Mindy Goldman

Amelioration of sexual adverse effects in the early breast cancer patient.

BackgroundAs the number of breast cancer survivors increases, the long term consequences of breast cancer treatment are gaining attention. Sexual dysfunction is a common complaint amongst breast cancer survivors, and there are few evidence based recommendations and even fewer well designed clinical trials to establish what treatments are safe or effective in this patient population.DesignWe conducted a PubMed search for articles published between 1995–2009 containing the terms breast cancer, sexual dysfunction, libido, vaginal dryness, testosterone, and vaginal estrogen. We initially reviewed articles focusing exclusively on sexual issues in breast cancer patients. Given the paucity of clinical trials addressing sexual issues in breast cancer patients, we also included studies evaluating both hormone and non-hormone based interventions for sexual dysfunction in post-menopausal women in general.ConclusionsAmong breast cancer survivors, vaginal dryness and loss of libido represent some of the most challenging long term side effects of breast cancer treatment. In the general post-menopausal population, topical preparations of estrogens and testosterone both appear to improve sexual function; however there are conflicting reports about the efficacy and safety of these interventions in women with a history of breast cancer, and further research is warranted.

Role of Sonography in the Recognition, Assessment, and Treatment of Cesarean Scar Ectopic Pregnancies

Objective. Cesarean scar ectopic pregnancies (CSEPs) are rare but may have serious adverse consequences and are therefore important to promptly recognize on sonography. We aim to describe the typical sonographic appearances. Potential treatments are discussed, including sonographic guidance for transcervical injection of methotrexate (MTX) into the gestational sac. Methods. Two patients with CSEPs were treated with systemic and intra‐amniotic administration of MTX under sonographic guidance. Results. Both patients were followed clinically after medical treatment, resulting in low maternal morbidity and mortality. Conclusions. Considering the increasing rate of cesarean delivery and the increased risk of CSEPs, sonologists should be familiar with the sonographic appearances of a pregnancy implanted into the cesarean scar. We show how to correctly diagnose scar implantation and describe how to perform sonographically guided transcervical injection of MTX.

Vaginal Testosterone Cream vs Estradiol Vaginal Ring for Vaginal Dryness or Decreased Libido in Women Receiving Aromatase Inhibitors for Early-Stage Breast Cancer: A Randomized Clinical Trial

Importance Aromatase inhibitors (AI) are associated with significant urogenital atrophy, affecting quality of life and drug compliance. Objective To evaluate safety of intravaginal testosterone cream (IVT) or an estradiol-releasing vaginal ring (7.5 &mgr;g/d) in patients with early-stage breast cancer (BC) receiving an AI. Intervention was considered unsafe if more than 25% of patients had persistent elevation in estradiol (E2), defined as E2 greater than 10 pg/mL (to convert to pmol/L, multiply by 3.671) and at least 10 pg/mL above baseline after treatment initiation on 2 consecutive tests at least 2 weeks apart. Design, Setting, and Participants Postmenopausal (PM) women with hormone receptor (HR)–positive stage I to III BC taking AIs with self-reported vaginal dryness, dyspareunia, or decreased libido were randomized to 12 weeks of IVT or an estradiol vaginal ring. Estradiol was measured at baseline and weeks 4 and 12 using a commercially available liquid chromatography and tandem mass spectrometry assay; follicle-stimulating hormone levels were measured at baseline and week 4. Gynecologic examinations and sexual quality-of-life questionnaires were completed at baseline and week 12. This randomized noncomparative design allowed safety evaluation of 2 interventions concurrently in the same population of patients, reducing the possibility of E2 assay variability over time and between the 2 interventions. Main Outcomes and Measures The primary objective of this trial was to evaluate safety of IVT or an estradiol vaginal ring in patients with early-stage BC receiving an AI; secondary objectives included evaluation of adverse events, changes in sexual quality of life using the Cancer Rehabilitation Evaluation System sexuality subscales, changes in vaginal atrophy using a validated 4-point scale, and comparison of E2 levels. Results Overall, 76 women signed consent (mean [range] age, 56 [37-78] years), 75 started treatment, and 69 completed 12 weeks of treatment. Mean (range) baseline E2 was 20 (<2 to 127) pg/mL. At baseline, E2 was above the postmenopausal range (>10 pg/mL) in 28 of 76 women (37%). Persistent E2 elevation was observed in none with a vaginal ring and in 4 of 34 women (12%) with IVT. Transient E2 elevation was seen in 4 of 35 (11%) with a vaginal ring and in 4 of 34 (12%) with IVT. Vaginal atrophy and sexual interest and dysfunction improved for all patients. Conclusions and Relevance In PM women with early-stage BC receiving AIs, treatment with a vaginal ring or IVT over 12 weeks met the primary safety end point. Baseline elevation in E2 was common and complicates this assessment. Vaginal atrophy, sexual interest, and sexual dysfunction were improved. Further study is required to understand E2 variability in this setting. Trial Registration clinicaltrials.gov Identifier: NCT00698035

