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Cancer
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Elyce Cardonick, Charlotte Maggen, Puja Patel
Breast feeding after treatment for breast cancer: Most women who have undergone irradiation for breast cancer are able to produce milk on the affected side, but the amount of milk produced may be less than that in a nonirradiated breast, particularly if the lumpectomy site was close to the areolar complex or transected many ducts [171]. Even when breast milk is produced, breast-feeding from the irradiated breast is not advised because mastitis will be difficult to treat if it occurs [172, 173]. As chemotherapy has the ability to cross over to breast milk, breastfeeding is contraindicated. Patients that received chemotherapy demonstrate reduced lactational ability [174]. Breastfeeding can only be resumed following a safety period (of at least 3 weeks, depending on the cytotoxic drug), when potential harmful metabolites are cleared from the maternal circulation [175]. Aromatase inhibitors are indicated during lactation because of the impact on the estrogen metabolism of the infant, whereas the lactational safety of tamoxifen is unknown [176]. The ongoing POSITIVE trial, a prospective randomized trial, is designed to obtain a better insight on the safety of interrupting endocrine therapy for up to 2 years for childbearing and breastfeeding [177].
Endocrine Therapies
Published in David E. Thurston, Ilona Pysz, Chemistry and Pharmacology of Anticancer Drugs, 2021
Many breast cancers are stimulated to grow by estrogen and progesterone. The aromatase inhibitors are a family of agents that reduce the amount of estrogen in the body by blocking the cytochrome P450 aromatase enzyme (P450AROM), which is key for the synthesis of estrogen in certain parts of the body. However, as they do not inhibit ovarian estrogen synthesis (the main source of estrogen in premenopausal women), they can only be used in postmenopausal women, or those in whom the ovaries have stopped working or have been removed. In postmenopausal women most of the estrogen is produced via conversion of the androgens androstenedione and testosterone to estrone and estradiol, respectively, by P450AROM (a process known as aromatization) as the final step in the steroidogenesis pathway from cholesterol (see Figure 8.1). This occurs in peripheral tissues such as the fatty tissues (i.e., adipose tissue) of the breast, muscle, and skin, and in some sites in the brain. Estrogen produced in this way acts locally in these peripheral tissues where it was synthesized. For example, breast tissue can contain up to a twentyfold higher concentration of estrogen than other tissues, and any circulating estrogen in postmenopausal women (as well as in men) is the result of locally produced estrogen escaping local metabolism and entering the circulatory system. Selective inhibition of P450AROM leads to reduced estrogen levels in the body, and this can lead to a reduction in tumor growth without affecting other hormones produced by the steroidogenesis pathway.
Breast Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Gaural Patel, Lucy Kate Satherley, Animesh JK Patel, Georgina SA Phillips
Aromatase inhibitors can be classified as irreversible steroidal inhibitors e.g. exemestane or reversible non-steroidal competitive inhibitors e.g. anastrozole, letrozole. BIG 1-98 and ATAC trials established that aromatase inhibitors are associated with increased disease-free survival in postmenopausal women compared to tamoxifen. Aromatase inhibitors are associated with loss of bone density; therefore, bone density should be monitored by DEXA scan.
The influence of age, menstrual state and body mass index on the relation between osteopenia and osteoporosis associated with breast cancer
Published in Journal of Obstetrics and Gynaecology, 2022
Ali Abdul Hussein S. Al-Janabi
A case–control study was designed to include 200 breast cancer patients (34–88 years old) and 200 women without breast cancer as a control group (31–89 years old). The study was conducted in subjects visiting AI-Ammam Hussein Medical City Hospital in Karbala province from August 2019 to April 2020. Breast cancer was diagnosed based on histopathological examination of biopsy of suspected patients. Osteopenia and osteoporosis were determined according to the T-score of BMD measured using dual X-ray absorptiometry (DXA)(DMS Stratos, France) for hips and lumbar spine. According to the WHO (Nuttall 2015; Mincey et al. 2000), BMD T-score between −1 and −2.5 was considered an indicator of osteopenia and those with ≤ −2.5 are osteoporosis. Queteletʼs equation was used to calculate BMI. The values of BMI for obesity recommended by the WHO, including underweight: ≤18.5 kg/m2, normal weight: 18.5–24.9 kg/m2, overweight: 25.0–29.9 kg/m2, and obesity: ≥30.0 kg/m2 were used (Mazocco and Chagas 2017). Pregnant women and women on chemotherapy or aromatase inhibitor were excluded from this study.
Medical management of non-obstructive azoospermia: A systematic review
Published in Arab Journal of Urology, 2021
Mohammad H. Alkandari, Armand Zini
Common ways of increasing intra-testicular testosterone levels in men with NOA and hypergonadotrophic hypogonadism are by use of aromatase inhibitors (steroidal and non-steroidal) and anti-oestrogens. Aromatase inhibitors block aromatase enzyme, which converts testosterone to oestrogen in peripheral tissues. A comparative study on 140 infertile men with an abnormal testosterone:oestrogen ratio showed that both groups of aromatase inhibitors significantly improved that ratio but were never successful in producing sperm in the ejaculate [14]. The same study group also reached the conclusion that patients might benefit from this treatment if they are undergoing a sperm retrieval surgery. Another study showed similar results when men with low testosterone and either a low testosterone:oestrogen ratio or failed clomiphene were prescribed daily anastrozole (non-steroidal aromatase inhibitor) [15]. Although, none of these men had sperm in the ejaculate after treatment, 73% underwent successful micro-TESE after anastrozole.
Bone health in women with breast cancer
Published in Climacteric, 2019
S. K. Ramchand, Y. M. Cheung, M. Grossmann
Extending aromatase inhibitor treatment duration from 5 to 10 years increases disease-free survival by 3.8%, largely due to reduced risk of local recurrence13, and can be worthwhile for high-risk women, especially in those with node-positive breast cancer14. However, this is at the expense of increased bone toxicity, with an almost doubling of osteoporosis (11% vs. 6%) and a 3.5% absolute increase in fracture rates, despite the fact that almost half of the women in this study13 received bisphosphonates. A recent systematic review including 16,349 women confirmed that extending aromatase inhibitor treatment beyond 5 years was associated with increased odds of bone fractures (odds ratio 1.34, 95% confidence interval [CI] 1.16–1.55)15. Therefore, the length of endocrine treatment has to be carefully individualized. The oncologic benefits of endocrine treatments, as well as their adverse effects, validate the concept that low residual postmenopausal estradiol concentrations are physiologically important.