Ask the expert: Q & A on breast cancer, exercise and diet – Dana-Farber Cancer Institute

Jennifer Ligibel, MD

Dana-Farber Cancer Institute partnered with CancerConnect so that patients could ask Jennifer Ligibel, MD, their questions about breast cancer, exercise, and diet. Dr. Ligibel is a medical oncologist in the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute. She is also an assistant professor of medicine at Harvard Medical School. Dr. Ligibel has authored several papers on the role of lifestyle factors and breast cancer, including a recent study on the impact of exercise on reducing drug-related joint pain.

Lifestyle factors, breast cancer and depression

Q: Are there any ‘lifestyle’ factors — diet/nutrition — that might help with anxiety and depression? (I didn’t seem to have these issues until after my breast cancer diagnosis. )

Dr. Ligibel: There are many studies that show that exercise has a positive impact on anxiety and depression. Studies suggest that fairly modest amounts of exercise can improve mood. We generally recommend that women start slowly and check with their physicians
before starting an exercise program, but research suggests that moderate physical activity, such as walking, is safe for most breast cancer survivors and can have many positive health effects.

Although information is more limited in cancer survivors, there is also evidence that weight loss can have a positive effect on depression in women.

Health benefits of green tea or turmeric

Q: What do you think of the health benefits of green tea, specifically Matcha green tea? Also, what about turmeric?

Dr. Ligibel: There is a lot of interest in the health benefits of specific supplements, but not much evidence that these products have any benefits for cancer survivors. Green tea has been studied as a potential nausea-preventing intervention, but the
results of these studies have been mixed. Some preliminary results from animal studies have suggested health benefits from turmeric, but it is too early to know whether either of these supplements will eventually be shown to be beneficial for cancer
survivors.

It is important to note that green tea and turmeric, like most supplements, are foods rather than medications. This means that they are not regulated by the FDA. Companies that produce them can make all kinds of health claims as long as they include the
statement that the claims are not supported by the FDA. This can be confusing for patients, as many of these products are marketed as “cancer-fighting.”

Optimal types of fat

Q: I’m a 9-year breast cancer survivor. I’ve seen studies which favor a low-fat diet to reduce the risk of breast cancer and recurrence. These studies do not specify types of fat. Do they look at or compare trans fats; fat from meat, dairy, and processed foods; fats from nuts, seeds, olive oil, coconut oil, etc. ? I am mostly vegetarian, and my diet is actually fairly high in fat since my protein comes from nuts, seeds, and some eggs. What is your sense about high fat vs low fat and if the types of fats consumed contribute to higher or lower risk? I’d like to believe that healthy fats are not risk factors! Thank you.

Dr. Ligibel: The study that showed that eating a low-fat diet reduced the risk of breast cancer recurrence — called the Women’s Interventional Nutrition Study or “WINS” — was largely conducted in the 1990’s, when there was not as much of a focus on different
types of fat. Thus, there is, unfortunately, not a lot of evidence to provide an answer for your question about the impact of different types of fat on breast cancer recurrence rates.

However, in the years since the WINS study, research in other diseases, such as heart disease, has shown that all fats are not equal in terms of the impact that they have on a person’s risk of developing different diseases. There is also evidence from
population studies to suggest that individuals who consume healthy fats seem to be at lower risk of some kinds of cancers, although we can’t determine if there is a cause-and-effect relationship between the types of fats a person eats and their risk
of cancer from this kind of study.

A number of ongoing studies are looking at whether there is a “best” diet for breast cancer survivors, but evidence is not conclusive at this point. Some evidence suggests that keeping weight in a good range might be more important than specific dietary
ingredients. The National Heart, Lung and Blood Institute, a group that prepares many of the recommendations about weight and diet for the US population, currently supports the use of a number of diets to maintain a healthy weight.

Thus, there is no simple answer to your question, but if your diet is successful in keeping your weight in a good range, it is likely a reasonable plan for you to continuing following.

Exercise and health benefits

Q: I have a very physically demanding job where I move at a great clip outdoors for at least 3-4 hours each day. When I am done work I have no energy for formal exercise (especially since BC treatment and Tamoxifen), just stretching or a little yoga. Is this enough?

Dr. Ligibel: Studies have shown that physical activity, no matter how it is achieved, is linked to better outcomes in breast cancer. Sometimes it is hard to know how much activity a person is doing as part of a work day, so one way to make sure that you
are doing enough exercise is to wear a pedometer to track the distance you walk each day as part of your job and during your leisure time. You should aim for 10,000 steps per day. If you are accomplishing this much walking during your average work
day, you are likely achieving enough physical activity to provide health benefits.

Weight gain/weight loss

Q1: I am taking anastrozole. It is very difficult to lose weight. Do you have any suggestions as to offsetting the effects of this medication on weight loss? What should the majority of the diet include, and what should be omitted in order to lose weight?

Dr. Ligibel: There are many reasons why woman with breast cancer gain weight or have difficulty in losing it after breast cancer diagnosis. Some women go through menopause as a result of chemotherapy or other cancer treatments. The average woman who undergoes
a “normal” menopause (not due to cancer treatment) will gain 5-10 pounds in the years after her menstrual cycles stop. This weight gain can be even greater when it occurs suddenly as a result of breast cancer treatment. Many women also feel fatigued
as a result of their breast cancer therapy and become less physically active. Studies have shown that weight gain is not increased in women taking tamoxifen or anastrozole, but it is harder to study the effects of these drugs on a woman’s ability
to lose weight.

Regardless of the reasons for weight gain, weight loss requires calorie reduction. This can be accomplished in many ways. A diet that is low in fat and high in fruits and vegetables has been a standard for weight loss for many years, but low-carbohydrate,
vegetarian, low-glycemic index, and Mediterranean diets can also be used to lose weight. Many people find keeping a journal of what you eat and drink is a first step to understanding your eating patterns. You might be surprised by “hidden” calories
you are consuming. Some people also find a structured meal plan to be helpful when starting a weight loss program. Commercial programs can also be useful to teach you how to recognize where your calories are coming from and create new eating patterns.

Q2: I was diagnosed with Stage 4 inflammatory breast cancer last July at the age of 31. I am currently on maintenance treatment and need to lose about 40-50 pounds. I lost a lot of my strength during treatment, and I am a pretty picker eater who hates to cook. The thought of having to lose that much weight is so overwhelming, even though I know it will help to decrease recurrence. Can you tell me what 2 or 3 things (whether nutrition- or exercise-related or both) I can start with?

Dr. Ligibel: It can be daunting to know where to to start when you would like to lose a lot of weight. We find that people are most successful when they start with an attainable goal. Studies have shown that smaller amount of weight loss, 5-10% of your
starting body weight, can have many benefits, even if people can’t lose 50 pounds.

I would recommend that you start with keeping track of what you eat for a week. Look for “hidden” calories like soft drinks, alcoholic beverages, or juices, which are high in calories and not filling. Processed foods and sweets are also very high in calories
with less nutritional value. Try to limit the amount of these you consume.

Start slowly with exercise if you have not been active. Make a plan to start with walking at a moderate pace for 10-15 minutes three times per week and gradually increase to every day, and then for longer periods of time.

Joining a group program (like Weight Watchers) can also be helpful for some people, or working with a weight loss “buddy,” a person with whom you can explore low-calorie recipes and exercise, works for some people.

Soy

Q: My question concerns tamoxifen, nutrition, and products that contain soy. I was diagnosed 1/19/12 with invasive ductal carcinoma PR+ ER+ HER2+ and received bilateral lumpectomies, no lymph node involvement either side, 16 taxol/herceptin weekly infusions, 33 radiation rounds, 4 A/C, and the year’s course of herceptin. I have been taking tamoxifen for the last year and a half and have read conflicting information about soy products.

Although my hot flashes have subsided a bit, they do keep waking me up at night. I realized that many protein-rich yogurts and nutrition bars have traces of soy in them. I considered soy as a supplement initially but decided against it, since the research appeared to be “out” on the final word (soy mimics estrogen but does it tend to promote my type of estrogen-driven cancer?). What are your thoughts on how much soy is good or harmful in contributing to recurrence?

Dr. Ligibel: There is a lot that we do not know about the relationship between soy and estrogen-driven breast cancers. Early studies showed that high doses of soy led to breast cancer formation in lab experiments, but it is not clear whether this amount
of soy was remotely similar to what a woman could consume through diet. A number of recent reports looking at the diet patterns of women in Asia and the US suggested that the risk of breast cancer recurrence was not increased by soy intake. Although
there are some difficulties in using this information to completely conclude that soy intake is “safe” for breast cancer survivors, most experts at this point feel fairly confident that some soy intake in the diet is unlikely to be dangerous for breast
cancer survivors. This means that it is likely not necessary to be reading food labels to avoid products containing soy, but I would personally stop short of endorsing soy as a supplement for a breast cancer survivor.

Foods to avoid

Q: Are there any specific foods we should stay away from specifically if you are positive to estrogen?

Dr. Ligibel: There is a lot of debate regarding the use of soy products in women with an estrogen-positive breast cancer (see question above regarding soy). Other foods also contain phytoestrogens, which are plant-based substances that are similar in
structure to hormonal estrogen but come from plant sources. There is not a lot of definitive evidence about the risks or benefits of any of these products in women with breast cancer, but as a general rule, the moderate amounts of most of these substances
in foods are considered safe.

Therefore, I would not say that there is good evidence that any food needs to be avoided for women with breast cancer, but soy products, flax seed, and alcoholic beverages (which also increase estrogen in some situations) should be taken in moderation.

Diet/exercise resources

Q: Do you have any recommendations for books or resources that would be a good guide to helping with navigating the best things to do for nutrition/exercise after breast cancer

Dr. Ligibel: The American Cancer Society has developed a set of diet and nutrition guidelines for cancer survivors that is available on its web site.

The American Society of Clinical Oncology has also made “Obesity and Cancer” one of its primary initiatives this year and will be releasing a set of materials about weight, nutrition, and diet for cancer survivors in the next few weeks. These materials
will be available in print and online through their website, www.cancer.net.

Neuropathy

Q: Can diet or exercise help neuropathy from chemo?

Dr. Ligibel: There is not a lot of evidence that diet or exercise can help neuropathy from chemotherapy. There are studies looking at glutamine, a supplement, but this product seems to work best while an individual is receiving chemotherapy treatments.
Ongoing studies are looking at acupuncture as a potential treatment for chemotherapy-induced neuropathy.

