Does hormonal therapy decrease tamoxifen associated hot flashes

The manuscript by Osborne et al. [1] addresses the question of whether hormonal therapy will decrease hot flashes in patients receiving tamoxifen. Managing hot flushes is important as they are a very challenging side effect of tamoxifen which can negatively impact various areas of a woman’s life; including sleep and relationships. One of the important aspects of this manuscript regards the role of hot flashes in motivating women to start hormone therapy as well as to stop taking tamoxifen. As an example, in this study the authors report 22 patients who withdrew from the trial related to severe hot flashes. This information leads to a critical point, that being the need to assertively evaluate and manage hot flashes and other related side effects of tamoxifen or any other pharmacologic treatment, whether the purpose of that medication is to prevent or to treat cancer. Whether hot flash therapies work to different degrees in patients receiving tamoxifen, compared to those who are not receiving tamoxifen and/or in patients with a history of breast cancer versus not, have been repeatedly raised questions. A retrospective review of the Mayo Clinic/North Central Cancer Treatment Group hot flash trial experience supports that hot flash therapies work equally well in patients receiving tamoxifen, compared to women who are not receiving tamoxifen and also in women with a history of breast cancer versus not [2]. This experience involved a large number of non-hormonal hot flash treatment’s and progestogen treatments, but, admittedly, did not include any therapies which involve estrogen treatment. Osborne et al. [1] conclude that the addition of hormonal therapy (estrogen with or without a progestogen) to tamoxifen does not ameliorate tamoxifen-induced vasomotor symptoms. While the data presented in this manuscript do support this conclusion, they come short of actually proving it. The women studied in this trial received either tamoxifen or tamoxifen with hormonal therapy, but were not randomized to these treatments. Rather, women chose whether or not to be receiving concomitant hormonal therapy with the tamoxifen that was prescribed in this clinical trial. In the women who received concomitant hormonal therapy, the mean duration of hormonal therapy at the time the study entry was almost 10 years. These women would be expected to have more trouble, in general, with hot flashes than women who were not receiving hormonal therapy, given that the main reason that women take hormonal therapy is for the relief of hot flashes. Of interest, previous work has illustrated that the incidence and severity of hot flashes in postmenopausal women receiving tamoxifen is associated with whether or not they had at least moderate hot flashes when they went through menopause [3]. Another reported trial also examined the issue of whether hormone therapy would ameliorate tamoxifen induced hot flashes [4]. This trial involved 7,154 women assigned to receive tamoxifen versus placebo in a breast cancer chemoprevention clinical trial. As would be expected, more women receiving tamoxifen had hot flashes compared to those receiving a placebo (71 vs. 57%). In concert with the data presented by Osborne et al. in women receiving tamoxifen on this trial, the women who were also receiving hormone therapy at study initiation had more hot flashes in the first 6 months than did those who did not This is a comment to doi:10.1007/s10549-008-0284-y.