Female Health Issues After Breast Cancer
Dr. Elena Kamel: Well the point of using vaginal estrogen, number one, is that the majority of estrogen, if dosed properly in the vagina, will only work locally and so you will not get systemic absorption. So that’s what you want to avoid, is you don’t want to get, you want to use a medication that will give you so much of a level that you will get blood levels and so whether it’s using a small amount of estrogen cream or whether you use the tablets, we know the dosing schedule as such can be titrated to such that you really get just local effect and that you don’t get high systemic levels and therefore it’s really safe to the individual who is estrogen receptor positive.
Felice: Okay, because I had asked about it and both my gynecologist and my oncologist were hesitant.
Dr. Elena Kamel: Right. Well, I think that unfortunately that is an old, again, it’s like the: You can’t get pregnant after you’ve had breast cancer. It’s an old dictum. Actually if you go to the Northern American Menopausal Society’s website, which is www.menopause.org, you can look up some of the work that Lila Nachtigall has done with the Vagifem product and you’ll see that we feel in small doses, it’s safe and what you want to do is most women would like to maintain some form of sexual function…
Felice: Right.
Dr. Elena Kamel: …and we always encourage people to start with the non-estrogen containing products like Replens, Astroglide, KY Jelly, Eros, which is glycerin. So you try those, if they work, great. But honestly, in the majority of women, they don’t. It’s still uncomfortable. So we want to try and maintain the opportunity of intimacy and so a small dosing of estrogen is safe for the patient and does wonders for the vagina.
Felice: Thank you.
Operator: Michelle from Indiana’s online. Please go ahead.
Michelle: Hi. I have two questions. First, I was wondering with the chemo is there any affect on the eggs? I know you said that it can affect ovarian function but I don’t think that you addressed any affect on the eggs. My second question, you had said that there’s no evidence supporting correlation between the gestational hormones and recurrence, but having known several women who were diagnosed during pregnancy or while nursing and then a couple more who were diagnosed with recurrences during pregnancy, I’m wondering what can be done as far as screenings, breast screenings during pregnancy and nursing?
Dr. Elena Kamel: Well let’s start with the question number one with respect to what does chemotherapy do to the egg? Now you were talking about the egg that’s fertilized or just the resting oocyte?
Michelle: Resting.
Dr. Elena Kamel: Okay, so we certainly do know that the chemotherapy does affect the entire ovary, so that includes the eggs, the follicles, and, depending on age, different age ranges are affected more. The 35 and younger egg has a higher chance of recovery, so you do lose some function but it seems that we’re able to recover. The 35 and older, like 35 to 40 range, we see more and more loss of ovarian function and so in many of those women the chemotherapy causes premature ovarian failure, so it basically knocks out the functioning of the egg.
Michelle: If the egg has become fertilized though…
Dr. Elena Kamel: If the egg has become fertilized and one has chemo in the first trimester, that is a very, that’s very disconcerting. In fact the reports that we do have show that that is where the chemo is the most dangerous to a fetus. There are reports, actually, that they’ve looked at chemo, the women who have been diagnosed in their second and third trimester and those fetuses have done well. But it makes sense that’s the time of formation, that is during the time of organogenesis and that is the worst time to expose a fetus to these different chemotherapeutic agents. So that would not be something that we would want to pursue.
Michelle: But if the fertilization has occurred years after the chemotherapy, then you’re not…
Dr. Elena Kamel: They show no increase in chromosomal abnormalities if the fertilization is after chemotherapy has been completed. So the rational is that it’s safe to conceive after chemotherapy has been completed. With respect to what can we do for women who are nursing or during pregnancy, that’s a challenge because we don’t have screening that we’re comfortable using on a, just a general basis. So, for example, mammography is not something that we routinely offer women during pregnancy. So what we’re limited to is self-examination and ultrasound. Certainly women who are at high risk for breast disease during their pregnancy still need to be examined. Any mass that’s disconcerting should be at lest evaluated with ultrasound and, if need be, we can use MRI in pregnancy if one has to. If one really has to, you can do mammography, you just have to shield the belly, but it’s not something we can use as a routine screen. What we try to do with patients who are at high risk for breast disease is try to get their screening done before they become pregnant and so it’s nice to have a plan with someone of what you’re going to do before they get pregnant, manage them during the pregnancy, and then screening afterwards. The problem with a lactating breast is it’s very difficult to image and interpret accurately, so when a woman is lactating, a mammography is very difficult to interpret.
Michelle: Thank you.
Operator: Wendy from Indiana’s online. Please go ahead.
Wendy: Hi. Yes, I have two questions as well. You had mentioned that your daughters should be screened ten years prior to the age that their mother was. I was 36 when I was diagnosed. My two daughters are 19 and 22 right now, so the oldest one is quickly approaching the age of 26, and I wondered what type of screening should start at that point. Is it just mammograms? Should they get MRIs?
Dr. Elena Kamel: I think with the data that we have now, I think that is something definitely to think about in that you were very young; 36 is very young. If I may ask, has the thought of genetic testing been introduced?
Wendy: No one’s mentioned it. I have thought about it but that’s about as far as it’s gone.
Dr. Elena Kamel: Well what I would like to see is I would like you to sit down with a geneticist who can counsel you on the risks and the impact of getting that information and if you have two daughters, that information is huge for them.
Dr. Elena Kamel: Their screening certainly, the aggressiveness of their screening would be impacted by the fact if you were positive and one would also want to entertain the thought of at some point soon screening them if you were positive. If you’re gene positive, then part of their education is to have them screened because that will impact on how they’re taken care of. My answer would be: If you’re positive and one of them is positive, yes, you would want them enrolled in a very aggressive MRI program. Then they need the counseling of what their choices are if they’re gene positive as they get older.
Dr. Elena Kamel: That may even affect their reproductive choices of when they decide to have children and as we now have technology that allows us to do all kinds of different preservation of ovarian function, that may enter into some of their choices. So my answer to you would be: I’d want your girls already able to do self-breast exams, absolutely now. I would want you to consider being counseled and tested because that information would then impact on the decisions that are and the testing that’s available to them.
Wendy: I had a second question and d**n that chemo brain, I can’t for the life of me remember what it was.
Dr. Elena Kamel: You know what happens is it’ll bounce back and then I’d love for you to call back.
Wendy: If I think about it, if remember what the question was, I will certainly do that. Thank you.
