due to the different mechanism of action, the side effect profile of AIs is slightly different to that of Tamoxifen.

The gynaecological side effects are less of a problem with the use of AIs compared with tamoxifen. However, the AIs may cause joint pain, stiffness and bone loss.

Women who are scheduled to start an AI should have a baseline and then periodic Bone Mineral Density assessments (an outpatient X-ray or DEXA scan). Calcium,Vit D supplementation and, in some cases, bisphosphonates may need to be considered.

Ovarian ablation/ suppression

Surgical removal of the ovaries or ablation of the ovaries with radiotherapy has been shown to arrest breast cancer growth due to the depletion of oestrogen.

Ovarian suppression can be achieved medically by using gonadotrophin-releasing hormone (GnRH) analogs. This has been shown to have equivalent effects as surgical or radiation induced menopause with the added benefit of being reversible after the completion of therapy.

Examples of these treatments are goserelin (Zoladex) and leuprorelin (Lucrin).

They are administered as an injection under the skin either monthly or 3 monthly.

These drugs can be used in combination with tamoxifen and aromatase inhibitors in both pre-  and peri-menopausal women.

Resistance

Although tamoxifen and the AI’s have been proven to be extremely effective treatments, resistance to treatment has been described. Further research is being done in order to understand mechanisms of resistance and to combat resistance pathways.

Endocrine treatments such as fulvestrant (Faslodex) are being used in cases of advanced or metastatic disease or recurrence of breast cancer during endocrine therapy. It is an oestrogen receptor down- regulator and is given as a monthly injection.

Selection

The selection of which endocrine therapy or combination of therapies is individualised and depends on whether the patient is pre- or post-menopausal, whether she has contraindications to any of the treatments, treatment interactions with medication she may be taking for other conditions and the extent of the side effects she may develop on the medication. Of course, patient preference is an important consideration. Financial implications may influence treatment decisions too.

Dr Ronelle de Villiers

MBChB, DCH, BSc(med)

 

 

 

 

 

 

 

 

 

 

 

Keeping cool in the tough times

It is hard to imagine feeling hot and bothered in our chilly winter weather, but cancer treatment can play havoc with our normal body temperature.

And even if you are not feeling the heat, you can always do with a fruity vitamin boost!

Two Coolers
When you feel hot and bothered or sore try these to soothe and refresh.

Strawberry and Citrus Sorbet

Fresh juice of 2 big oranges
Fresh juice of 1 pink grapefruit
Fresh juice of 2 tangerines
Zest of 2 organic oranges, finely grated
10ozs (250g,2 cups) fresh strawberries or raspberries, cleaned
5 tablespoons maple syrup

Whizz together in a goblet blender or food processor. Pour into a shallow dish and freeze for 2-3 hours. Break into chunks and process again (using a sharp blade) until smooth and creamy. Return to the freezer for 30 minutes before serving. If you want to leave it longer in the freezer put it into little ice-lolly moulds at the final freeze and get them out as you feel the need.

For a change with added food value, try adding:

4ozs (100g, ½ cup) plain silken tofu
2 tablespoons more of maple syrup
2 teaspoons vanilla essence

Include frozen bananas at the final whizz stage before the second freeze.

Frozen Bananas

The simplest soother ever! Just peel ripe, firm and perfect bananas, wrap them individually in kitchen wrap/film and freeze overnight. Nibble on them whenever you fancy something cool and creamy. Don’t keep them in the freezer for too long, just do a few at a time.

If you can find sugar-free carob drops (try health food shops) melt them like chocolate in a ‘bain-marie’ (double saucepan) and dip your bananas in for an iron fortified, luxurious treat.

THANKS TO DR ROSY DANIEL, WHO HAS GENEROUSLY SHARED THE CANCER LIFELINE RECIPES WITH US. THIS RECIPE IS FOR THE TOUGH TIMES, FOR USE WHEN YOU ARE VERY ILL, DURING TREATMENT, WHILE THE APPETITE IS POOR AND THE WEIGHT LOW.

Blood tonic!

This is another in our series of recipes for the Tough Times, for use when you are very ill, during treatment, while the appetite is poor and the weight low.

Blood Tonic Juice
Delicious and enlivening.