Prevention

Q: What should we tell our daughters, sisters, mothers, wives, girlfriends about diet/exercise to help them prevent breast cancer?

Dr. Ligibel: There is a lot of evidence that a “healthy” lifestyle — keeping your weight in a healthy range, exercising regularly, and consuming a diet that is higher in fruits and vegetables and lower in fat — could reduce the risk of developing breast
and other cancers. This doesn’t mean that these behaviors are 100% effective in preventing breast cancer or that people who don’t do any of these things will necessarily develop breast cancer, but the evidence does suggest that maintaining a healthy
lifestyle should be part of a cancer prevention strategy.

General nutrition and physical activity recommendations from the American Cancer Society for Cancer Prevention include the following:

1. Stay active: perform at least 150 minutes of moderate-intensity aerobic exercise each week, such as walking at a brisk pace.
2. Consume a healthy diet that is low in fat and high in fruits, vegetables, and fiber.
3. Maintain your weight in a healthy range, and attempt weight loss if you are overweight or obese.
4. Limit alcohol to no more than 1 drink per day for women and 2 drinks per day for men.

Immune system

Q: My questions are: 1) Does boosting the immune system help prevent breast cancer? 2) Is there a diet that boosts the immune system (I am a vegetarian)? 3) I just read something about a study showing that a vegetarian diet is linked to poor health — what does this mean to me as a breast cancer survivor?

Dr. Ligibel: There is a lot that we do not know about the biology that links nutrition and exercise to breast cancer. Some scientists have hypothesized that the immune system may play a role in this connection, but there is little conclusive evidence.
Similarly there is not much known about how specific foods or supplements affect the immune system, so I would not recommend a particular diet to enhance the immune system.

Finally, vegetarian diets can be very healthy, as long as they contain a good balance of essential nutrients. It can be hard to consume enough protein, for example, for individuals who maintain a vegetarian diet. As long as you ensure that you consume
a balanced diet, there is no reason why a vegetarian diet would be unhealthy. If you have specific concerns regarding your diet, I would recommend meeting with an oncology nutrition specialist.

Diet/exercise to help with fatigue

Q: I have metastatic breast cancer — have been on multiple treatments for what seems like forever. I am grateful to be alive but am beginning to feel what I assume are the cumulative effects of all of my treatments. Are there any recommendations for food or exercise that might help with my fatigue?

Dr. Ligibel: There is, unfortunately, very little information about the role of diet and exercise in patients with advanced breast cancer. However, exercise has been shown to be an effective way to reduce fatigue in many studies performed in women with
early-stage cancer undergoing chemotherapy. There have been a few small studies of moderate-intensity exercise in women with advanced cancer that suggest that exercise is safe and may have benefits. I would recommend asking your doctor about starting
an exercise program. As long as he or she is supportive, I would recommend slowly starting to exercise. It is important to set reasonable goals, and begin slowly. If you have not been exercising at all, even just walking around the block once per
day can be a good start. Build up the time that you spend exercising each week, and you will likely begin to see some benefits in terms of your energy level.

Maca

Q: I am taking femara for ER & PR + stage III breast cancer. Is it safe to take maca to help manage side effects of the AI?

Dr. Ligibel: There is unfortunately no safety data for this supplement for women with breast cancer.

Please note: The information above is general in nature and is not intended as a guide to self-medication by consumers or to substitute for advice provided by your own physician or other medical professional.

New study in mice helps scientists understand how tamoxifen reduces food intake and prevents fat accumulation, insulin resistance, and fatty liver deposits, according to a report — ScienceDaily

Tamoxifen, a selective estrogen receptor modulator, is the gold standard for endocrine treatment of estrogen-receptor positive breast cancer. Tamoxifen is also known to have metabolic effects. A new study in The American Journal of Pathology reports that the drug also prevents obesity, fatty liver, and insulin resistance in female mice who were fed a high-fat diet and whose ovaries had been removed. The study was also able to pinpoint which estrogen receptors underlie these protective effects, opening up possibilities for new therapies to treat these conditions.

“For the past two decades, estrogen receptor α (ERα) has been identified as a key regulator of energy and glucose homeostasis and consequently proposed as a promising target to develop new therapeutic strategies to fight against obesity-related metabolic disorders, such as type 2 diabetes and nonalcoholic fatty liver disease. However, understanding the mechanisms of the metabolic protection conferred by ERα activation has been a crucial challenge,” explained Pierre Gourdy, MD, PhD, INSERM UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse (France).

Mice whose ovaries had been removed were fed a high-fat diet and treated with either tamoxifen or a placebo for 12 weeks. Investigators found that tamoxifen prevented weight gain, which was attributed to a significant reduction in food intake compared with controls. Tamoxifen-treated mice were less likely to develop glucose intolerance, insulin resistance, as well as deposits of fat in the liver.

The researchers knew that ERα exerts its effects through two activation functions known as ERα-AF1 and ERα-AF2, directly involved in the transcriptional regulation of gene expression. Tamoxifen acts as an ERα-AF1 agonist or an ERα-AF2 antagonist according to its tissue/organ targets. To better understand the molecular mechanisms underlying tamoxifen’s metabolic effects, the scientists treated mice genetically bred to be deficient either for the entire ER-α (ERα-/-) or just ERα-AF1 (AF1-/-°) with either tamoxifen or placebo and compared the results to wild-type mice (ERα+/+ or AF1+/+) that underwent similar treatment. All the mice were fed a high-fat diet.

Prevention of high-fat diet-induced glucose intolerance, insulin resistance, and fatty liver (steatosis) by tamoxifen was abrogated in mice with ERα-AF1 deficiency. According to Dr. Gourdy, “Altogether, these data indicate that activation of ERα-AF1 by tamoxifen is sufficient to elicit metabolic protective effects in vivo.” In addition, the researchers found that selective activation of ERα-AF1 by tamoxifen also regulated most hepatic metabolic genes.

“Altogether, the present study first suggests that the metabolic effects of tamoxifen, as well as other selective modulators of ERα, deserve to be cautiously reconsidered in women, according to their menopausal status. It also opens new perspectives for the treatment of obesity-related complications toward a pharmacologic strategy eliciting selective ERα-AF1 activation,” noted Dr. Gourdy.

Story Source:

Materials provided by Elsevier Health Sciences. Note: Content may be edited for style and length.

How To Beat Weight Gain On Tamoxifen (A Success Story!)

If you are taking tamoxifen, you have A LOT of questions. And when it comes to weight loss, these two probably rank near the top:

1. Will I gain weight on tamoxifen? And,
2. If I do, is there anything I can do to stop it—and actually lose weight?

Both of these are valid questions. You’ve heard so many women talk about how they put on weight while on tamoxifen.

Kathy, a MyBodyTutor success story, said, “My oncologist told me he’d never seen any women on tamoxifen lose weight.” 

Luckily, that wasn’t the case. She has a happy and powerful story!

(Keeping reading, we’ll pick Kathy’s story back up soon.)

Is weight gain something you’re struggling with now?

If so, we’re going to talk about how you can challenge your beliefs and assumptions and beat this extra weight.

But first, let’s start with:

What is Tamoxifen?

Tamoxifen is a medication prescribed for breast cancer treatment. And, as a preventative measure for women at high risk of developing breast cancer.

It works by attaching to estrogen receptors and blocking the effects of estrogen on the breast tissue. So it helps prevent the growth of breast tumors that need estrogen; which, according to the National Cancer Institute, is about 80%.

The benefits of tamoxifen are tremendous, but it’s not without risk of side effects.

Is Weight Gain A Side Effect?

A major concern among women on tamoxifen is if they will gain weight. And whether we’re talking about tamoxifen (or a countless number of other medications), weight gain is possible.

Here are just a few potential side effects from Breastcancer.org:

• Hot flashes
• Blood clots
• Mood swings
• Depression, and
• Weight gain

The Mayo Clinic also details weight gain or loss as a possible side effect.

So the risk of gaining weight is very real.

But how common is it?

To answer that, we’ll dive into the research. And, the study we’re going to look at is one of the most comprehensive out there.

This women’s healthy eating and living (WHEL) study spanned a six-year period and included more than 3,000 breast cancer survivors—ranging in age from 27 to 74.

Among the study’s goals, one was to determine if tamoxifen had an effect on weight change after a breast cancer diagnosis.

The study had two key conclusions:

1. That there was no link between weight gain and tamoxifen.
2. However, chemotherapy is significantly associated with weight gain.

So, to answer the question: Should I worry about gaining weight on tamoxifen?

The answer is:

Weight gain is a potential side effect of tamoxifen. However, most studies suggest there is no direct link.

But,

An unfortunate fact remains. Many women will gain weight after diagnosis.

In fact, according to an article published in the World Journal of Clinical Oncology, you can expect to gain anywhere from 2 to 11 pounds.

Right now, you may be asking…

If there is no link between tamoxifen and weight gain, 

why am I gaining weight?

And the answer is…there is no single aspect we can put our finger on. It is a combination of many, many reasons.

1.)

Chemotherapy

In the WHEL study we looked at earlier, we learned that chemotherapy has a significant association with weight gain. But, there are other reasons to consider as well.

2.)

Emotional Stress

Beyond the initial shock of a cancer diagnosis, there is the inevitable stress, anxiety, and worry that go with that kind of life-changing news.

• How will I take care of my family during treatment?
• What will I do about my job?
• How will I pay for all this?
• What happens if cancer returns?

Your life just got turned upside down, and there are a million worries you have today that you didn’t have yesterday. Emotional stress can play a huge role in contributing to weight gain.

3.)

Metabolism

Your metabolism (the rate at which you burn calories) slows as you age. So naturally, losing weight becomes much more difficult than it once was. Luckily, there are ways, like exercise, that can help you battle a slowing metabolism.

Which brings us to the next factor…

4.)

A Lack Of Physical Activity

Studies show that physical activity will decline after a breast cancer diagnosis, which is completely natural. You are recovering from surgery or chemotherapy.

However, less activity means fewer calories burned, which can easily translate into increased weight.

If we consider the magnitude of the situation, combining:

• A cancer diagnosis,
• An intensely emotional situation (worry, anxiety, and fear),
• A lack of physical activity, and
• The treatment itself.

