Dr. Roach: The quality of life under an aromatase inhibitor is very poor
Dr. Roach: I am an 80-year-old female and a 25-year survivor of ovarian cancer. In the past three years, I have also had Merkel cell cancer, breast cancer, and now squamous cell cancer on my lip.
I have been on an aromatase inhibitor for the past eight months and have side effects that keep me from having a good quality of life. I am supposed to be on it for five years, but I do not want to live the rest of my life like this. I cannot find any statistics for someone my age. I would appreciate any advice you have for me. — S.M.
Answer: There's no statistics on anyone like you because you are unique. I doubt anyone in the world has had your experience. So, in absence of data, we physicians have to use our clinical judgement.
The real issue here isn't the ovarian cancer, the Merkel call cancer, or the squamous cell cancer. It's the breast cancer and its treatment — an aromatase inhibitor (AI). Aromatase is the enzyme that makes estrogen from androgens, which are mostly made by the adrenal gland. Estrogen levels are very low in patients who are on AIs; these medications suppress the growth of receptor-positive breast cancer cells, but can have side effects.
The most common side effects I see are musculoskeletal: bone pain and joint stiffness. There are other side effects, including osteoporosis, but the ones that affect quality of life the most are pain and stiffness. Regular moderate exercise, both aerobic and strength training, as well as anti-inflammatory drugs are the first-line treatment and are effective for most women at reducing symptoms.
Sometimes oncologists will try a different AI; some often work well for one particular woman but not for another. Some experts believe a trial showing improvement with acupuncture and an antidepressant medicine commonly used for pain syndromes, duloxetine can be helpful.
Although AIs are slightly superior to an older medicine, tamoxifen, at preventing breast cancer recurrence, I certainly suggest you discuss switching to tamoxifen with your oncologist if the usual treatments don't improve your quality of life. Tamoxifen is usually much better tolerated than AIs. Especially given your age and complicated cancer history, I don't think it makes any sense for you to have a miserable quality of life for the next four years.
Dr. Roach: I have a minor case of essential tremors. It doesn't bother me, except when I raise my hand to my mouth. I appreciate any information you can give on the subject. — T.S.
Answer: Essential tremors are very common and often run in families. It may begin at any time, but I most commonly diagnose it in people over 50. I most often see it in the hands and arms, but it can involve the head, voice, face or trunk. When it is clinically typical and runs in families, a generalist can usually make the diagnosis, but a definitive diagnosis may require an expert, such as a movement disorder neurologist.
YOften, those affected by essential tremors notice that it gets better temporarily with alcohol, but alcohol is not an effective long-term treatment and can bring on other complications. Essential tremors tend to worsen slowly with time.
Treatment for mild essential tremors is usually medical, with propranolol or primidone. For people like you, who may have trouble eating, I've had some luck with adaptive devices, such as a spoon/fork with active-cancellation-of-tremor technology.
Severe cases need to be seen by an expert, and I have had a handful of patients treated with focused ultrasounds, deep brain stimulations, or surgery.
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