1 teaspoon linseed (flax) oil
2 medium size, fresh beetroots, peeled and chopped
3 medium size, carrots, scrubbed/peeled and chopped
2 sweet apples, chopped
½ cucumber, chopped
2 tablespoon fresh parsley, chopped
1 tablespoon fresh mint leaves, chopped
1 large orange, deseeded and chopped including skin

Pass through your juicer and drink at least half the amount immediately – drink the rest as soon as you can.
THANKS TO DR ROSY DANIEL, WHO HAS GENEROUSLY SHARED THE CANCER LIFELINE RECIPES WITH US. THIS RECIPE IS FOR THE TOUGH TIMES, FOR USE WHEN YOU ARE VERY ILL, DURING TREATMENT, WHILE THE APPETITE IS POOR AND THE WEIGHT LOW.

The DITTO project

The Ditto project is an initiative run by Reach for Recovery to provide indigent women access to a silicone prosthesis which helps to restore her self-image and confidence after the traumatic breast cancer diagnosis and surgery.

Surgery after a breast cancer diagnosis may involve part or all of a breast being removed (mastectomy). Having a mastectomy leads to a tier of decision making regarding whether to have surgical reconstruction, wear an external breast prosthesis, or not wear anything at all to replace the amputated breast.  External breast prosthesis may be the best option a woman has, especially if she cannot afford to undergo reconstructive surgery.  However, not all patients can afford the cost of a permanent prosthesis.

Reach for Recovery believes that all women who have had breast cancer surgery should have access to appropriate breast prostheses, regardless of whether they can pay for it or not. The reality is that many breast cancer patients in South Africa cannot even afford a bra, let alone a breast prosthesis. Reach for Recovery wants to help these women who come from low income groups to feel confident again after the traumatic diagnoses and surgery.  We believe that a breast prosthesis is an important step in her recovery, especially to those women from communities where a there is still a stigma attached to a cancer diagnoses.  A more natural appearance with a breast prosthesis, together with the emotional support that she can continue to receive from Reach for Recovery volunteers through support groups, will help her to return to her place of employment and continue to provide for her family.

Any breast cancer patient who can present a current Provincial Hospital Card qualifies for access to subsidised silicone prosthesis.  The patient is asked to make a donation of R80 towards the project (R160 in case of a bilateral).   However, no patient has ever been turned away because she could not afford to make a donation.  The prosthesis may be replaced after three years.

Unfortunately Reach for Recovery cannot provide the paying customer with an invoice to claim back from their medical aid as we do not have a Medical Practice Number.  However, we do offer as much support as possible in terms of general information on local and international manufacturers, suppliers etc.

The Ditto Project started in 2011.  Since then, a total of 3235 silicone prostheses costing more than R2 million were given to women who could not afford one.  Many women donated a small amount (R80) as a token of their gratitude, but we also supported women who could not afford any donation at all.

Apart from state patients, a growing number of women only have a Hospital Plan which does not cover breast prostheses. Pensioners are particularly hard hit.

We have also seen a steady increase in the number of women needing silicone prostheses since 2011:  from 475 in 2011 to 930 in 2015.  There is without doubt a growing need for this service.   Unfortunately a silicone prosthesis is guaranteed to last for only two years; therefore we are also experiencing women returning to Reach for Recovery to have their prostheses replaced.

The need for silicone prostheses for newly referred breast cancer patients plus the need for replacements impacts heavily on the funds that we use to subsidise these products. A needs analysis has shown that we would subsidise at least 1000 women with a new silicon breast prosthesis in the new financial year.  This includes women who would need a replacement.

We are extremely thankful to our donors who help us to ensure the sustainability of this project!

Reach to Recovery is one of the breast cancer organisations that is a part of ABC.

 

Rice porridge for the tough times

Creamy rice porridge

Delicious, nutritious and comforting. Traditional oat porridge is good too but try this one for extra food value. It is well worth the investment in a small ‘slow cooker ‘as it will be perfect at breakfast time. It keeps for 2 or 3 days in the fridge. Re-heat with a little extra soya milk or enjoy it cold with maple syrup, a chopped banana and a sprinkle of sesame seeds.

2ozs (50g, generous ½ cup) brown rice

2 pints (1 litre) soya milk

Handful of dried fruits (optional)

Cook overnight in an electric slow cooker. If you do not have an electric slow cooker then just bring to the boil in a nice heavy casserole, lower heat to barely simmering, cover and cook for 2 ½ hours. You may need to add a little more soya milk. You can also pop it into a low oven for about 3 hours.

Serve with a little maple or date syrup or compote of fruit.

You can add any dried fruit you like – it is especially scrumptious with apricots or dates.