It is entirely understandable why one would gain weight.

But, what can we do about it?

How To Beat Weight Gain Following A Breast Cancer Diagnosis.

Make no mistake, losing weight is a challenge even under normal circumstances. And it can be even harder after breast cancer.

But it is possible, and you CAN do it.

And where we need to start is with challenging our assumptions.

1.) Challenge Your Assumptions

When you hear you will gain weight after a diagnosis and not many women will ever lose weight enough times, that belief starts to solidify.

Remember when I mentioned earlier that Kathy said, “My oncologist told me he’d never seen any women on tamoxifen lose weight.”

It’s easy to start believing that is true, especially when you keep trying to lose weight without seeing any results.

So we have got to expect a different result. Kathy didn’t believe she could lose weight…

AND YET SHE DID!

So if you’re thinking, “There is no way I am going to lose this weight!”

I ask, what emotion does that thought trigger?

…Is it anger?
…Dispare?
…Hopelessness?

And if you feel hopeless, what action will you most likely take? You guessed it…you probably won’t take action.

So now I ask, How can you challenge this belief? How can you trigger a new emotion?

Maybe it’s thinking like this:

Losing this weight is a challenge, but I will succeed DESPITE this diagnosis. Not only for my family, but for myself and for others. I will be an inspiration for other women in my situation.

These thoughts trigger feelings of hope and determination, right?

And when you are determined, like I know you are and like Kathy is, you will take action. And actions lead to results.

2.) Describe Your Why

The reason “why” you want to lose weight is the fire that fuels your motivation.

Weight loss after a diagnosis can be a long road with many bumps and discouragements along the way. And that’s why it is absolutely critical to describe why you want to lose weight, so you can turn to it when times get tough.

What is your why?

• Are you doing this to regain control?
• To improve your self-image?
• To prove to yourself that you can?

Loving the way you feel and look contributes so much to your overall well-being.

BUT, IT’S SO MUCH MORE THAN THAT…

It’s about the confidence you gain. It’s about the new outlook on life you get. It’s about realizing your beliefs and assumptions were just that…beliefs and assumptions.

It’s about a new attitude of, “What’s next?” because when you conquer yourself, you truly feel like you can overcome anything, and that is life changing!

Here’s how gaining control changed Kathy’s life.

“In one week my husband and I are having the holiday of our dreams. We are going to Canada (very long plane ride for us from Sydney!) and doing 2 weeks of walking in the Rockies. I am the most fit and able I have been since cancer 5 years ago.”

This is the power of why!

3.) Conquer Emotional Eating

Emotional eating is when we eat outside of being physically hungry. It’s when we turn to food to fill a void or to numb our emotions.

This is an important concept, especially now. Earlier, we spoke about anxiety, worry, and despair. So often, eating is a way to comfort ourselves and how to cope with these negative emotions.

So not only do we have to question our beliefs, we must question our hunger.

If you suspect your hunger might be emotional, ask yourself what you are really hungry for?

• Perhaps, it’s been a stressful day.
• Maybe we’re seeking the pleasure of food.

Sometimes, it can be very helpful to explore what it feels like to have the need go unmet by simply writing about it. Many clients have reported that this eases the discomfort tremendously, and of course, like all discomfort (and pleasure) it will subside.

Helping clients overcome emotional eating is a big part of what we do.

4.) Get Support

Deciding to lose weight is a big step in putting your health first. And you may genuinely believe you cannot beat this extra weight.

That’s why it is important to have someone on your side. Someone in your corner that will give you daily support and motivation.

Kathy points out, “The daily feedback was key to getting me over the line! I genuinely was not sure I could lose weight.”

And this exactly what we do at MyBodyTutor, we are there with you every step of the way.

• We have countless examples of people who were told they could expect to gain weight and to just accept this fact, but didn’t, like Amy.
• Countless examples of people who just believed their body was stuck like Laurie.
• Countless examples of people who thought it was “genetically impossible” to have the body they wanted like Matt.

If you need help losing weight and building a plan that will work for you, this is what we live for!

When you join MyBodyTutor, you’ll get practical, real-life support from coaches that understand the struggles of life.

And if you have questions about the program, email me. I read and respond to every email I get.

More Stories For You

Cancer of the Breast | About Tamoxifen

More than 20 years ago oral tamoxifen was introduced to treat early and advanced breast cancers. Today it is also prescribed after primary treatment for early-stage breast cancer. The drug acts to block the female hormone estrogen, which promotes cancer growth.

Medical oncologists at Beaumont constantly monitor new drugs and protocols to find the best individual treatment plan for each patient. Beaumont’s clinical trials are so well respected that the National Cancer Institute (NCI) has designated the hospital as a Community Oncology Research Program, where results from leading-edge clinical studies are integrated into the standard of care.

Today’s research is every bit as crucial as the studies that first established the value of tamoxifen in treating breast cancer. As new information gleaned from research is quickly applied, patients benefit from the exciting discoveries that improve breast cancer diagnosis and treatment.

What is tamoxifen?

Tamoxifen (Nolvadex

^®

) is a drug that reduces and/or stops the effects of estrogen (a female hormone) in the body. It was developed over 20 years ago and has been used to treat both advanced and early stage breast cancer. More recently, tamoxifen is being used as an adjuvant, or additional, therapy following primary treatment for early stage breast cancer.

Tamoxifen is taken by mouth in tablet form and is usually prescribed as a single daily dose.

How is tamoxifen used for breast cancer treatment?

As a breast cancer therapy, tamoxifen works against the effects of estrogen, which has been shown to promote the growth of breast cancer cells. It is often called an “anti-estrogen.”

• As a treatment for breast cancer, the drug slows or stops the growth of cancer cells that are already present in the body.
• As adjuvant therapy, tamoxifen has been shown to help prevent the development and recurrence of breast cancer. Research has shown that when tamoxifen is used as adjuvant therapy for early stage breast cancer, it not only prevents the recurrence of the original cancer but also prevents the development of new cancers in the opposite breast, in many cases.
• As a preventative therapy, tamoxifen has been shown to help prevent the development of breast cancer in high-risk women. The Study of Tamoxifen and Raloxifene (STAR) trial, which evaluated the use of tamoxifen and another drug, raloxifene, in preventing breast cancer, found that raloxifene decreased the risk of invasive breast cancer equally as well as tamoxifen, but it did not protect as well against non-invasive cancers, such as lobular carcinoma in situ(LCIS) or ductal carcinoma in situ (DCIS). Raloxifene did, however, have a lower risk of uterine cancer and blood clots in the legs or lungs, compared to tamoxifen.

Additional benefits of tamoxifen

While tamoxifen acts against the effects of estrogen in breast tissue, it acts like estrogen in other body systems. According to the National Cancer Institute, women who take tamoxifen may share many of the beneficial effects of menopausal estrogen replacement therapy, such as a lowering of blood cholesterol and a slowing of bone loss (osteoporosis).

What are the possible side effects of tamoxifen?

Women considering taking tamoxifen should consult their physician. Different women experience side effects differently. Some of the more common side effects may include:

• hot flashes and sweats
• nausea and vomiting
• loss of appetite
• weight gain
• vaginal discharge
• irregular menstrual cycles
• fatigue
• headache
• vaginal dryness
• irritation of skin around the vagina

Less common side effects may include:

• blood clots
• depression
• eye problems
• uterine cancer
• other cancers

Some physicians and researchers caution, however, that tamoxifen therapy may not be appropriate for all women who are at increased risk for breast cancer. Consult your physician for more information regarding your individual case.

Other related medications

Medications recently approved by the US Food and Drug Administration (FDA), called aromatase inhibitors, are used to prevent the recurrence of breast cancer in postmenopausal women. These drugs, such as anastrozole (Arimidex®), letrozole (Femara®), and exemestane (Aromasin®), prevent estrogen production. Anastrozole is effective only in women who have not had previous hormonal treatment for breast cancer. Letrozole is effective in women who have previously been treated with tamoxifen. Possible side effects of these drugs include osteoporosis or bone fractures.

Another new drug for recurrent breast cancer is fulvestrant (Faslodex®). Also approved by the FDA, this drug eliminates the estrogen receptor rather than blocking it, as is the case with tamoxifen, letrozole, or anastrozole. This drug is used following previous antiestrogen therapy. Side effects for fulvestrant include hot flashes, mild nausea, and fatigue.

Tamoxifen – Chemotherapy Drugs – Chemocare

Chemocare.com

Care During Chemotherapy and Beyond

(ta MOKS i fen)

Trade names: Nolvadex^®

Chemocare.com uses generic names in all descriptions of drugs. Nolvadex is the trade
name for tamoxifen. In some cases, health care professionals may use the trade name
Nolvadex when referring to the generic drug name tamoxifen.

Drug type: Tamoxifen is a hormone therapy. This medication
is classified as an “anti-estrogen” (for more detail, see “How this drug
works” section below).

What Tamoxifen Is Used For:

• Tamoxifen may be given as adjuvant therapy (treatment after successful surgery)
  in women or men with lymph node negative or lymph node positive breast cancer.
  Cancers with positive estrogen and progesterone receptors are more likely to benefit
  from tamoxifen. Tamoxifen reduces the risk of getting breast cancer in the
  opposite breast.
• Tamoxifen may be prescribed in metastatic (cancer that has spread) breast cancer
  in both women and men.
• Tamoxifen may be prescribed in women with ductal carcinoma in situ (DCIS) who have
  completed surgery and radiation therapy. Tamoxifen may reduce the risk of
  invasive breast cancer. Risks and benefits of tamoxifen therapy should be
  discussed in this setting.
• Tamoxifen may be prescribed for women at high risk of breast cancer to reduce the
  incidence of developing breast cancer. Risks and benefits of tamoxifen therapy
  should be discussed in this setting.
• Tamoxifen may also be prescribed for treatment of ovarian cancer.

Note: If a drug has been approved for one use, physicians may elect to use this same drug for other problems if they believe it may be helpful.

How Tamoxifen Is Given:

• Tamoxifen is a pill, given by mouth. The pill should be swallowed whole.
• Tamoxifen should be taken at about the same time each day with a full glass of water.
  If you miss a dose, do not take a double dose the next day.
• The amount of tamoxifen that you will receive depends on many factors, including
  your general health or other health problems, and the type of cancer or condition
  being treated. Your doctor will determine your dose, schedule and duration
  of treatment.

