Mixed Medication Message

Dear Dr. Roach: I have a question regarding a medication that was prescribed to me. I originally had breast cancer in 2000 in my left breast when I was 43 years old, which also spread to two of my lymph nodes. I was treated with radiation and chemotherapy. I have been in remission all these years. I took various medicines for several years, such as tamoxifen and femara. I no longer take any of these drugs.

In May, I was operated on for DCIS in my right breast. I also received radiation to my right breast. The doctor said that I am fine now, but he suggested that I take exemestane. He showed me a graph indicating that there is no proof that it helps someone with DCIS.

I would prefer not to have to take any additional medicine, especially if there is no proof that it will help me. I also am concerned about the side effects, such as aches in the bones and joints, hot flashes and problems with sleep. In your opinion, should I just take my chances and go without this medication? Will taking the medicine prevent a recurrence of cancer in another part of the body? — E.M.

Answer: Let’s start with a definition of DCIS. Ductal carcinoma in situ is a breast condition where cancerous or pre-cancerous cells are inside the mammary ducts but without any invasion into the surrounding breast tissue. The goal for treatment is to prevent invasive breast cancer. DCIS now accounts for 20 percent of breast cancer diagnoses, but it has a much better prognosis than infiltrating ductal cancer, the most common type of breast cancer.

On the one hand, exemestane has been shown to reduce future cancers in people with DCIS. On the other, the survival benefit was very small or zero, presumably since the cancers prevented would be likely to be detected by screening and could be effectively treated. I think that’s why your doctor is saying what seems like a contradictory statement: He wants you to take it, but there is no proof it will help somebody like you.

However, you have had another diagnosis of breast cancer in 2000, and the fact that you have had two different breast cancer diagnoses means you are at higher risk than many of the people in the study, which would therefore mean the exemestane might have a higher likelihood of a benefit for you.

Because the magnitude of expected benefit is small, and because all medicines have side effects, I think that either choice you make would be reasonable. In my mind, the small benefit of the medication is similar to the small likelihood of harm from it — the side effects you mentioned, plus the possibility of osteoporosis. It sounds to me like you really don’t want to take it, and I wouldn’t try to talk you into it. I would go back to your oncologist with your decision that you are inclined not to take the meds, and see what he says.

This is a complex issue, and once again it shows the limitations of even the best evidence we have. I did speak to a colleague in oncology as well in formulating my answer.

Dear Dr. Roach: I have been reading your articles regarding gout and blood pressure medications. I suffer from pseudogout and take Diovan/HCTZ. Would changing this medication have any effect on my condition? — E.S.

Answer: Pseudogout (literally, “false gout”) looks a lot like gout, and both diseases are caused by deposition of crystals inside joints. In gout the crystal is uric acid, whereas in pseudogout, the crystal is calcium pyrophosphate. Pseudogout tends to affect larger joints, such as the knees, whereas the big toe is the classic place for gout. Hydrochlorothiazide (HCTZ), a common diuretic, can make gout worse, but it should have no effect on pseudogout.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.