Because of the side effects of the medications and the invasive nature of the surgery, they should only be offered to individuals with high risk for breast cancer. The women included in this group are those who have many family members with breast cancer and/or ovarian cancer and those who are carriers of a mutated BRCA gene. Women with previous breast biopsies showing the conditions such as atypia or lobular carcinoma in situ, may also be considered for preventative intervention.
Probably the most serious side effect of tamoxifen is blood clotting, which can be life-threatening such as deep venous thrombosis (DVT - clots in the veins, usually the leg veins), pulmonary embolism (clots in the lung veins) and stroke. DVT more frequently occurs in the legs. One may experience leg swelling, calf pain and redness at the involved area. When untreated, DVT might lead to pulmonary embolism, although pulmonary embolism and stroke could happen without DVT. Symptoms associated with pulmonary embolism are shortness of breath, chest pain and cough.
The chances of having a stroke are somewhat higher if you are taking these medicines, which could manifest in many ways, including, but not limited to, weakness, numbness, difficulty of walking or talking, etc.
Endometrial cancer (cancer of the internal lining of the uterus) is another serious uncommon side effect of tamoxifen. The first sign may be vaginal bleeding/discharge, and menstrual irregularities. Patients who did not have hysterectomy (uterus removal) should have regular check-ups with their gynecologists while taking tamoxifen. Prompt evaluation of any of these symptoms usually provides good outcome, as they can lead to an early diagnosis of uterine cancer.
Impaired vision because of cataracts (deposits of opaque substances in the eye lenses) could be another side effect of tamoxifen.
Recently, a large multicentric study, enrolling almost 20,000 post-menopausal women, compared tamoxifen and another drug raloxifene in breast cancer prevention. The study showed that both medications are similar in reducing breast cancer incidence with some differences in their side effects. Raloxifene use was associated with fewer cases of uterine cancer than tamoxifen; however the difference was not significant. Episodes of stroke occurred equally in patients taking either medicine. DVT and pulmonary embolism (clotting of the legs and lungs) were more common in the tamoxifen group. The group treated with raloxifene had lower incidence of cataracts and cataract surgery. While tamoxifen is more suitable for both young and older women, raloxifene is limited to postmenopausal women.
Prophylactic mastectomy may occur in the following scenarios:
For both groups the decision should be made only after thorough discussion and careful consideration as this is a radical extirpative procedure.
Bilateral prophylactic mastectomies (removal of both breasts) may be considered in women who have not been diagnosed with breast cancer if:
A discussion regarding this decision should take place with an experienced surgeon, familiar with breast cancer diagnosis and treatment. A reconstructive option should be considered at the same time. As there is no urgency for the decision making, open and frank discussions between doctor and woman, among the family members, an additional surgical opinion and psychological counseling are all helpful to assist the patient in making the right choice.
Prophylactic mastectomy to remove the healthy breasts can also be considered in patients who were undergoing breast cancer surgery for the other breast when:
Helena Chang, M.D., Ph.D. and Raquel Prati, M.D.