Side Effects:

Important things to remember about the side effects of tamoxifen:

• Most people do not experience all of the side effects listed.
• Side effects are often predictable in terms of their onset and duration.
• Side effects are almost always reversible and will go away after treatment is complete.
• There are many options to help minimize or prevent side effects.
• There is no relationship between the presence or severity of side effects and the
  effectiveness of the medication.

The following side effects are common (occurring in greater than 30%) for
patients taking tamoxifen:

• Hot flashes (see sexuality)
• Vaginal discharge (see sexuality)
• Swelling (fluid retention in feet, ankles, or hands)
• Loss of libido (particularly in men) (see sexuality)

These side effects are less common side effects (occurring in about 10-29%)
of patients receiving tamoxifen:

• Nausea
• Menstrual irregularities
• Vaginal bleeding
• Weight loss
• Mood changes (see anxiety and/or depression)

A rare, but serious side effect of tamoxifen is blood clots, including
deep vein thrombosis (DVT) and pulmonary embolus. You should seek emergency
help and notify your health care provider immediately if you develop sudden chest
pain and shortness of breath. Notify your health care provider within 24 hours
if you notice that one leg is swollen, red, painful and/or warm to touch and the
other is not.

A rare, but serious side effect of tamoxifen can be the development of
uterine cancer. Women who have not had a hysterectomy should have regular
pap smears and gyn examinations. Abnormal vaginal bleeding should be reported
to your health care provider.

Your fertility, meaning your ability to conceive or father a child, may be affected
by tamoxifen. Please discuss this issue with your health care provider.

Not all side effects are listed above. Some that are rare (occurring in less than
10% of patients) are not listed here. However, you should always inform your
health care provider if you experience any unusual symptoms.

When to contact your doctor or health care provider:

Seek emergency help immediately and notify your health care provider,
it you experience the following symptoms:

• Sudden shortness of breath and/or chest pain

The following symptoms require medical attention, but are not an emergency.
Contact your health care provider within 24 hours of noticing any of the
following:

• Swelling, redness and/or pain in one leg or arm and not the other
• New breast lumps
• Excessive vaginal discharge or bleeding, menstrual (period) pain or irregularities
• Nausea (interferes with ability to eat and unrelieved with prescribed medication)
• Depression (interfering with your ability to carry on your regular activities)
• Changes in vision

Always inform your health care provider if you experience any unusual symptoms.

Precautions:

• Before starting tamoxifen treatment, make sure you tell your doctor about any other
  medications you are taking (including prescription, over-the-counter, vitamins,
  herbal remedies, etc.). Do not take aspirin, products containing aspirin unless your doctor specifically permits this.
• Let your health care professional know if you have ever had a blood clot that required
  medical treatment.
• Inform your health care professional if you are pregnant or may be pregnant prior
  to starting this treatment. Pregnancy category D (tamoxifen may be hazardous to
  the fetus. Women who are pregnant or become pregnant must be advised of the
  potential hazard to the fetus).
• For both men and women: Do not conceive a child (get pregnant) while taking tamoxifen.
  Barrier methods of contraception, such as condoms, are recommended. Discuss with
  your doctor when you may safely become pregnant or conceive a child after therapy.
• Do not breast feed while taking this medication.

Self-Care Tips:

• Do not stop taking this medication unless your healthcare provider tells you. You
  may be on it for as long as 5 years.
• If you are experiencing hot flashes, wearing light clothing, staying in a cool environment,
  and putting cool cloths on your head may reduce symptoms. Consult your health care
  provider if these worsen, or become intolerable
• This medication causes little nausea. But if you should experience nausea,
  take anti-nausea medications as prescribed by your doctor, and eat small frequent
  meals. Sucking on lozenges and chewing gum may also help.
• Avoid sun exposure. Wear SPF 15 (or higher) sunblock and protective clothing.
• In general, drinking alcoholic beverages should be kept to a minimum or avoided
  completely. You should discuss this with your doctor.
• Get plenty of rest.
• Maintain good nutrition.
• If you experience symptoms or side effects, be sure to discuss them with your health
  care team. They can prescribe medications and/or offer other suggestions that
  are effective in managing such problems.

Monitoring and Testing:

You will be checked regularly by your health care professional while you are taking
tamoxifen, to monitor side effects and check your response to therapy. Periodic
blood work to monitor your complete blood count (CBC) as well as the function of
other organs (such as your kidneys and liver) may also be ordered by your doctor.

Women will need a gynecologic (GYN) examination before therapy, and during therapy,
at regular intervals. Discuss the appropriate schedule with your health care
provider.

How Tamoxifen Works:

Hormones are chemical substances that are produced by glands in the body, which
enter the bloodstream and cause effects in other tissues. For example, the
hormone testosterone, made in the testicles and is responsible for male characteristics
such as deepening voice and increased body hair. The use of hormone therapy
to treat cancer is based on the observation that receptors for specific hormones
that are needed for cell growth are on the surface of some tumor cells. Hormone
therapy can work by stopping the production of a certain hormone, blocking hormone
receptors, or substituting chemically similar agents for the active hormone, which
cannot be used by the tumor cell. The different types of hormone therapies
are categorized by their function and/or the type of hormone that is affected.

Tamoxifen is an antiestrogen. Antiestrogens bind to estrogen receptor site
on cancer cells thus blocking estrogen from going into the cancer cell. This
interferes with cell growth and eventually leads to cell death. The following are
antiestrogen medications.

Note: We strongly encourage you to talk with your health
care professional about your specific medical condition and treatments. The information
contained in this website is meant to be helpful and educational, but is not a substitute
for medical advice.

Chemocare.com is designed to provide the latest information about chemotherapy to patients and their families, caregivers and friends. For information about the 4th Angel Mentoring Program visit www.4thangel.org

Do’s & Don’ts of Eating While Taking Tamoxifen

There are some foods you should not eat while taking
tamoxifen.  There are other foods that
are fine to eat.  And there are some
foods that can make your tamoxifen work harder for you.  I am going to tell you some of the do’s and
don’ts of eating while taking tamoxifen.

I took tamoxifen for a little over 1.5 years for my ER+
breast cancer.  I didn’t tolerate it well
and asked for my oncologist to find another way to prevent my breast cancer
from returning.  However, hundreds of
thousands of women are alive today because of this drug.  While it has a long list of side effects,
tamoxifen can save lives.

Estrogens Promote Growth of Some Breast Cancers

Over 70% of breast cancers respond to the female hormone,
estrogen.  The estrogens stimulate the
cancer cells to grow and replicate, making tumors bigger and spreading the
cancer to other areas of the body.  So,
doctors are always trying to reduce a breast cancer patient’s estrogen levels
or response to estrogen.  There are a few
techniques that oncologists use to do this, but by far tamoxifen is one of the
most common.

There are millions of people taking tamoxifen to prevent estrogen responsive breast cancer growth and recurrence.  It is the most widely prescribed hormonal drug for cancer patients on the market. 

What Is Tamoxifen & How Does It Work?

Tamoxifen is a drug classified as a SERM, or selective estrogen receptor modulator.  This means that tamoxifen binds to estrogen receptors and blocks the effects of estrogen on breast cancer cells.  Thus, these cells can’t grow or replicate.  Hence, tamoxifen stops breast cancer from growing and spreading. And it is very successful at doing its job.  Tamoxifen reduces the rate of breast cancer recurrence by 30 – 50% and mortality rates by 25% over 10 – 14 years. 

What Is The CYP Catalytic Cycle?

CYP stands for Cytochrome P.   There are many different liver enzymes that
belong to the Cytochrome P450 family. But the one that is most important for
people taking tamoxifen is CYP2D6.  This
is the enzyme, found in the liver, that breaks down tamoxifen into its active
compounds.  People taking tamoxifen that
have low CYP2D6 levels seem resistance to tamoxifen and are at a higher risk of
cancer recurrence. 

Drugs & Foods Can Affect The CYP Catalytic Cycle

This is important to know because many drugs, supplements
and some foods affect the level of CYP2D6 activity in our liver.  There also seems to be a genetic and ethnicity
component to the level of this enzyme activity. 
I will just be talking about food in this article.  But it is important for you to talk to
your oncologist or pharmacist about all the drugs & supplements you are
taking while on tamoxifen. 

There are many drugs, including over the counter
medications, and concentrated supplements, including those found in health food
stores, that can lower activity of these enzymes and prevent you from getting
the full benefit from tamoxifen.   

You can see some of the drugs that interact with the CYP enzymes here.  But, honestly, it’s easier just to have a chat with your pharmacist.  That is what they are there for, after all.

Foods Can Affect The CYP Cycle.  

There are some foods that can activate or inhibit CYP2D6.  However, for the most part, if you eat in moderation and eat a variety of foods, you should be fine.  There are studies published that focus on specific foods and the effects they have on the CYP cycle.  But if you dive in and read the research in depth, many of those studies are using levels of food concentrates that we just don’t consume when we eat normally. 

But there are some foods that have enough scientific evidence that justify tweaking our eating habits.  I have simplified this research into do’s and don’ts of eating while taking tamoxifen below. 

Be Careful with Food Supplements

But before we get to that, let me just say one thing.  Be careful with taking concentrated food
supplements.  For example, you may
have heard that turmeric is good for breast cancer patients.  And while that seems to be true, if you take
tamoxifen, you should not take a concentrated turmeric supplement.  Turmeric in higher doses can inhibit CYP
enzymes and limit the effectiveness of tamoxifen. 

It is a good idea to also discuss all supplements you may be taking with your oncologist or pharmacist. 

Okay, now let’s get to what you have been waiting for… The
do’s and don’ts of eating while taking tamoxifen. 

The Do’s of Eating While Taking Tamoxifen

Eat More Vegetables, Fruits & Whole Grains

Many organizations recommend that
cancer patients move to a plant-based diet. 
That doesn’t mean eliminating meat entirely.  But, animal fats and proteins should be
consumed in limited amounts.  I explain
why later in “The Don’ts of Eating while taking Tamoxifen” below.

Plant foods, such as vegetables, fruits and whole grains, contain powerful phytochemicals that can help us fight cancer.  I have already written about many of them in the Healthy Eating Archives here at Pink Ribbon Runner.  Be sure to subscribe to my emails, as I have plans for many more articles about healthy food choices for cancer survivors. 