A rare drug reaction to methotrexate after treatment for ectopic pregnancy.

BACKGROUND: Ectopic pregnancies are commonly diagnosed and treated in physicians’ offices. In the hemodynamically stable patient, therapy often includes treatment with methotrexate. Well-known adverse effects of this drug include mucositis, abdominal cramping, and malaise. We report a case of a rare drug reaction after treatment with methotrexate. CASE: A 34-year-old, gravida 2, para 0, at 7 weeks of gestation by last menstrual period was diagnosed with an ectopic pregnancy and treated with methotrexate. The patient had an anaphylactoid reaction shortly after administration of methotrexate. CONCLUSION: Methotrexate is a commonly used therapy for ectopic pregnancies in the outpatient setting. Practitioners should be aware of the potential adverse reactions to methotrexate.

Survivorship, Version 2.2017: Clinical practice guidelines in oncology

Many cancer survivors experience menopausal symptoms, including female survivors taking aromatase inhibitors or with a history of oophorectomy or chemotherapy, and male survivors who received or are receiving androgen-ablative therapies. Sexual dysfunction is also common in cancer survivors. Sexual dysfunction and menopause-related symptoms can increase distress and have a significant negative impact on quality of life. This portion of the NCCN Guidelines for Survivorship provide recommendations for screening, evaluation, and treatment of sexual dysfunction and menopausal symptoms to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period.

Survivorship: Fatigue, version 1.2014 - Clinical practice guidelines in oncology

Many posttreatment cancer survivors experience chronic pain, often leading to psychological distress; decreased activity, motivation, and personal interactions; and an overall poor quality of life. This section of the NCCN Guidelines for Survivorship provides screening and management recommendations for pain in survivors. A multidisciplinary approach is recommended, with a combination of pharmacologic treatments, psychosocial and behavioral interventions, physical therapy and exercise, and interventional procedures.

A Phase II Study of Vaginal Testosterone Cream (TEST) vs. Estring for Vaginal Dryness or Decreased Libido in Women with Early Stage Breast Cancer (BC) Treated with Aromatase Inhibitors (AIs).

