Running head: MANAGEMENT OF HOT FLASHES

Management of Hot Flashes in Breast Cancer Survivors Hollis Misiewicz NURS 916

MANAGEMENT OF HOT FLASHES

Management of Hot Flashes in Breast Cancer Survivors In the United States more women are diagnosed with breast cancer than any other type of cancer. A woman today has a 12% chance of developing breast cancer in her lifetime (American Cancer Society, 2009). In 2010 the number of estimated new cases of breast cancer in women in the United States was 209,060 (American Cancer Society, 2010). Since 1990 the mortality rate for breast cancer has been steadily declining. Earlier detection of breast cancers and new modalities for treatment are cited as reasons for this trend (American Cancer Society, 2009). As the number of breast cancer survivors grows, nurses need to address the long-term problems secondary to cancer treatment that these women now face. Breast Cancer Treatment and Hot Flashes For women who have received treatment for breast cancer, one of the most frequent, long-term effects of treatment is the development of the vasomotor symptoms of menopause, most notably, hot flashes (Berger, Treat Marunda, & Agrawal, 2009; Mouridsen, 2006). The hot flashes induced by breast cancer treatment occur more frequently and are more severe than those experienced by the healthy postmenopausal woman (Gross, 2006; Kontos, Agbaje, Rymer, & Fentiman, 2010; Savard, Savard, Quesnel, & Ivers, 2009). Cytotoxic agents, Tamoxifen, and aromatase inhibitors are the gold standard of treatment for most breast cancers. All of these agents induce symptoms of estrogen deficiency with the abrupt onset of hot flashes (Morales et al., 2004; Savard et al., 2009). Frequent, severe hot flashes have been linked to significant sleep disturbances and a decline in the quality of life (Drisko, ; Fenlon, Corner, & Haviland, 2009; Schultz, Klein, Beck, Stava, & Sellin, 2005). A significant number of breast cancer patients will stop their endocrine treatments early because of severe hot flashes even though this could increase the risk of their cancer recurring (Filshie, Bolton, Browne, & Ashley, 2005; Gross,

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2006; Savard et al., 2009). Treatments for Hot Flashes Hot flashes are a symptom of estrogen deficiency and hormone replacement therapy is currently the most effective treatment available for alleviating this symptom. For breast cancer survivors, however, hormone therapy is contraindicated because its use has been linked to an increased risk of cancer recurrence (Goodwin et al., 2008; Kenemans et al., 2009; Loprinzi et al., 2006; Marsden, Whitehead, A'Hern, Baum, & Sacks, 2000). Research has supported the use of antidepressants for the treatment of menopausal hot flashes in healthy postmenopausal women. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine, which is a serotonin-norepinephrine reuptake inhibitor, have shown effectiveness in reducing hot flashes by 30 to 65% in women without a history of breast cancer (Carroll & Kelley, 2009). The SSRIs, however, are not recommended for women taking Tamoxifen as they are inhibitors of the CYP2D6 enzyme which decrease the concentration of endoxifen, the active metabolite of Tamoxifen, decreasing the effectiveness of this treatment (Desmarais & Looper, 2009; Kimmick, Lovato, McQuellon, Robinson, & Muss, 2006). Venlafaxine is associated with troublesome side effects (Biglia et al., 2005; Loprinzi et al., 2000; Mariani et al., 2005). Other medications, such as gabapentin and clonidine have been used to treat hot flashes with minimal to modest effect but also with significant side effects (Gross, 2006; Ruhstaller et al., 2009). Breast cancer survivors are often reluctant to use pharmacologic treatments for hot flashes while receiving adjuvant therapy for their cancer (G. Walker, de Valois, Davies, Young, & Maher, 2007). Stellate ganglion blocks are used effectively for the treatment of hot flashes, however, it is an expensive alternative to other more conventional treatments with a cost of $1000 to $3000

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per treatment in the United States (Kontos et al., 2010; Lipov et al., 2008; Lipov, Joshi, Xie, & Slavin, 2008). Herbal supplements, vitamin E, isoflavones, soy products, red clover and melatonin have shown no advantage in diminishing hot flashes as compared to placebo (Biglia et al., 2009; Kontos et al., 2010; Newton et al., 2006; Secreto et al., 2004; Van Patten et al., 2002). There is some evidence to support the use of hypnosis or structured relaxation as an effective treatment for hot flashes (Elkins et al., 2008; Nedstrand, Wyon, Hammar, & Wijma, 2006; Rada et al., 2010). Different types of acupuncture have been studied for the treatment of hot flashes. Traditional acupuncture, electro-acupuncture, ear acupuncture and self-administered acupuncture have all demonstrated efficacy in reducing the incidence of hot flashes in the breast cancer population with few side effects (de Valois, Young, Robinson, McCourt, & Maher, 2010; Deng et al., 2007; Filshie et al., 2005; Frisk et al., 2008; Hervik & Mjaland, 2009; Nedstrand, Wijma, Wyon, & Hammar, 2005; Porzio et al., 2002; Tukmachi, 2000; E. M. Walker et al., 2010; G. Walker et al., 2007). For this reason acupuncture is a viable alternative to medication for the treatment of hot flashes in the breast cancer population. Conclusion Nurses are integral in the assessment, management and counseling of women with breast cancer from the time of diagnosis through treatment and then afterwards in dealing with issues of survivorship. Many breast cancer survivors experience hot flashes that can have a significant impact on their activities of daily living so it is imperative that nurses are knowledgeable about therapies that will diminish hot flashes. Effective counseling by the nurse to assist women with breast cancer deal with this issue can provide a great benefit towards improving the patients quality of life.

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