Soy & Flax Seed Are Okay

I do want to talk a bit about soy
and flax seeds here.  You may have heard
that breast cancer survivors should not eat these foods as they contain
estrogen-like chemicals.  While it is
true that these foods contain phytoestrogens, these plant-based estrogens don’t
react with breast cancer cells like animal-based estrogens do.  Many studies have found that soy and flax
seeds are safe to eat.

But wait!  There is more.  Not only do these studies say that it is okay to eat these foods, but they also go on to suggest that people taking tamoxifen should be eating these foods.  There is a synergy effect between tamoxifen and these foods that enhance the effectiveness of the drug at blocking the growth of breast cancer cells.  But, don’t go overboard.  Always eat foods in moderation. 

Portion Control

Tamoxifen Can Lead To Weight Gain

Tamoxifen can lead to weight gain,
which can lead to higher risks of cancer recurrence.  Estrogens like to hang out in our fat.  The more fat we have, the more estrogen can
be stored up for a rainy day.  So,
keeping your weight in the healthy range is ideal. 

And as I say that, I know how
extremely hard it can be to battle weight gain on tamoxifen.  I gained about 25 pounds when I was on
it.  But, controlling how much we eat can
limit the amount of weight we gain.  Had
I just ate whatever I wanted, that 25 pounds may have been 50 or even 100
pounds. 

I have some tips for permanent weight loss without dieting in this article found here.

Tamoxifen Can Lead To Weight Loss

Some women lose weight on
tamoxifen. This can also be a troubling side effect, if they were a normal
healthy weight to begin with.  These
women may need to also control their portions, but with larger portions of healthy
foods.

We should always strive to eat portions that aim to maintain our weight, without added gain or loss, even when we are battling the side effects of tamoxifen.  Journaling can help you keep track.  I wrote about it in this article, 7 Benefits of Journaling Your Weight Loss Journey. 

Lower Total Daily Fat Intake

Since estrogens are stored in fat, it makes sense to limit the amount of animal fat we consume to avoid exposure to extra hormones.  There is also some scientific evidence that suggest that breast cancer patients on tamoxifen have better survival rates when fat is limited to less than 20% of total daily calories (the general recommendation is 20 – 35%).  It is best to stick to healthy plant-based fats, such as olive oil, canola and avocado. 

Drinking Coffee is Okay too

There have been a few studies that suggest drinking coffee can help prevent tamoxifen resistance. One study, published in the Cancer Causes & Control Journal, reported that tamoxifen-treated patients with ER+ breast cancer who drank 2 – 5+ cups of coffee per day had significant decreased risk for cancer recurrence. However, we need to be cautious in interpreting this finding. The researchers further went on to state that more research is needed to confirm this.

So, if you like to drink coffee, go ahead and drink coffee. If you don’t drink coffee, there is no reason to start the habit just yet.

The Don’ts of Eating While Taking Tamoxifen

Avoid Grapefruit

While I said that most foods are
okay to eat in moderation, grapefruit is an exception.  Grapefruit and grapefruit juice are well
known CYP disruptors.  Most pharmacists
will tell you to stay away from grapefruit if you are taking any medications,
including tamoxifen, that uses the CYP Catabolic Cycle.  Just one glass of grapefruit juice is enough
to limit the effectiveness of tamoxifen. 

There are some studies that suggest mango and hot red peppers interfere with CYP2D6.  However, it isn’t known if these foods reduce the effectiveness of tamoxifen specifically.  If you like mango or hot peppers, then perhaps enjoy them in moderation. 

Careful With Tangerines & Seville Oranges

These oranges contain a compound
called tangeretin that is a known CYP inhibitor.  However, this phytochemical is concentrated
in the peel, with very little in the interior of the fruit.  So, you should be fine if you peel the orange
and only eat the inside.  Where this may
be a problem is if you eat a lot of marmalade or other products that contain
the peels. 

Tangeretin can also be purchased
as a supplement.  It is thought to have
some anti-cancer properties, so may be tempting to take.  But, as I have warned already, sometimes
these supplements are not a good idea if you are taking tamoxifen. 

Other oranges do not interfere with CYP enzymes and are fine to eat as a whole fruit. However, orange juice filters out the beneficial fiber and can concentrate other phytochemicals that can interfere with absorption of some medications.  It is always better to take medications with water and not fruit juices, unless otherwise instructed by a doctor or pharmacist. 

Limit Meat Protein

Leucine is one of the 9 essential
amino acids.  It is found primarily in
animal proteins, such as beef, chicken, pork and fish.  Plant proteins are low in leucine. 

Recent studies in cell culture
and rodents suggest that tamoxifen resistance may occur when we eat a lot of
leucine in our diet.  Controlled clinical
trials have not been completed yet, so this is just scientific speculation at
this point.  However, there are other
reasons to limit the amount of meat we eat, especially red meats.

Limit Red Meats

Red meats, such as beef and pork, when cooked on high heat can produce carcinogenic compounds.  The scientific research is so compelling that the World Health Organization has released a statement saying that diets high in red meat have an increased risk for cancer. They further explain that we should avoid cooking these meats in direct contact with a flame or hot surface, such as in grilling or broiling.  I explain this further in my blog post Are We Cooking Ourselves Sick?

Limit Animal Fats

In addition, some meats contain
added estrogens, which tamoxifen is trying to combat.  Some countries allow the meat industry to use
growth hormones to boost growth of the animals. 
Neither Canada nor the USA allow this in pork and chicken, but they do allow
it in beef cattle.  Many European
countries no longer allow this practice in any meat production.  Breast cancer patients should be aware of
these practices and look for meats raised without hormones.  If this isn’t possible, then at least trim
the fat off the meats, as the estrogens are stored in the fat, with little
residue in the fleshy muscle.     

Limit Milk & Dairy

In the same way that beef may contain added estrogens, milk may also contain extra hormones.  Some countries, including the US, allow dairy farmers to boost production with growth hormones.  Canada and some European countries do not allow added hormones in milk. 

However, animal estrogens are found naturally in milk regardless. These may influence human health, perhaps even influencing the recurrence of breast cancer.   However, the research to date is not conclusive.

“During the last couple of years, increasing body of evidence are indicating another property of hormones in dairy products as possible impact on human health including the role of some estrogens and insulin-like growth factor-1 in initiation and provoking of breast, prostate and endometrial tumours.” – Source: Hormones in Dairy Foods and Their Impact on Public Health

There is also some evidence that milk may increase risk for breast cancer.  However, this research is not conclusive and there are an equal number of conflicting studies.  I wrote more about milk in my article on Milk: Healthy or Not?

Food Does Not Directly Cause Cancer

It is important to point out that what you ate did not directly cause your cancer.  Cancer is a complicated subject that scientists are still working hard to figure out.  But diet does play a role in cancer risk and surviving cancer.  We need to continue to eat as healthy as we can with the information we have today.  As I always say, I will fight with all the tools in my cancer fighting toolbox.  And that includes eating healthy foods.

I hope you found this article helpful.  Again, be sure to subscribe to receive my emails.  I have more information on healthy eating coming soon. 

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Tamoxifen diets

Key points from literature

• Length of treatment varies from one to two weeks^1,2,5,6,7,8 to one to two months^3,4,8
• Pure tamoxifen1,5,8 and tamoxifen citrate^1,2,3,4,6,7 are both effective
  Usual tamoxifen doses are ~40-80 mg per kg body weight per day
• Typical inclusion for pure tamoxifen is 250 mg8 or 500 mg1,5 and for tamoxifen citrate is 400 mg per kg diet^1,2,3,4,6,7
• Initial weight loss of ten % is reported^1,2,4,7,8, associated with reduced food intake²
• Subsequent recovery of body weight after returning to regular diet may be compromised by gene inactivation^2,7

Selected tamoxifen references

¹ Andersson KB, Winer LH, Mork HK, Molkentin JD, Jaisser F. 2010. Tamoxifen administration routes and dosage for inducible Cre-mediated gene disruption in mouse hearts. Transgenic Res 19:715-725.

² Chiang PM, Ling J, Jeong YH, Price DL, Aja SM, Wong PC. 2010. Deletion of TDP-43 down-regulates Tbc1d1, a gene linked to obesity, and alters body fat metabolism. Proc Natl Acad Sci USA 107:16320-16324.

³ Kardakaris R, Gareus R, Xanthoulea S, Pasparakis M. 2011. Endothelial and macrophage-specific deficiency of P38alpha MAPK does not affect the pathogenesis of atherosclerosis in ApoE-/- mice. PLoS One 6:e21055.

⁴ Kiermayer C, Conrad M, Schneider M, Schmidt J, Brielmeier M. 2007. Optimization of spatiotemporal gene inactivation in mouse heart by oral application of tamoxifen citrate. Genesis 45:11-16.

⁵ Koitabashi N, Bedja D, Zaiman AL, Pinto YM, Zhang M, Gabrielson KL, Takimoto E, Kass DA. 2009. Avoidance of transient cardiomyopathy in cardiomyocyte-targeted tamoxifen-induced MerCreMer gene deletion models. Circ Res 105:12-15.

⁶ Kratsios P, Catela C, Salimova E, Huth M, Berno V, Rosenthal N, Mourkioti F. 2009. Distinct roles for cell-autonomous Notch signaling in cardiomyocytes of the embryonic and adult heart. PCirc Res 106:559-572.

⁷ Miro-Murillo M, Elorza A, Soro-Arnaiz I, Albacete-Albacete L, Ordonez A, Balsa E, Vara-Vega A, Vazquez S, Fuertes E, Fernandez-Criado C, Landazuri MO, Aragones J. 2011. Acute Vhl gene inactivation induces cardiac HIF-dependent erythropoietin gene expression. PLoS One 6:e22589.

⁸ Welle S, Burgess K, Thornton CA, Tawil R. 2009. Relation between extent of myostatin depletion and muscle growth in mature mice. Am J Physiol Endocrinol Metab.Oct;297(4):E935-40.

90,000 Breast cancer treatment with hormone therapy – what are the risks?

Hormones in a woman’s body play a very important role. They affect how a woman looks and what her mood is. But most importantly, hormonal balance determines overall health.

The most important groups of female hormones – estrogen and progesterone – regulate cellular functions, namely their growth, division and death. The cells of some types of breast cancer are sensitive to estrogen and progesterone and are stimulated by them to divide and spread uncontrollably.Hormonal (endocrine) therapy is aimed at suppressing the production of hormones in the body or changing their interaction with tumor cells.