Thanks to Dr Rosy Daniel, who has generously shared The Cancer Lifeline recipes with us. This recipe is for the Tough Times, for use when you are very ill, during treatment, while the appetite is poor and the weight low.

Staying fit, feeling good

Do daily exercises

After a mastectomy or if you have surgery to your armpit, your surgeon and physiotherapist will ask you to do regular exercises to help you recover. Your arm may feel stiff on the side where your breast was removed. Simple arm exercises can help to

• give you back your full range of movement (also important for radiotherapy treatment)
• relieve pain and stiffness
• reduce swelling

After surgery, do the exercises until you have full movement back in your arm and shoulder. Ideally, you should do these twice a day.

To start with, the exercises are quite gentle. The aim is to get your arm and shoulder moving as it was before the surgery. You can begin each session by circling your shoulders, to get the muscles moving. Other early exercises are brushing or combing your hair, putting your arms behind your back and touching your shoulder with your hand. As you get stronger and more confident, you can do more of the exercises and gradually increase the range of movements.

Have a look at this excellent video:

https://www.youtube.com/watch?v=vo1S-K2MetM

Talk to your surgeon or physiotherapist if you have ongoing problems with arm or shoulder pain, stiffness or swelling.

If you have had breast reconstruction surgery the exercises you do are different and depend upon the type of reconstruction you have had. Check with your surgeon and physiotherapist!

Stay physically active

Tiredness and weakness is finally being recognised as one of the most common side effects from cancer treatment. It’s called: Cancer Related Fatigue. The reasons for it are multifold: the cancer itself drains your energy, the treatment is intense and often toxic, but also the lack of normal physical activity during treatment leads to loss of fitness.

It is encouraging that taking regular exercise can help to combat it. More and more research is showing that exercise during and after treatment is safe and helps recovery after cancer. Regular exercise can reduce stress and give you more energy.

 

But how much, and how often, and what exercise is suitable for me?

To be beneficial, exercise should be 30 minutes a day, 5 days a week, of moderate intense activity such as walking, cycling or dancing. You should get warm and increase your heartbeat without getting out of breath. This level of activity is helpful for people even during treatment.

Everyone is different and exercise needs to be tailored to individual people, taking into account your diagnosis and treatment (weightlifting shortly after breast surgery), other problems (diabetes, cancer in the bones) and not least: what you love to do and feel is possible in terms of time, travel and costs! A physiotherapist or biokineticist can help you on your way.

Have a look at the pyramid and see what daily exercise you can easily incorporate in your life.

Exercise can also be helpful in a number of cancer related side effects:

• neuropathy (pins and needles, problems with balance): aerobic exercise helps with the recovery of the damaged nerve ends by increasing blood flow.
• osteoporosis (thinning of the bones): weight bearing exercise means running or rowing or anything where your bones are doing some work. This type of exercise may protect you against osteoporosis (thinning of the bones). Osteoporosis is a concern for many post menopausal women who have had hormone dependent cancers and so cannot take hormone replacement therapy.
• depression/anxiety: many women with breast cancer battle with depression; regular exercise, possibly in a group, leads to less anxiety and need for medication.

Keep your pace

A very important advise to women fighting cancer is to listen to your body. But how can you do that, juggling a family, doctor’s appointments, medication, work obligations and loosing a breast at the same time?

• set your pace: this is about you, take the time you need and be direct to your husband, children and work colleagues of what you Make a list of what you want and need.
• keep involved: do what you want to do and can do at work and at home, and leave the rest to others (shopping, cooking). Set clear boundaries to prevent guilt and miscommunication. Learn to say “no, not now”.
• plan your day to conserve energy: and plan for 30 mins of exercise.
• learn to listen to your body: practice relaxation techniques or yoga (plenty of great apps http://www.healthline.com/health/fitness-exercise/top-yoga-iphone-android-apps#2 and classes) or mindfulness (https://www.youtube.com/watch?v=19Dkf3KJqIY)
• learn how to engage in physical contact again with your spouse or partner: touch, talk and stroke, and go slow. http://www.breastcancer.org/tips/intimacy/changes , http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/sex-sexuality-and-cancer/sex-and-cancer-for-women
• simply be beautiful: spend time on feeling feminine, spoil yourself with clothes or a massage or a lovely wig: going through cancer is an assault on your body, and (learning to) love your body is helpful to survive cancer.