Background: Sexual issues including vaginal dryness and decreased libido are common among breast cancer patients. Many interventions are hormonally based. The risk of these treatments is unknown and is of interest, particularly for patients with hormone receptor positive disease. Design: In a randomized open label study, we are evaluating the safety, based on serial measurements of serum estradiol (E) levels, of intravaginal TEST or Estring used for 12 weeks (wks) for relief of vaginal dryness and/or decreased libido in women with early stage BC taking AIs. Planned enrollment is 35 patients (pts) per arm, and accrual will stop if a predetermined number of pts has a sustained elevation in serum E while on study. E is measured by an ultrasensensitive liquid chromatography-tandem mass spectrometry based assay. Eligible pts have not had a menstrual period for 12 months. and have taken an AI for at least one month. Pts who received chemotherapy or who are on ovarian suppression must have a serum E of 10 pg/ml or if there is a > 10 pg/ml elevation above their baseline value.Results: 29 pts have been enrolled; 15 to TEST, 14 to Estring. 20 pts have completed the 12 wk study period. Adverse events are rare and include grade 1 vaginal discharge, odor, or burning, and hair growth. Two pts did not complete the study due to the Estring falling out. One pt discontinued Estring due to vaginal discharge and irritation. One pt using TEST discontinued treatment due to a herpes outbreak. Among the Estring pts, two had an elevation in serum E to >10 pg/ml (14 pg/ml and 70 pg/ml) at wk 4 or at wk 12; but E returned to 10pg/ml at wk 4 or at wk 12; one remained modestly elevated (17 pg/ml) 4 wks later. Vaginal atrophy scores showed improvement in pts receiving both treatments, although the study is not powered to show a difference between the two arms.Conclusions: Both vaginal TEST and Estring appear to be effective options to treat vaginal dryness in pts with early stage BC on AIs. The number of pts with sustained elevations in serum E levels to date has not reached the pre-defined threshold for stopping the study. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5038.

Women's Health, Breast Health A Review of the Gynecologic Effects of Breast Cancer

Breast cancer is very common and seen in both premenopausal and postmenopausal women. Research into prevention, better screening, and more effective treatments is occurring continually, and changes are translated into clinical practice relatively quickly. It is important for womens health care providers to have an understanding of breast cancer treatments and the gynecologic side effects. For premenopausal women interested in fertility, options should be discussed prior to chemotherapy. Issues pertaining to pregnancy after breast cancer should be discussed in a multidisciplinary fashion, involving the obstetrician/gynecologist, breast surgeon, and oncologist. Ovarian suppression is often used as part of breast cancer treatment in premenopausal women with hormone positive disease, and menopausal symptoms may be severe. Hormonal therapies including tamoxifen and the aromatase inhibitors are used in the treatment of hormone positive breast cancers. Each of these drugs has a variety of gynecologic implications. Understanding the options for treatment for menopausal complaints in breast cancer patients is important for womens health providers. Although most breast cancers are sporadic, a small percentage will be due to mutations in the BRCA genes. It is imporatant for womens health providers to take an appropriate family history and refer to genetic counselors for possible testing when hereditary cancer is suspected. This review focuses on the various womens health issues pertaining to breast cancer and treatment. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to identify potential impact of breast cancer treatment on a womens future fertility, organize a logical approach to the gynecological care of a patient on tamoxifen for breast cancer, and describe the gynecological factors of importance to women who are BRCA1/2 positive.

Integrative Tumor Board: Recurrent Breast Cancer or New Primary?

History of present illness: 1994 – Bilateral mammogram revealed bilateral benign calcifications confirmed by ultrasound. 1995 – increase in calcifications in the left breast. Excisional biopsy – 2.5 × 2 × 2 cm tumor positive for welldifferentiated intraductal and infiltrating ductal carcinoma, grade I. Borderline high S-phase. Estrogen and progesterone receptors positive. Her-2/ neu is negative. 1996 – Left axillary dissection, which revealed 1/17 positive lymph nodes. 1996 – Patient received cytoxan, methotrexate, 5-FU (6 cycles) with radiation sandwiched in between at 6,640 cGy over 36 fractions. Patient was then on tamoxifen for 5 years. Patient did well with routine physical exams, mammograms, and occasional ultrasounds until spring 2002 when a mammogram revealed a cluster of calcifications in the left breast. Left breast lumpectomy revealed an infiltrating ductal carcinoma with clear margins. Estrogen receptor positive. Progesterone receptor negative. Her-2/neu negative. Within 1 month, the patient was started on Arimidex. Whole body PET/CT scan was negative for metastatic disease. BRCA-1 and 2 = negative.

Survivorship, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common physical and psychosocial consequences of cancer and cancer treatment to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period. This portion of the guidelines describes recommendations regarding the management of anthracycline-induced cardiotoxicity and lymphedema. In addition, recommendations regarding immunizations and the prevention of infections in cancer survivors are included.