There are two types of hormone therapy for breast cancer:

• Medicines that interfere with the communication of estrogen and progesterone with cancer cells and inhibit tumor growth.
• Medicines that suppress the production of hormones in the body.

Do not confuse hormone therapy with hormone replacement therapy (HRT).HRT is a treatment that uses hormones to reduce the effects of menopause.

In what cases is hormone therapy prescribed?

If you have been diagnosed with hormone-dependent breast cancer. The doctor will prescribe a study of the tumor for the presence of receptors sensitive to estrogen and progesterone. The presence of these receptors indicates hormone-dependent cancer – that is, the growth of cells in this type of cancer depends on hormones. In this case, your doctor will likely prescribe hormone therapy as part of your treatment.

If you have already been treated for breast cancer. Hormone therapy reduces the likelihood of recurrence and tumor spread to healthy breasts.

If you have a family history of breast cancer.

If you have mutations in your genes that increase your risk of disease. Hormone therapy may reduce the risk of breast cancer.

Need Help? Make an application on the website, we will contact you as soon as possible and answer all your questions about the appointment of hormone therapy based on the results of genetic testing.

Apply for a consultation

Hormone therapy drugs:

• Anastrozole (Arimidex)
• Exemestane (Aromasin)
• Fulvestrant (Faslodex)
• Goserelin (Zoladex)
• Letrozole (Femara)
• Leuprorelin, leuproline acetate (Lupron)
• Megestrol (Megace)
• Tamoxifen (Nolvadex, Soltamox)
• Toremifen (Fareston)

Tamoxifen

Tamoxifen is a tablet preparation for the treatment of breast cancer.It suppresses the action of hormones and interferes with the effects of estrogens on tumor cells. By binding to estrogen receptors like estrogens, it is translocated into the nucleus of the tumor cell and blocks the action of estrogens.

Doctors prescribe Tamoxifen to women whose cancer has spread throughout the body – it slows down or stops the spread of tumor cells. It has also been shown to be effective in reducing the likelihood of early recurrence of certain types of breast cancer.

Tamoxifen is prescribed for women at high risk of breast cancer to reduce the likelihood of the disease. This is a kind of alternative to watchful waiting or breast removal surgery, called mastectomy, before the disease manifests itself.

Tamoxifen is prescribed for:

• Treatment of an early form of breast cancer, ductal carcinoma in situ (DCIS), in conjunction with surgery.
• Treatment of abnormal cells in the mammary gland – lobular carcinoma in situ (LCIS) to reduce the likelihood that they develop into cancer.
• Treatment of hormone-dependent breast cancer in men and women, whose cell growth depends on estrogen.
• Treatment of breast cancer that recurs or has spread to other parts of the body.
• To reduce the risk of cancer in women with a predisposition to the disease.

Tamoxifen is contraindicated:

• during pregnancy;

90,009 women planning pregnancy;

90,009 patients who have previously had blood clots or stroke.

Talk to your doctor to see if tamoxifen is right for you.

The side effects of Tamoxifen in women are similar to some of the symptoms of menopause. The two most common of these are hot flashes and vaginal discharge.

Other side effects in women:

• vaginal dryness or itching;
• menstrual irregularities:
• headache;
• vomiting and nausea;
• skin rash, redness, itching;
• fatigue;
• edema and weight gain.

Side effects may be similar to those of menopause, but tamoxifen does not cause menopause.

In men, tamoxifen can cause:

• headache;
• nausea and vomiting;
• skin rash;
• erectile dysfunction or decreased sex drive.

Risks associated with the use of tamoxifen:

• Fertility. Tamoxifen induces ovulation, which increases the risk of pregnancy, therefore women of reproductive age need to use reliable methods of contraception during therapy.Hormonal contraceptive drugs are contraindicated. They can change how the drug works and affect the tumor.
• Thrombosis. during the period of treatment, the risk of blood clots in the lungs or large veins may increase. The risk is higher in smokers.
• Stroke.
• Cancer of the uterus or sarcoma. There is a possibility of an increased risk of developing uterine cancer or sarcoma. But this risk is small and generally outweighs the benefits of Tamoxifen treatment.Talk to your doctor to find out for sure.
• Cataract. Tamoxifen in some cases may increase the risk of developing cataracts, changes in the cornea and retina of the eye.
• Interaction with other drugs. The active ingredients of other drugs may interfere with the work of Tamoxifen, reduce its effect or increase the risk of side effects. Please consult your doctor before using.

Tamoxifen and Breast Cancer Prevention

A large study by the National Cancer Institute (USA) investigated the effect of Tamoxifen on the likelihood of breast cancer in healthy women at risk.The results of the study showed a 50% reduction in the incidence in women who took the drug.

Studies have also shown that the use of the drug reduces the risk of recurrence of breast cancer (ductal carcinoma in situ (DCIS)) in women at an early stage.

Can other medicines prevent breast cancer?

Another drug, Raloxifene (Evista), which prevents osteoporosis, which causes thinning of the bones, is similar to tamoxifen. Studies have shown that it has some effect on preventing breast cancer in high-risk women and causing fewer side effects.The FDA has approved this drug for the prevention of breast cancer.

Other hormonal preparations:

Aromatase inhibitors – a class of drugs sometimes called antiestrogens. They prevent the breakdown of testosterone into estrogen and thus lower the total estrogen levels in the body. Tumor cells are deprived of “nutrition” by estrogens, their growth slows down or stops. This class of medicinal products includes:

• Anastrozole (Arimidex)
• Exemestane (Aromasin)
• Letrozole (Femara)

Aromatase inhibitors prevent the spread of hormone-dependent breast cancer in the late stages more effectively than tamoxifen.

For women in menopause, the drugs can fight cancer even in the presence of metastases.

These drugs are usually taken once a day.

Side effects of drugs

Common side effects when taking drugs of the aromatase inhibitor class are as follows:

• vomiting and nausea;
• diarrhea or constipation;
• tides;
• headache;
• bone pain;
• severe fatigue;
• skin rash;
• edema;
• flu-like symptoms;
• Increased bone loss.

Fulvestrant (Faslodex): is an injectable drug that prevents estrogen from attaching to cancer cells.

Side effects include:

• pain at the injection site;
• nausea and vomiting;
• loss of appetite;
• weakness and fatigue;
• tides;
• cough;
• pain in joints, bones, muscles;
• constipation;
• shortness of breath.

References

https: // www.webmd.com/breast-cancer/hormone-therapy-overview

🏥 Does Tamoxifen Cause Weight Gain? 2021

Review

Tamoxifen is a type of selective estrogen receptor modulator (SERM) used in the treatment of breast cancer. It is also sometimes used to prevent breast cancer in people at high risk for the disease. The drug works by attaching to estrogen receptors in breast cells to minimize the effects of estrogen on breast tissue.

Although mostly women take, tamoxifen is also used by some men.

Read more: Breast cancer in men »

As with any treatment, there is always a risk of side effects. One of the problems with tamoxifen is the potential for weight gain. However, there is little evidence that this is a common side effect. Many studies point to other causes of weight gain in people taking this drug.

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Side effects

Tamoxifen side effects

Potential side effects of tamoxifen include:

• blood clots
• depression
• hot flashes
• menstrual irregularities
• spotting

Changes in weight have been reported as a side effect among several healthcare providers, but with conflicting reports.Some argue that weight gain is a potential side effect, while other sources point to weight loss as a side effect.

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Weight gain and cancer

Weight gain after cancer

Changes in weight may not have one cause. Weight gain can occur after breast cancer, especially in women. Tamoxifen is not necessarily to blame.

Other possible causes of weight gain include:

Chemotherapy

Chemotherapy can cause more side effects than vomiting and hair loss.In fact, the researchers have seen significant weight gain in women with breast cancer who have had chemotherapy. The reasons for this link are not clear.

Hormonal changes after menopause

If you are taking tamoxifen for menopause, chances are the weight gain may be due to hormonal changes rather than medication.

Learn More: Weight Gain & Menopause »

Inactivity

Cancer and related procedures can significantly reduce energy levels.This can lead to a reduction in daily activities and exercise.

Dietary changes

Cancer treatments can affect your appetite and even change the types of foods you crave. Gradual weight gain can occur as a result, especially if you start eating more carbs, sweets, and processed foods.

Other undiagnosed health conditions

If you are living a balanced, healthy lifestyle, then there may be another health problem that needs diagnosis, such as thyroid disease or diabetes.

Increased stress can also lead to weight gain.

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Weight Management

Weight Management

Weight management can be tough after cancer. This is true whether you are on medications such as tamoxifen, or if your body is making changes on its own.

Here are six ways to help your weight after cancer:

1. Eat the right foods

Reducing the amount of insulin trigger foods you eat can also help.For example, when you eat brown rice instead of white rice, carbohydrates will not cause blood sugar spikes and fat accumulation.

2. Don’t rely solely on calorie counting

When it comes to weight loss as well as overall nutrition and wellness, fresh whole foods should be emphasized over calories. A diet low in calories but high in simple carbohydrates and processed foods is unlikely to produce results when compared to a diet of fresh foods, lean meats, grains, and heart-healthy fats.

3. Track what you eat

You can track what you eat without counting calories. Chances are, you can eat more than you realize, or eat more of a certain type of food, such as pulling out, than you thought. Keeping a journal can help you monitor your eating habits and uncover opportunities for improvement.

4. Gradually start moving again

After cancer, you can’t get to the gym for high intensity workouts.Instead of giving up exercise entirely, gradually increase your activity level. Gardening, walking, and swimming are all good options. These activities can also boost your mood.

Learn more: Tips for dealing with breast cancer »

5. Learn Meditation

Deep breathing exercises can help you deal with the stress hormones that contribute to weight gain. It also helps to cope with depression.Even a few minutes a day can affect your prognosis. If you’re ready to take meditation to another level, try integrative exercises like tai chi and yoga.

6. Be patient

Finally, remember that losing weight can take a long time. This becomes especially difficult as you get older. If you still have difficulty managing weight despite your lifestyle change, talk to your doctor about possible medical interventions.