This great advice was shared with us by the fabulous physiotherapist Liesbeth Raymakers

 

Staying active and healthy

We’re on a mission to help you to live an active and healthy life during cancer treatment, to empower you actively to cope with the cancer journey.

The recipies we are sharing are part of that, and here is a great list of things to do (and not to do) to make your journey easier.

Do’s:

• talk with your loved ones about your feelings of loss, speak to other breast cancer survivors, find support online
• get adequate pain medication
• contact your doctor or nurse when you develop problems
• massage the scars daily, dry or gently with a non-irritating skin oil. There’s a good video here to help you.

• get information of breast prosthesis and options (cansa.org.za, www.reach4recovery.org.za)
• eat healthy, stay active
• do shoulder exercises

Don’ts:

• push yourself: be mild and accept the pace your body is healing at
• lift or carry anything heavy for the first few weeks after surgery. This includes vacuuming, shopping and lifting a full kettle or a child.

Watch out for:

Wound infection

If your operation site becomes red, inflamed, or painful, or there is a fluid (discharge) leaking from your wound site, you may have an infection. Contact your surgeon or breast care nurse immediately. If you have an infection, you will need antibiotics to clear it up.

Fluid collecting around the operation site (seroma)

Sometimes fluid continues to collect near the wound after your wound drains have been taken out. This is called a seroma. It causes swelling and pain and can increase the risk of infection. The fluid usually goes away on its own. Sometimes a nurse needs to drain the fluid off with a needle and syringe. They may need to do this a few times.

For some women, the fluid takes a long time to go. It can take up to a few months after your surgery.

Nerve pain

You may have numbness or tingling in your upper arm, particularly if you had your lymph nodes removed. This is normal and happens because some nerves are cut during the operation and need to repair themselves. It can take a few weeks or months to go. If it continues, get in touch with your breast care nurse or surgeon.

Swelling of your arm or hand

You may have some swelling in your arm or hand after your operation. This is normal. But it should start to go away as you do the exercises (see below) to get back the movement of your shoulder and arm.

If you continue to get a lot of swelling, heaviness, pain or tenderness in your arm or hand, let your breast care nurse or surgeon know as soon as possible. After surgery or radiotherapy to the armpit, there is a risk of developing permanent swelling called lymphoedema. Once you have lymphoedema it can’t be cured but early treatment can effectively control it. Look at the information about lymphoedema page for ways of preventing lymphoedema.

Scar tissue in the armpit (cording)

Some women develop scar tissue in the armpit (axilla), which forms a tight band. This can happen 6 to 8 weeks after the operation. The scar tissue is called cording or banding and can feel something like a guitar string. Cording is harmless but can be uncomfortable. It can get better after some time if you massage the area of the scar tissue. Your specialist nurse or a physiotherapist can teach you how to do this.

This great advice was shared with us by the fabulous physiotherapist Liesbeth Raymakers

 

 

Keeping the balance

Over the next couple of weeks, we will be posting a series of recipies that will help you as you go through treatment. The Cancer Lifeline recipies are divided into three phases:

• Tough Times, for use when you are very ill, during treatment, while the appetite is poor and the weight low.
• Clean Machine, for detoxification of the body, post cancer treatment, or to kickstart a holistic health creation programme.
• Eat Right, to set the right style of eating for the rest of your life to generate optimum health.

The recipies have been created by celebrity chef and nutrition consultant, Jane Sen, for the nourishment and healing of people with cancer. The recipies are part of the Cancer Lifeline Kit by Dr Rosy Daniel, which she has generously shared with us.

Making an impact

The Breast Course for Nurses: who we are and what we have done over the last 12 months     

We have run several courses over the last 12 months:

Cape Town, South Africa – 15 nurses trained
Lilongwe, Malawi – 26 nurses trained
Windhoek, Namibia – 30 nurses trained
Ongwediva, Namibia – 30 nurses trained
Harare, Zimbabwe – 257 health care providers trained
Johannesburg, South Africa – 42 nurses trained

An account of each course can be found on the blog: http://www.jennyedge.co.za and Facebook page: www.facebook.com/breastcourse4nurses

The course is constantly evolving and I want to highlight some of the new changes we have made this year.

The major challenge we have addressed is allowing the course to run independently.

I have learnt a lot about teaching through the whole process.  The course was set up along the principles of the flipped class technique.

