My sister diagnosed to have metatstatic breast cancer on July 2011 which undergoing surgery on Nov 2011, radiation therapy on Dec 2011 and chemotherapy as well as targeted therapy Herceptin for 18 doses with the start of tamoxifen since January this year. She is ER strong positive, PR negative, C-erb B2 equivocal as shown on surgical specimen. Since the disease showed progression with the increasing in bone metatstasis on spine, shoulder and pelvic region in recent PET scan on June 2012 , oncologist suggested her to do ovarian ablation using RT and using another hormonal drug called AI. As I think that Tamoxifen has no benefit to my sister, then is another hormonal drug may help? My another concern is that ovarian ablation may induce some other adverse effect on the body as it may interfere with the hormonal/eco system inside the body. Besides, my sister already got multiple bone metatasis , one of the side effect of AI may induce osteoporosis, then would it make the bone more osteopenic and therefore easier to break. Do you think ovarian ablation is really got beneficial to my sister? What is the gain in survival rate as well as the psychological benefit with the use of it? I know that you may think that I have too much worry but I really want to think of the best way of treatment to my sister and she can maintain her quality of life during her last time. We are very afraid to do as we think that it might not be useful, so we are now just depending on Chinese medicine alone. Besides, I may start using alternative cancer treatment suggested by Budwig center which based on the alternation of diet and have additonal nutritional supplement for the patient. I know that cancer patient may end in a difficult life. My only wish is that sister can maintain her quality of life and we can live under psychological healthiness. Looking forward for your advice on the future management of my sister.
With many thanks for your advice,
Reply # - August 30, 2012, 06:12 AM
Hello Teresa, I'm very sorry your sister is dealing with such an awful disease.
Please take a few minutes to read the link below and look at the focused breast cancer posts. Dr. Cianfrocca has spent a great deal of time preparing this information to help with many of the common questions people have. They are very easy to read and understand. I hope you can find a better understanding from them.
Too, I will contact her for more input on your questions. You should here back from within 12 hours.
This is a link to Dr. Cianfrocca's introduction to understanding breast cancer
Also, at the top of each page you will find a green bar with one section entitled "Focused Cancer Info" click on it and pick breast cancer for much more information.
Reply # - August 30, 2012, 07:31 AM
Teresa, I'm sorry but our breast cancer specialist will be out of her office today. We will try again tomorrow. I think this will give you a good opportunity to familiarize yourself (if you haven't already) with the information I posted in the previous post.
If your inquiries have changed once you've read more indepth info, great. We're doing our job! Please let us know if they have.
Best to you and your sister,
Reply # - August 30, 2012, 09:55 AM
This being the end of the summer, I suspect Dr. Cianfrocca may well be on vacation or speaking somewhere (she's in the Phoenix area, so perhaps she snuck out to somewhere less likely to be over 100 degrees). However, I can assure you that an aromatase inhibitor, or AI, is really a cornerstone of treatment for patients with hormone receptor-positive breast cancer, particularly after they have progressed on tamoxifen, but this needs to be accompanied by ovarian ablation in premenopausal women. I can't quote you hard stats on the proven survival benefit, but this intervention is really widely accepted as being potentially beneficial for months and sometimes years, and an AI is an oral agent that is also typically pretty well tolerated, primarily with issues of muscle and joint aches as the leading issue (though variable). Though we all have our biases, I would say that both hormone therapy and chemotherapy for metastatic breast cancer has a much more established benefit than the Budwig diet, various self-promoting nutritional supplements, etc. By all means, an informed adult can accept or refuse whatever treatments they want, but I would recommend hormone therapy and potentially chemotherapy (generally with chemo following the time when hormone therapies have done what they can do) are what I would recommend for my own family member, far ahead of other ideas that I think have some marketing appeal but little actual quality evidence to show they really help.
Reply # - August 30, 2012, 06:12 PM
As Dr West said, using a hormonal drug such as tamoxifen or an aromatase inhibitor is standard when the breast cancer is ER-positive. Tamoxifen and AIs work differently and an AI can work even when tamoxifen does not. However, as Dr West said, an AI can only work if your sister is postmenopausal (ovaries not working). In regards to AIs weakening the bones, that is usually not an issue with metastatic breast cancer to bone because we routinely give bone-strenghtening drugs such as xgeva or zometa to those women.
All the best,
Reply # - August 30, 2012, 08:32 PM
As my sister is on bromocriptin for the control on her prolactinoma since 1995, does it affect the function of AI? Besides,if our clinician dosen' t supply us zometa with the combination of AI, can i proceed to AI?
As far as you know, is budwig protocol combination with hormonal therapy beneficial to patient?
With many thanks,
Reply # - August 30, 2012, 09:50 PM
I'll need to see what we can find out about bromocriptine; it doesn't come up as an issue in my lung cancer patients.
It's not that a drug like Zometa is absolutely critical for patients receiving an AI, but it can combat the acceleration of osteoporosis that can occur with hormone therapies. However, it's not our place to make a medical recommendation for whether someone here should or shouldn't pursue a specific treatment.
