Questions and Experts Session Guide: A Medical Oncologist Answers Questions about HR-Positive Breast Cancer

A breast cancer diagnosis comes with so many questions and there never seems to be enough time at appointments to have some of these questions answered. To help address this, we developed a "Q&E: Questions and Experts" series. In this series, a variety of experts spend the entire virtual session answering pre-submitted and live questions from participants. Watching the videos on-demand might be a little difficult to get through. So, we’ve created this guide to help you get right to the questions and answers that matter the most to you.

In today’s post, we provide the questions that were sent in and asked during the live session of our Questions and Experts session held in April 2021. In this session, Dr. Sandeep Sehdev, MD, FRCPC, a Medical Oncologist, answered questions about HR-positive breast cancer. In the parentheses, you’ll find the timestamp of where to find the question in the on-demand video.

COVID-19: Vaccines, Clinical Trials, and the Impact on Cancer Treatment

1. I have read new research from the UK that highlights the need for the second dose of the COVID-19 vaccine to be administered within 3 weeks for cancer patients. Will this be the recommendation in Canada as well? (3:35)  
2. Do you we know or have a standardized approach across Canada for vaccine administration across cancer patients? (6:04) 
3. Is there a possibility of an increased risk of blood clots from the AstraZeneca vaccine among those who take Tamoxifen, since Tamoxifen has its own risk of blood clots? (7:55)

Breast Cancer Drugs

1. When is it indicated to give Tamoxifen for more than 5 years for triple positive and HR-positive breast cancer? (11:43) 
2. If you do not have any, or lot of side effects from Tamoxifen, does that mean it is not working? Is that a way to gauge how effective it is for you? (19:56) 
3. Some women recur while they are on Tamoxifen, so is there a way to tell if it is working for you or if it is not? Why does it work for some women and not others? (23:00) 
4. I’m 47 years old and I have been on Tamoxifen since March 18, 2018. Recently, I’ve started getting my period back. Very spotty, but I never know when it will start. My oncologist says that I have to go two full years with no period and no signs of a period before I can have my ovaries taken out. What are your thoughts on this? (25:51) 
5. How much does your risk of recurrence increase if you are not able to tolerate an AI or Tamoxifen? How can you mitigate the side effects that are not tolerable? (52:19) 
6. Can you comment on the over-the-counter medications or supplements that should be avoided if taking Tamoxifen or Letrozole? For example, things  like Benadryl, Gravol, turmeric.  (1:01:12) 
7. What is the minimum effective dose for Tamoxifen? (1:16:14) 
8. Is there an alternative to the Zometa infusion? (1:19:41) 

Side Effects

1. If you do not have any, or lot of side effects from Tamoxifen, does that mean it is not working? Is that a way to gauge how effective it is for you? (19:56) 
2. How much does your risk of recurrence increase if you are not able to tolerate an AI or Tamoxifen? How can you mitigate the side effects that are not tolerable? (52:19) 
3. What are the different anti-hormone drugs available for early-stage HR-positive breast cancer and which would cause the least amount of side effects for a post-menopausal woman? (44:21) 

Testing, Treatments and Treatment Decision-Making

1. In women who have high estrogen proliferation, greater than 90%, do they benefit more from endocrine therapy than those with 50% estrogen proliferation? And if so, is high proliferation an indicator for extending endocrine therapy for 10 years?  (17:22) 
2. Is the amount and intensity of side effects from chemotherapy a way to gauge if it’s working? For instance, neutropenia, people who get their neutrophiles wiped out because of the chemotherapy, is that a better success story that the chemotherapy has worked at a higher rate? Or is that not an indicator at all? (21:08) 
3. I’m 47 years old and I have been on Tamoxifen since March 18, 2018. Recently, I’ve started getting my period back. Very spotty, but I never know when it will start. My oncologist says that I have to go two full years with no period and no signs of a period before I can have my ovaries taken out. What are your thoughts on this? (25:51) 
4. Can you speak to the role of CDK4/6 inhibitors in both the metastatic setting as well as whether or not they are being used in the early breast cancer setting? (32:28)  
5. What are the different anti-hormone drugs available for early-stage HR-positive breast cancer and which would cause the least amount of side effects for a post-menopausal woman? (44:21) 
6. What is compliance like and how it is that measured or tracked? (48:30) 
7. How much does your risk of recurrence increase if you are not able to tolerate an AI or Tamoxifen? How can you mitigate the side effects that are not tolerable? (52:19) 
8. Is electrotherapy available in Ontario to treat breast cancer that has metastasized to skin? (1:07:22) 
9. What are some additional treatments particularly for skin metastases? (1:08:10) 
10. I had 3 positive lymph nodes and 26 removed on my right arm, along with a mastectomy on my right breast. My Oncotype DX test said that chemotherapy would only offer a 2-3% better chance of the cancer not returning, and given the toxicity of chemotherapy, my physician recommended not having it. I also did not have radiation; however, I have not met any other patients who had a similar experience and I’m wondering if taking Exemestane alone is enough to reduce my risk of recurrence? What else would help reduce this risk?  (1:09:57) 
11. What is the difference between Oncotype DX and MammaPrint? Does it matter which one patients are receiving if they are having those tests done? (1:21:48) 
12. Over the time you have been a clinician and an oncologist treating patients, do you find that patients are much savvier and understanding their diagnosis since the time you started? (1:26:14) 
13. Is there any situation where patients would not be advised to take hormone blockers? (1:28:10) 

Ovaries, Fertility and Menopause

1. I’m 47 years old and I have been on Tamoxifen since March 18, 2018. Recently, I’ve started getting my period back. Very spotty, but I never know when it will start. My oncologist says that I have to go two full years with no period and no signs of a period before I can have my ovaries taken out. What are your thoughts on this? (25:51) 
2. What are the different anti-hormone drugs available for early-stage HR-positive breast cancer and which would cause the least amount of side effects for a post-menopausal woman? (44:21) 

Risk of Recurrence

1. Some women recur while they are on Tamoxifen, so is there a way to tell if it is working for you or if it is not? Why does it work for some women and not others? (23:00) 
2. How much does your risk of recurrence increase if you are not able to tolerate an AI or Tamoxifen? How can you mitigate the side effects that are not tolerable? (52:19) 
3. What are the top three ways to prevent recurrence of breast cancer? (54:58) 
4. What are the effects of Vitamin D and Aspirin in reducing recurrence? (57:56) 
5. I had 3 positive lymph nodes and 26 removed on my right arm, along with a mastectomy on my right breast. My Oncotype DX test said that chemotherapy would only offer a 2-3% better chance of the cancer not returning, and given the toxicity of chemotherapy, my physician recommended not having it. I also did not have radiation; however, I have not met any other patients who had a similar experience and I’m wondering if taking Exemestane alone is enough to reduce my risk of recurrence? What else would help reduce this risk?  (1:09:57) 

Metastatic Breast Cancer

1. Can you speak to the role of CDK4/6 inhibitors in both the metastatic setting as well as whether or not they are being used in the early breast cancer setting? (32:28)  
2. Is electrotherapy available in Ontario to treat breast cancer that has metastasized to skin? (1:07:22) 
3. What are some additional treatments particularly for skin metastases? (1:08:10) 

Prevention and Risk Factors: Familial, Environmental and Lifestyle

1. How much of a driver is the CHEK2 mutation in HR-positive breast cancer and what considerations should be given to that? (30:12) 
2. I don’t have a family history of breast cancer, what are the chances of my daughter getting breast cancer? (38:30)

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