Unlike teaching at school, the participants on the courses are very varied and most are experts in their own areas.  We were constantly faced with the challenge of having large numbers of health care workers with vastly differing levels of knowledge about breast cancer and differing needs from the course.  In Zimbabwe, we were asked to extend the training to include doctors.  We met the challenge by dividing the 2 day course into 3 day long modules:
Module 1 was capped at 80 students and aimed at primary health care workers, breast cancer advocates and registered nurses.
Module 2 was capped at 50 participants and was aimed at registered nurses from the clinics, oncology sisters and doctors.
Module 3 was capped at 30 participants and was aimed at oncology sisters and doctors.  It allowed us to teach biopsy techniques.

We were also asked to have a “train the trainers” day. In many ways, the request ran against our aim to equip nurses to be self sufficient in their learning.  (The principle behind PEP is that health care workers should educate themselves with the material provided.)  Nevertheless, we blended the 2 approaches and Prof Woods and I ran a day in which we looked at different teaching modalities and tried to apply them to the course.  We defined “teaching” as the “sharing of understanding”
The result was that Module 1 of the Breast Course for Nurses was entirely taught by the nurses who attended the train the trainer’s day and studied the book (Breast Care).  I was immensely proud!

In Johannesburg, we took a different approach to deal with the challenge.  The course was run at Charlotte Maxeke Hospital by Dr Sarah Nietz and her team.  I wasn’t there at all.  I understand that 45 nurses completed the course.  The faculty were entirely local.

Many thanks to everyone who has been involved with the Breast Course for Nurses.  If you wish to become involved, run a course or know more, please contact us.

Dr Jenny Edge, Founder and director of Breast Course for Nurses (PBO No.: 930050375)

Facebook: http://www.facebook.com/breastcourse4nurses

Blog: www.jennyedge.co.za

Email: lieskewegelin@gmail.com

 

 

The Breast Course for Nurses: who we are and what we do

Regular readers of this blog will know that the Cancer Alliance is a collective initiative by South Africa’s main breast cancer organisations. We will be introducing each of our partners over the next few months. Today, meet Breast Course for Nurses. This blog was written by Dr Jenny Edge, Founder and director of Breast Course for Nurses.

     

It is an indisputable fact that women who are diagnosed with breast cancer at an earlier stage have a much better outcome than those diagnosed at a later stage.  Breast cancer screening programmes are well established in high income countries.

The modality of screening used is generally mammographic screening.

There has been a lot of debate about why women are diagnosed late in low income settings.  Do they present late because they are scared or cannot afford to access the health facility?  Do they present with symptoms that are not recognized as cancer by the health care worker (generally a nurse in a primary clinic)?  Do they get lost in the journey of diagnostic tests?

We don’t have the answer to these questions.  The Breast Course for Nurses aims to educate nurses working in primary clinics and equip them with the skills to recognise normal changes to the breast and differentiate them from changes associated with breast cancer.  We teach clinical breast examination with an aim to identifying breast cancers at an earlier stage.

Does clinical breast examination work as a means of breast screening?

Clinical breast examination, as a screening modality, has been studied with mixed results.   A recent study carried out in Sudan showed that clinical examination does pick up breast cancer at an earlier stage than in the control population.¹    In Canada, where clinical breast examination was compared to mammographic examination, the mortality from breast cancer, 20 years later, was similar in both groups although more cancers were diagnosed in the mammographically screened population².

The Breast Course for Nurses is a combination of a self-learning program (PEP educations series) and a residential program that contextualizes the theory in the book, encourages networking amongst the participants and stimulates debate as to how to improve access to care.  The courses are taught by local faculty and no course is the same.

Does our method of transferring understanding work?  We will be doing various projects to look at the impact of running our course.

In the next blog, we will give details of the courses we have run over the last 12 months.

References

1. Abuidris DO1, Elsheikh A, Ali M, Musa H, Elgaili E, Ahmed AO, Sulieman I, Mohammed SI. Breast-cancer screening with trained volunteers in a rural area of Sudan: a pilot study. Lancet Oncol. 2013 Apr;14(4):363-70. doi: 10.1016/S1470-2045(12)70583-1. Epub 2013 Jan 31.

2. Anthony B Miller, Claus Wall, Cornelia J Baines, Ping Sun, Teresa To, Steven A Narod.. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast. Screening Study: randomised screening trial. BMJ: g366 doi:10.1136/bmj g 366

Facebook: http://www.facebook.com/breastcourse4nurses

Blog: www.jennyedge.co.za

Email: lieskewegelin@gmail.com