Tamoxifen Alone Discouraged as Adjuvant Tx

Guidelines Define Menopause

Critical to the appropriate clinical application of the updated NCCN breast cancer treatment recommendations is a standardized definition of menopause.

“You wouldn't think a definition of menopause would be needed, but just about all studies that have been done in postmenopausal women define [menopause] differently,” Dr. Carlson said. This can cause problems and confusion, particularly with respect to treatment with aromatase inhibitors, which are most effective in postmenopausal women.

Menopause is generally the permanent cessation of menses. “As the term is used in breast cancer management, it includes a profound and permanent decrease in ovarian estrogen synthesis,” the revised guidelines state. Reasonable criteria for determining menopause include any of the following:

▸ Prior bilateral oophorectomy.

▸ Age 60 years or older.

▸ Age younger than 60 years and amenorrheic for at least 12 months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression, and FSH and estradiol in the postmenopausal range.

▸ Age younger than 60 years and FSH and plasma estradiol levels in postmenopausal range in women taking tamoxifen or toremifene.

It is not possible to assign menopausal status to women receiving an LHRH agonist or antagonist, the guidelines state. Amenorrhea is not a reliable indicator of menopausal status in women who are premenopausal at the outset of adjuvant chemotherapy.

“Women who undergo chemotherapy treatments that permanently stop menses may still produce estradiol at levels that are premenopausal,”commented Dr. Carlson, stressing that premenopausal estrogen levels can influence treatment with aromatase inhibitors.