Hormonal therapy using progestins like megestrol acetate can be used for women with early endometrial cancer who want to preserve their fertility. However, there is no role for hormonal therapy (like tamoxifen or megestrol) after surgery (or adjuvant treatment). I sometimes will use it to treat women with metastatic disease whose tumors express estrogen and progesterone receptors or in a woman who is not symptomatic of her disease.

Intermittent hormonal therapy has now been in use for more than a decade. It is used in 2 settings; patients who have only PSA as their marker of disease after having had a localized treatment such as surgery or radiation, or in patients who have known sites of metastases. Many small trials have demonstrated the safety and feasibility of intermittent hormonal therapy in both these groups. A large randomized trial was reported a year ago in patients who have had radiation as their primary therapy and who then had a rise in PSA. They were randomized to either continuous or intermittent therapy; that trial demonstrated that intermittent was no worse than continuous therapy and that it was safe to do so.

This year a large trial was reported in patients with metastatic disease and had a similar design as the previous trial; this trial however was not able to show that intermittent was no worse than continuous therapy. The overall survival for the group getting continuous hormonal was 5.8 years vs. 5.1 years for those receiving hormonal therapy intermittently. Based on this trial continuous hormonal therapy is recommended for patients with metastatic disease. Treatment should be individualized based on side effects and a discussion with your doctor about the optimal therapy.

The role of hormonal therapy for risk reduction should be carefully considered and discussed with experts in breast cancer risk assessment and management in a shared decision-making environment. Guidelines from expert groups recommend that the risks and benefits of breast cancer prevention be discussed with premenopausal and postmenopausal women who are at high risk for the disease.

Women at high risk may include some women over the age of 60; women with certain high-risk conditions found on breast biopsy, such as lobular carcinoma in situ (LCIS) or atypical ductal or lobular hyperplasia; women between the ages of 35 and 59 years who have a calculated five-year risk of developing breast cancer of 1.7 percent or higher, according to a system called the Gail model. The Gail model uses a woman's current age, age at first menstrual period, age at first live birth, the number of first-degree relatives with breast cancer, and the number and pathologic findings of any breast biopsies to estimate the probability of breast cancer over time. This model, and others, is used by health professionals to calculate an individual’s risk and the results should be interpreted with an expert in breast cancer risk assessment. It is also important to remember that the presence of breast cancer risk factors does not mean that cancer is inevitable as many women with risk factors never develop breast cancer.

Another very important issue is that the Gail model does not consider the risk of cancer associated with inherited breast cancer-predisposing genes such as BRCA1 and BRCA2. If an individual has a strong family history that suggests the possibility of an inherited predisposition to breast cancer, then that individual should be referred for genetic counseling. Other components of a risk/benefit assessment and counseling include a careful discussion of the side effects of hormonal therapy, options for participation in clinical research and healthy lifestyle changes.

This question was answered in large part here:http://talkabouthealth.com/what-can-an-esophageal-cancer-patient-expect-at-their-first-meeting-with-the-gastroenterologist. In general, the best test for suspected esophageal cancer is upper endoscopy (EGD). This will allow visualization of the esophagus and identification cancer if present. After cancer is diagnosed, a CT scan of the chest, abdomen, and pelvis as well as PET imaging are typically performed. Early stage cancers may be managed by the gastroenterologist, while more advanced cancers are managed by the chest or cancer surgeon and medical and radiation oncologists, who administer chemotherapy and radiation therapy.

For chemotherapy, usually two-drug regimens are preferred; three drugs are offered for patients who have good performance status, are physically fit, and can be frequently monitored for drug toxicities. There are several drug combinations, but paclitaxel/carboplatin and cisplatin/5FU being the two most common regimens. Between 40-50.4 Gy of radiation is used for induction regimens. However the doses and schedules can vary according to personal preferences and patient toxicities; there are published guidelines such as those by the National Comprehensive Cancer Network (NCCN). In general the histology does not influence the regimen, but the location and treatment intent can vary the schedules.

There were some early reports in the literature that soy foods may reduce the effectiveness of Tamoxifen in animal studies, but at least one study from the Univ of So Cal (wu, JCO, 2007) showed that soy food consumption had no effect on the active metabolites of Tamoxifen in Asian American breast cancer survivors.

Initiation of hormonal therapy is commonly begun after the completion of chemotherapy (and after completion of radiation therapy if you receive both). In terms of actual timing, hormonal therapy will typically begin approximately four to six weeks following completion of chemotherapy. A preference for sequential timing of chemotherapy and hormonal therapy, i.e., adjuvant chemotherapy followed by hormonal therapy, was suggested by a clinical trial, in which sequential versus concurrent chemo/hormonal therapy were directly compared and sequential treatment had superior outcomes for disease free and overall survival.

I would add that there are limited clinical data and no consensus on the use of concurrent hormonal therapy and radiation therapy, thus some medical oncologists advise overlap of hormonal therapy with radiation and others advise waiting until radiation is complete. I generally advise waiting until radiation is complete.

The usual risk factors include a history of gastroesophageal reflux, smoking and alcohol use. Unfortunately we don’t have any biomarkers or xrays to help us determine who is high risk. There are certain diseases which can increase the risk, such as Barrett’s esophagus, achalasia, or a history of a caustic injection that damages the esophagus; these patients should be monitored long-term for developing esophageal cancer. Patient with high grade Barrett’s disease may already have invasive cancer present.

There are three different types of hormonal therapy medicines:

- AIs (Aromatase Inhibitors):
- Arimidex (anastrozole)
- Aromasin (exemestane)
- Femara (letrozole)

- SERMs (Selective Estrogen Receptor Modulators):
- tamoxifen
- Evista (raloxifene)
- Fareston (toremifene)

- ERDs (Estrogen Receptor Down Regulators):
- Faslodex (fulvestrant)

For pre-menopausal women with estrogen positive breast cancer, the hormonal treatment options are:
- tamoxifen is the most common treatment
- medications that temporarily stop the ovaries from producing estrogen are: Zoladex (goserelin acetate), Lupron (leuprolide), or Trelstar (triptorelin)
- surgical removal of ovaries
- radiation treatment to stop ovaries from working

A couple of less common treatments are Megace (megestrol) and Halotestin (fluoxymesterone). These treatments are used in specific cases.