I am not aware of any actual evidence that indicates a significant benefit of the Budwig protocol with hormone therapy or in metastatic breast cancer in general.
Reply # - August 31, 2012, 01:21 AM
Dear Dr West,
Thank you again for your opinion, may i ask how can i get the information about interaction between AI and bromocriptin.
Reply # - August 31, 2012, 07:53 AM
Hi Tong, I hope you feel more equiped to know your sister's situation and ways that may help. I must confess reading your interaction with these two doctors reminds me how little I know about most of this. As you can see from my signature below my husband has lung cancer. The treatments are very different between lung and breast cancer.
You want to know more about the interaction between Al and bromocriptin. I googled it yesterday but came up with nothing. We will wait and see if Dr. West comes up with anything. Maybe he will also let us know how or where he found his information if he finds it.
The best to you both,
Reply # - August 31, 2012, 07:58 AM
The purpose of a drug like zometa or xgeva for patients like your sister is not so much to prevent osteoporosis due to an AI. The purpose is to prevent fractures and other complications that can occur when cancer is already in the bone. However I want to emphasize Dr West's comment that it is not our place to make medical recommendations since we don't know and are not treating your sister. There is likely a very valid reason that she is not receiving one of these drugs.
Bromocriptine can induce ovulation and therefore make an AI ineffective. This should not be an issue however if her ovaries are radiated or removed. A woman absolutely must be completely postmenopausal to be able to benefit from an AI. Your sister should be sure to discuss any concerns about interactions between any of her medications with all her treating physicians
I am not familiar enough with the Budwig protocol to comment on it.
Reply # - August 31, 2012, 08:07 AM
Thank you so much Dr. Cianfrocca for following this thread. It's so very helpful.
Reply # - August 31, 2012, 04:33 PM
Also, many of these issues, including around bromocriptine, were previously discussed in a thread you had initiated many months ago, at which time, we were fortunate enough to have both Drs. Cianfrocca and Walko comment:
Reply # - August 31, 2012, 05:32 PM
Dearest doctors and modulator,
Thank you again for your valuable comments. I understood more about the direction of the treatment plan.We will have medical consultation next Friday, hoping we can brave enough to decide the treatment.
Fighting against cancer need faith and brave without regret under each decision.
With many thanks,
Reply # - September 2, 2012, 01:37 PM
The result of my sister's recent blood test ready today. The level of "Alkaline Phosphatase,Total" increased dramatically from 43 to 85 IU/L in only three months time. I know that it might due to the increasing bone activity. Recently she got increasing bone pain over metatstatic area. May i ask whether AI shown effectiveness in controlling bone metatstasis? Or only RT can work? Sorry for asking so much as I really want to decide the best trestment plan for my lovely sister.
With many thanks,
Reply # - September 2, 2012, 01:47 PM
AIs, like other hormone therapies, can work very well against bone disease. In general, if they are going to be effective, they tend to be similarly effective throughout the body. The brain is one area where many of our systemic therapies don't penetrate, but otherwise, systemic therapies, whether chemotherapy or hormone therapy or targeted therapy, often works comparably on lesions throughout the body.
Reply # - September 2, 2012, 09:56 PM
I agree with Dr. West's comments.
All the best
Reply # - September 8, 2012, 07:20 PM
My sister now decide to proceed to ovarian ablation , the procedure will start one week later. As she got severe bone pain now, clinican suggested her to have Zometa 4mg infusion last Friday. After that, she always felt very high in body temperature, sometimes around 38.7 and got muscle pain, is it a common side effect of Zometa? If yes, then how long does this symptom fade out?
Her recent blood result shows Alkaline Phosphatase, Total 85IU/l (normal range is 33-84) , Calcium 2.41mmol/L ( normal range 2.15-2.55).
The clinican prescribed her calcium carbonate tablet 1500mg daily. What is the use of this calcium tablet? As her calcium level is still within normal range, does the dosage of calcium tablet each day will make her body receive too much calcium? If she really need such supplement, anything can her to lower the adverse effect of the possibility of over calcium.
With many thanks
Reply # - September 8, 2012, 07:32 PM
And what can we do to lower the adverse effect of Zometa if zometa infusion is a must for my sister.
Reply # - September 8, 2012, 08:34 PM
The acute effects like fever and pain/malaise tend to go away after the first 2-3 infusions. I don't know of any specific intervention for them -- you can give something like Tylenol just to help with the symptoms, but they tend to diminish with the next few infusions.
The calcium is given because Zometa (zoledronate) shifts calcium from the blood into the bones. Without taking the supplemental calcium, far more people on Zometa will develop a low blood calcium level. In fact, Zometa is a leading treatment for high blood calcium levels, which can occur with cancer and a few other conditions. It's important to follow the calcium levels to ensure that a person's levels aren't getting too high or too low, but it's very standard to have a person on Zometa or XGEVA take supplemental calcium and vitamin D.