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Outlook

Outlook

Weight gain is a possibility with hormone therapy for cancer, but there is insufficient evidence to specifically prove that it is inevitable with tamoxifen. Most people take tamoxifen for about five years. If you are concerned about this medication as a source of weight gain, talk to your doctor. If possible, you can switch to a different type of SERM. You and your doctor will need to carefully study the risks and benefits of tamoxifen.

drug for the treatment of breast cancer

Head of the oncology department at the Ichilov clinic.
Oncologist with 20 years of experience.

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Contents

How to get remote cancer treatment in Israel during the coronavirus epidemic?

Tamoxifen (Nolvadex or Soltamox) is an effective hormone therapy used to treat hormone receptor positive breast cancer in Israel.It can significantly reduce the risk of cancer recurrence and invasive cancer significantly . Some people take tamoxifen to lower their risk of breast cancer.

Daily oral treatment stops cancer cells from using estrogen and progesterone to grow and spread.

What is hormone-receptor breast cancer?

Breast cancer tumors, which are hormone receptors, require the hormones estrogen or progesterone (and sometimes both) to grow.Approximately 90,019 75% of 90,020 breast cancers are hormone-positive in postmenopausal women. Your attending physician at the Ichilov Cancer Center will conduct a biopsy and laboratory tests to determine the type of cancer and the most effective treatment .

How does tamoxifen work?

Tamoxifen is a type of hormone therapy known as Selective Estrogen Receptor Modulator (SERM). The drug binds to hormone receptors (specific proteins) in breast cancer cells.Once the drug gets inside the cells, it stops the cancer from accessing the hormones it needs to reproduce and grow.

Who Should Use Tamoxifen?

Tamoxifen may help women and men with hormone receptor breast cancer. The drug may reduce the risk of breast cancer in women . It’s worth taking:

• Women who are at high risk of developing breast cancer due to a family history of the disease or mutated (altered) breast cancer genes (BRCA).
• For women and men who have already been diagnosed with breast cancer, to prevent cancer recurrence (return), including:
  Development of breast cancer in the opposite, untreated breast.

How effective is tamoxifen?

Millions of people have used tamoxifen to prevent or treat breast cancer. The drug may reduce the risk of developing:

• breast cancer in the opposite breast by 50% ;
• the recurrence of breast cancer in premenopausal women is 90,019 from 30% to 50% 90,020;
• the recurrence of breast cancer in postmenopausal women is 90,019 from 40% to 50% 90,020;
• primary diagnosis of breast cancer – up to 40% ;
• invasive breast cancer after diagnosis of early stage non-invasive breast cancer (ductal carcinoma in situ or DCIS) up to 50% .

What are the other benefits of taking tamoxifen?

In addition to reducing the risk of breast cancer and cancer recurrence, tamoxifen:

• prevents bone loss after menopause;
• lowers cholesterol levels.

Application for breast cancer treatment in Israel

How do you take tamoxifen?

You should take tamoxifen daily, preferably at the same time every day.The drug is available in two forms:

• Nolvadex® tablet;
• Soltamox ® liquid.

How long should I take tamoxifen?

Most people have been taking tamoxifen or other hormone therapy for at least five years, and sometimes up to ten years . The duration of treatment depends on the individual characteristics of the cancer.

Your doctor at the Ichilov Cancer Center (Israel, Tel Aviv) may recommend taking tamoxifen for five years and then switching to another hormonal therapy for a few more years.

What are the side effects of taking tamoxifen?

Tamoxifen side effects may include:

• Vaginal discharge.
• Headaches.
• Skin rash.
• Irregular or falling menstruation.
• Swelling of the legs.
• Symptoms similar to menopause, including hot flashes, night sweats, and vaginal dryness.
• Nausea.
• Weight gain or edema.
• Fatigue.
• Erectile dysfunction.

What are the risks of taking tamoxifen?

Rarely, tamoxifen can cause serious problems such as:

• Cataract or other vision problems;
• uterine cancer;
• thrombi, deep vein thrombosis (DVT) and strokes.

When buying Tamoxifen in Israel, you get a 100% original medicine. And minimize the possibility of side effects. In Israel, there is strict control over the entire production process of medicines.

Is tamoxifen safe to take during pregnancy?

Tamoxifen may cause birth defects . You should not take medications if you are pregnant or planning to become pregnant. You will need to use contraception while taking tamoxifen and for two months after you stop taking the medication.

What other drugs can lower the risk of breast cancer?

Other medicines that can lower your risk of developing breast cancer include:

• Raloxifene (Evista®) is another type of SERM that blocks estrogen receptors on breast cancer cells.Unlike tamoxifen, this drug is approved only for postmenopausal women and is not associated with an increased risk of endometrial cancer. This can reduce the risk of invasive breast cancer by up to 40%.
• Aromatase inhibitors, including anastrozole (Arimidex®) and exemestane (Aromatazine®) , may reduce estrogen levels in postmenopausal women.

You can take the first step to recovery right now. To do this, fill out an application – and one of our doctors will contact you within 2 hours.

Or call: + 972-3-376-03-58 in Israel and + 7-495-777-6953 in Russia.

Clinical Study Retroperitoneal Fibrosis: Tamoxifen, Prednisone – Clinical Trials Registry

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What is a hormonal slimming agent?

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Effect of hormonal slimming agent

Reduslim differs from many pharmaceutical preparations, it has a natural composition. It is safe for the body and rarely causes allergic reactions.

Expert opinion

The composition of Reduslim tablets includes only natural herbal ingredients, therefore it has no side effects, with the exception of individual intolerance to certain substances.

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The composition of the Reduslim slimming drug is designed in such a way that, when faced with the acidic environment of gastric juice, the drug does not lose its effect. For example, most tablets, after taking, lose 8% of their effectiveness and are not able to provide a lasting result. In contrast to them, Reduslim does not lose its properties, is completely absorbed and gradually acts on subcutaneous fat.This provides a stable effect of stable weight loss, even after the end of the weight loss course, without the risk of weight return, after the end of the therapy period

I wanted to lose weight, but there was no time for exhausting training at all, and I could not adhere to certain diets. As a result, I earned myself digestive problems and a depression, constantly breaking down on loved ones. On the advice of a friend, I ordered Reduslim tablets and did not regret it.They perfectly suppress hunger, normalize metabolic processes. Minus 10kg per month. This is a great result for me. Where to buy a hormonal weight loss product? The composition of Reduslim tablets includes only natural herbal ingredients, therefore it has no side effects, with the exception of individual intolerance to certain substances.

Hormone pills are not the main weight loss product. They are needed in order to regulate hormones in the body, and weight loss is a concomitant effect of their use.You need to understand that hormonal pills by themselves are not a means for losing weight. They are produced with one purpose – to correct hormonal imbalances in the body, and weight loss is unique. Choice of hormonal diet pills for women. … To do this, you need to take special medications. … Women take these hormonal diet pills from the first day of the cycle, 1 piece per day. It is advisable to drink the drug at the same time. After three weeks. For quick weight loss, hormonal drugs are used.These are not harmless agents, they can cause significant damage, disrupt the work of the cardiovascular and endocrine systems. They perfectly improve hormonal levels. Hormonal birth control pills in demand: Jess and Yarina. For weight loss, you need to drink 50 mcg. funds once a day in the morning. To lose weight rather than gain weight, the correct dosage is imperative. 25 mcg. leads to muscle growth. How do hormonal weight loss drugs affect the body and the mechanism of weight loss in general? Rating of drugs, warnings when taking hormones.Hormonal drugs for weight loss. Author: Irina Lazur. … Rating of drugs for weight loss. Based on the analysis of this information, the brain builds long-term reactions (maintaining body weight) and short-term (suppressing or increasing appetite). Everything functions according to. Hormonal for weight loss – tablets with tamoxifen – are taken according to an individual scheme established by a doctor. The remedy is categorically contraindicated during pregnancy and lactation. All hormonal drugs are prescribed only in case of insufficient production, therefore, if the diet and.From all of the above, we can conclude that hormonal pills are not a magic remedy for losing weight, but serious drugs that can be taken under certain conditions.

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Methods for the treatment of gynecomastia | Alexander Markushin plastic surgeon

Gynecomastia is a benign enlargement of breast tissue in men.

Classification of gynecomastia

Gynecomastia is of two types: false and true.

False is not a real disease, but only the deposition of adipose tissue in the chest area. When true, a pathological proliferation of glandular tissue occurs.

True gynecomastia is of the following types:

• Idiopathic
• Physiological (neonatal, pubertal, senile)
• Pathological

1. congenital (with Klinefelter syndrome, anorchia, hermaphroditism, androgen resistance syndrome, enzymatic defects in testosterone synthesis, increased aromatase in peripheral tissues)
2. endocrine (with castration, mumps, Cushing’s syndrome, congenital adrenal hyperplasia, adrenocorticotropic hormone deficiency, hyperthyroidism, hypothyroidism, panhypopituitarism, hyperprolactinemia)
3. symptomatic (for tumors of the testicles; adrenal glands; pituitary adenoma; breast cancer; tumors that secrete human chorionic gonadotropin)
4. medicinal (when using hormones; antiandrogens; prolactin stimulants; when using drugs; anti-tuberculosis drugs)
5. metabolic (with thyrotoxicosis; renal failure; liver cirrhosis; starvation; alcoholism)
6. other (for HIV, chest wall trauma, cystic fibrosis, physiological stress)

Diagnostics

A thorough medical history is important to determine the underlying cause of gynecomastia and to rule out breast cancer and other tumors.On the other hand, it should be noted that about 25% of gynecomastia cases may be idiopathic (no known cause).

Must be considered when examining

• patient age,
• start and duration of breast augmentation,
• symptoms of associated pain,
• recent weight change and
• possible endocrine disorders.

It is necessary to establish whether any medications or narcotic drugs are being taken, as they can cause up to 10–20% of gynecomastia cases.

On physical examination, gynecomastia is defined as an overgrown glandular tissue under the nipple-areola complex and can be of various sizes.

True gynecomastia must be differentiated from pseudogynecomastia, or false gynecomastia, which is manifested by hypertrophy of adipose tissue without proliferation of the gland itself.

Breast cancer is rare and accounts for less than 1% of malignant neoplasms in men (according to UK and US data).It usually manifests itself on one side and is felt as a hard mass located outside the nipple-areola complex.

As part of a systemic review, the physical examination should include looking for signs of chronic thyroid, kidney or liver, or genital disease. When examining the genitals, it is also important to monitor testicular mass or testicular atrophy. Liver enlargement can sometimes occur.

