Premenopausal Women

The role of adjuvant AI therapy in premenopausal women undergoing ovarian suppression is not known. Two international randomized trials coordinated by the International Breast Cancer Study Group—the Suppression of Ovarian Function Trial (SOFT) and the Tamoxifen and Exemestane Trial (TEXT)—are examining this question. These trials are comparing ovarian suppression plus tamoxifen with ovarian suppression plus exemestane; in addition to the two combination regimens, SOFT has a third arm of tamoxifen alone. Patients can be enrolled either at the initiation of adjuvant therapy or after completion of chemotherapy, if they are still premenopausal.

The role of AIs in the adjuvant treatment of women who become postmenopausal while receiving either chemotherapy or initial treatment with tamoxifen is also unclear. Although some women with chemotherapy-induced amenorrhea were included in the adjuvant AI studies, apart from MA.17, the proportion was very small, making it difficult to extrapolate results to this specific population. Furthermore, amenorrhea following chemotherapy can be transient, and ovarian function may return months to years later, often not accompanied by a return of menses (31-33). In general, it is prudent to begin tamoxifen therapy in all women who were premenopausal at the time of diagnosis, regardless of their apparent menopausal status after chemotherapy. If one is going to consider a switching strategy after fewer than five years of tamoxifen, menopausal status should be ascertained biochemically when the patient discontinues tamoxifen and periodically thereafter.

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