Reply # - September 8, 2012, 09:41 PM
Dear Dr west,
As our clinican did not prescribed any Vit D, do i need to buy and what dosage you recommend?
You have mentioned that the adverse effect will go away after two to three infusion. As my sister will have infusion in four weeks time, which means she have such symptoms lasting for two months?
Thank you again for your information.
Reply # - September 8, 2012, 10:15 PM
The side effects you describe do occur with zometa, usually occur with the first few infusions and usually only last for a few days. There is no specific treatment for the symptoms, usually Tylenol or drugs like motrin are used for symptomatic relief.
Reply # - September 9, 2012, 03:24 AM
Apart from calcium 1500 mg daily, does she need vitamin D supplement as our clinican did not prescribe for her.
Reply # - September 9, 2012, 08:29 AM
It is up to her physician to decide if any additional vitamin supplementation is appropriate for her.
Reply # - November 4, 2012, 01:03 AM
My sister is now already stop taking tamoxifen as she got progression since july 2012. She undergone RT over pelvic region for pain relief and ovarian ablation. Today she starts new therapy of Xeloda 1300 mg daily ( 650 mg for each dose), and Lapatinib 1250 mg daily. Plus Zometa injection in six week times.
May i ask what i need to be aware if when taking those drugs? My sister now will take xeloda 650 mg just after breadfast and dinner and take Lapatinib at around 11:00 am and bromocriptin ( for prolactinoma) and Calcium carbonate tablet 1500 mg after lunch. As i quite afraid of food / drug interaction, may i ask what kind of food i must not eat when she is in this tx plan. I know that folic acid is a concern for xeloda, however many food contain folic acid , then what food i need to get rid of ?
thank you for your advice
Reply # - November 4, 2012, 06:00 AM
Tong, I'm very sorry your sister has progressed on her former therapy. I know it is usually very difficult to have to move onto another treatment plan. But I hope the radiation has helped with the pain and that the new treatment works for a long time.
There are no interactions with food that you must be careful of with xeloda. The interaction with folic acid maybe when given in a concentrated pill form. But as it appears in food is fine. This info is from the website linked to below and is very good for searching for info on drugs such as precautions with food. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001043/#a699003-precautions
From the same website I found your sister should not eat or drink grapefruit juice with lapatinib.
About bromocriptine I found this,
"What special dietary instructions should I follow?
Talk to your doctor about eating grapefruit and drinking grapefruit juice while taking this medicine.
Be sure to follow all exercise and dietary recommendations made by your doctor or dietitian.
Since she can't eat grapefruit with lapatinib, she won't need to worry about that. But I wonder what is meant by, "Be sure to follow all exercise and dietary recommendations made by your doctor or dietitian."
Were there any special instructions?
I will ask our pharmacologist to weigh in here.
Reply # - November 4, 2012, 07:49 AM
The most common side effects with xeloda and lapatinib are nausea, vomiting and diarrhea, particularly diarrhea. Also, redness and peeling of the hands and feet, otherwise known as "hand-foot syndrome", is also common. If she experiences these or any other side effects, she should let her Dr know as soon as they occur since they can usually be managed by changing the dose.
I wish her and you all the best,
Reply # - November 4, 2012, 10:44 AM
Just to explain a bit further...both bromocriptine and lapatinib are broken down in the body by the same liver enzyme, known as "CYP3A4". Grapefruit juice has been known to inhibit this enzyme and thus can increase the concentrations of the drugs and increase the risk of side effects. I definitely recommend avoiding it.
Bromocriptine and Xeloda should both be taken with food, Lapatinib should be taken on an empty stomach. This is very important since taking lapatinib with food can also increase the amout of the drug that gets into the body and increase the chance of drug toxicities.
Aside from avoiding nicotine and alcohol, I cannot find any other dietary recommendations. I agree with stopping any folic acid supplements (including multivitamins) as this was shown to increase the toxicity of the Xeloda (dietary folate is fine but I would not purposely increase the intake since overall folate stores in the body dictate these type of increase toxicities). Foods naturally high in folate (that I would recommend in moderation are green leafy vegetables, beans, asparagus, avocados, brussel sprouts, certain types of nuts and corn).
Reply # - November 10, 2012, 09:42 PM
Dear Dr Walko,
May i ask if i take Lapatinib just before sleep at night so as to ensure that no food in stomach and then take Zoloda in the morning just after breadfast and then take Bromocriptin and Calcium after lunch and take Zoloda again after dinner. Is the way of taking medication the best? Thanks for your comments.
With best regards,
Reply # - November 10, 2012, 09:46 PM
Dear Dr Walko,
Sorry for the typo error of Zoloda to Xeloda
Reply # - November 10, 2012, 09:57 PM
I'm afraid it's really not appropriate for us to make specific recommendations like this. We are happy to provide general information for a broad group of people about issues that affect many people, but for very specific, individual situations, you'll need to speak with your own medical team to discuss specific recommendations.