Laboratory research

Biochemical evaluation includes tests to determine the function of the liver, kidneys and thyroid gland, as well as the level of testosterone, prolactin, follicle-stimulating and luteinizing hormone in the blood serum.

Additional tests may be needed in cases of recent or symptomatic gynecomastia to rule out tumors. For example, serum estrogen levels, human chorionic gonadotropin (hCG), dehydroepiandrosterone, and 17-ketosteroids in urine.

Routine mammography and breast ultrasound with or without biopsy are generally not recommended unless breast cancer is suspected or the patient has unilateral breast augmentation.

Similarly, testicular ultrasound or abdominal computed tomography may be performed if the testicle or adrenal gland is enlarged.

Diagnostic evaluation of gynecomastia

• Laboratory tests:
  • testosterone
  • human estrogen-β-chorionic gonadotropin
  • prolactin, follicle stimulating hormone and luteinizing hormone
  • urea and electrolytes
• Functional tests of the liver
• Thyroid function tests (thyroxine and thyroid stimulating hormone)
  • ± dehydroepiandrosterone or 17-ketosteroids in urine
• Instrumental examination
  • Ultrasound of the breast
  • Mammography
  • Computed tomography of the abdominal cavity
  • ± testicular ultrasound
  • Basic or fine needle biopsy

Selection of patients

Various clinical and histological classifications have been proposed for gynecomastia.The Simon classification is the most practical because it takes into account not only the size of the breasts, but also the amount of excess skin.

Indications for removal of gynecomastia

• Permanent increase after puberty (> 2 years)
• Inadequate response to treatment
• Strong breast augmentation
• Significant asymmetry or one-sided condition
• Patient request
• Post-massive weight loss
• Special clinical conditions

The boundaries between categories are not clearly defined, which leads to subjectivity.Therefore, in our practice, we classify gynecomastia into three stages:

• Small to moderate in size with no or minimal excess skin (Grades I and IIA)
• Medium to large in size with moderate to severe skin excess (grades IIB and III).

Gynecomastia Treatment

Drug treatment

Most cases of gynecomastia do not require treatment as they are benign and self-limiting.

Weight loss should be recommended first for patients with pseudo-comastia. Special care should be taken to eliminate any identified cause.

Drug therapy is mainly aimed at correcting the imbalance of androgens and estrogens. Medicines are most effective during the active, proliferative phase of gynecomastia. In patients with prolonged gynecomastia for more than 1 year, drug treatment is often ineffective, since the breast tissue progresses during this time to irreversible dense fibrosis and hyalinization.

Treatment of gynecomastia without surgery involves taking medications. Anti-estrogen drugs are often prescribed.

Most common drugs:

• Tamoxifen
• Clomiphene citrate
• Proviron
• Progestogel.

Taking medications must be agreed with the attending physician. It is he who prescribes the treatment regimen, determines the required dosage and duration of medication. Do not self-medicate, as this can greatly worsen the patient’s health.

Surgical treatment

The mainstay of gynecomastia treatment is surgical treatment, the purpose of which is to restore the normal looking contour of the male breast with minimal scarring while maintaining the vitality of the nipple-areola complex.

Surgical treatments for gynecomastia include various forms of liposuction, breast excision, skin tightening, and a combination thereof.

Liposuction is currently one of the main surgical techniques because it is minimally invasive, improves contouring by smoothing the contours and is often successful as a stand-alone technique.

Various types of liposuction have been described, including conventional, mechanical, ultrasonic, laser and vibration (VASER). The most common types are conventional and ultrasonic liposuction.

Anesthesia and infiltration

The operation is performed under general anesthesia. All patients undergo preoperative photography. All patients receive antibiotic prophylaxis.

Marking for patients is carried out before the operation in an upright position with the designation of the inframammary fold, the boundaries of the mammary glands, the planned incision sites.

Breast tissue is infiltrated through an incision in the inframammary fold, a special liposuction raster is inserted.

Liposuction allows you to achieve good breast contours with minimal scarring. Special liposuction cannulas are used.

Open gland removal

Open removal of the gland tissue is performed through the inferior areolar approach. Various other incisions have also been described, such as circumvertical, periareolar, transareolar, anchor, t-inverted.

Liposuction is often not effective for removing dense glandular tissue. Excision techniques are effective for these patient populations, although they are associated with a high complication rate with the possibility of gross scarring and contour deformities.

We use open excision in combination with liposuction. Liposuction serves several purposes, such as pre-tunneling to facilitate resection, reduce bleeding and bruising, and partially destroy breast tissue.After liposuction, the tissue can be removed through several small incisions.

We prefer the time-tested open excision method, when breast tissue is excised through a semicircular incision along the lower edge of the nipple-areola complex. At least 1 cm of breast tissue remains under the areola to prevent depression of the nipple-areola complex.

Open excision, even in combination with liposuction, sometimes does not completely correct large and ptosis breasts for which skin tightening is indicated.Some surgeons recommend avoiding skin resection, leaving the skin to contract on its own for 6-8 months. We prefer to remove excess skin at the first surgery. This has practical advantages such as cost savings, one-step operation, and reduced turnaround times.

Skin tightening

There are a number of techniques used to tighten the skin for gynecomastia. Although most of them are similar to those used for mastopexy in women, there are still some peculiarities.

Although skin tightening techniques can lead to larger scars compared to liposuction and simple removal, they are indicated for patients with large breasts, significant ptosis, or poor skin turgor. Therefore, in patients with obvious excess skin or very large breasts, skin tightening techniques should also be planned in advance and should be performed simultaneously with open breast tissue removal or in a second step, at least 4-6 months later.

However, there is no consensus on when and how to tighten the skin.We base this decision on skin elasticity, the presence of ptosis and excess skin, skin type, and the patient’s willingness to accept a potential two-step procedure. The surgeon’s preference also plays a role in the choice of method. Whenever there is excess skin or ptosis, we prefer to remove the excess skin at the initial surgery, especially in cases of poor or marginal skin elasticity.

The choice of skin tightening method is also highly dependent on the preference of the surgeon. Tightening possible

• circular
• vertical
• without vertical scar with transposition of the nipple-areola complex
• Anchor

Periareolar mastopexy

Periareolar skin tightening is the preferred method over other skin tightening methods, mainly because it avoids additional scarring.

We prefer to use the periareolar technique due to less visible scarring.

Vertical mastopexy according to Le Jour

In patients with true ptosis or very large breasts, skin tightening and tissue resection can be attempted using the LeJour vertical lift. The skin and underlying breast tissue are resected in a vertical ellipse, and then the edges of the wound are approximated.

However, a vertical scar may be visible.This technique is used as a last resort, especially in those patients who wish to avoid the T-scar.

Other methods of skin tightening

Lateral wedge, elliptical and inverted T excisions are sometimes used.

Patients with very large or ptosis breasts are suitable candidates for elliptical mastectomy and free nipple transplant.

It also avoids the characteristic scars of mastopexy in women.

In patients at high risk of developing keloid or hypertrophic scarring, we often use the Lalonde-style breast reduction technique without vertical scarring. After de-epithelialization, liposuction is performed prior to the open removal of the glands and through a horizontal incision. After hemostasis is achieved, the areola complex of the nipples is excellently transposed and brought to a new position.

Staged skin reduction

Patients with mild ptosis sometimes do not need to perform a gland removal with an immediate skin tightening.The operation can be performed in two stages. We start with liposuction followed by skin tightening at least 4–6 months later.

Sometimes patients planning for a two-stage surgery are satisfied with the initial result and refuse the second skin tightening procedure, since they can gradually self-tighten the skin.

However, the skin may still not shrink, and then we perform simultaneous skin tightening and excision techniques for severe gynecomastia with significant excess after liposuction.

Recovery after removal of gynecomastia

Drains are generally not used except for large resections or when skin resections are performed, for example in patients with massive weight loss. Patients are advised to wear a special compression bandage for gynecomastia day and night for 4-6 weeks.

Oral antibiotics are taken for a total of 5 days. Pain relievers must be used, as a rule, within 2-3 days.

Outcomes, prognosis and complications

Only an integrated approach can lead to predictable results in the surgical treatment of gynecomastia. Our starting point for all cases of gynecomastia is liposuction, even in cases with hard subareolar glands, as it facilitates subsequent open excision. It is also technically easier to perform liposuction at the beginning of surgery rather than after removal. We only use conventional liposuction when ultrasonic liposuction is not available.

In patients in whom open removal is optional in appearance and consistency, we always agree to open removal if liposuction leaves significant residual stromal tissue.

Whenever there is excess skin and / or ptosis, we prefer to remove the excess skin in the primary surgery, especially in cases of poor or marginal skin elasticity. This is done in order to avoid postoperative excess skin.

The choice of skin reduction technique depends largely on the preference of the surgeon.

Potential consequences of gynecomastia

• Bleeding and hematoma
• Seroma formation
• Infectious disease
• Skin necrosis / nipple
• Contour deformity such as nipple inversion or depression
• Altered nipple sensation
• Excess skin
• Residual asymmetry
• Unfavorable scars (wide, hypertrophy, keloid, pigmentation)
• Overcorrection, undercorrection
• Recurrent need for revision surgery: asymmetry, residual tissue, depressed nipples

Recurrence of gynecomastia

Gynecomastia patients are generally a surgically challenging group of patients, not least because of their high expectations for surgery.In patients who have undergone surgery, it is sometimes necessary to have revision surgery several months after the initial surgery for various reasons. These include inadequate correction, patient dissatisfaction, painful residual lumps, asymmetry, and relapse (often associated with weight gain). Overcorrection is rare.

Recommendations

It is often difficult for even experienced surgeons to choose the most appropriate treatment. Sometimes a combination of these methods is needed.Surgical treatment of gynecomastia consists of three main steps, which may not all be necessary for a given patient: liposuction, open excision, and skin tightening.

Liposuction should always be used for diffuse or large breast augmentation. It may not be necessary when correcting small breasts with a hard subareolar nodule, but facilitates subsequent open removal. Our results with ultrasonic liposuction have led us to conclude that, when available, it is preferred over conventional liposuction because it is more effective and stimulates better skin contraction.In addition, there may also be less bruising. After liposuction, breast consistency is re-evaluated and open excision is performed if residual gland tissue is present.