Personal Blog of a Doctor

Which hormone to choose for endocrine therapy of breast cancer is determined by the availability of the particular hormone and also by the toxicity profile of the hormone. Generally the initial endocrine therapy of choice is an aromatase inhibitor rather than tamoxifen (one of the commonly used drug in breast cancer).

Choice of endocrine therapy:

Although tamoxifen is very commonly used in breast cancer, generally endocrine therapy is started with an aromatase inhibitor if status of the breast cancer is not clear. Response to treatment to aromatase inhibitors is substantially higher than to tamoxifen in breast cancer, if the endocrine receptor status is positive. Patients who respond to one endocrine therapy have a 50% chance of responding to another (second) endocrine therapy. It is not uncommon for patients to respond to two or more sequential endocrines; but, combination endocrine therapies do not give superior result to individual agents, and also combinations of chemotherapy with endocrine therapy are not useful.

The median survival of patients with breast cancer, if metastasis is present, is approximately 2 years, and many patients, particularly older persons and those with hormone-dependent disease may respond to endocrine therapy for 3 to 5 years or sometimes longer.

Additive endocrine therapies, with progestogens, estrogens, and androgens, can also be tried in patients who respond to initial endocrine therapy; the mechanism of action of these therapies is not known clearly.

Some breast cancer cases have been reported, in which tumors shrink in response to tamoxifen withdrawal, this may be due to endogenous estrogen formation blockage by analogues of luteinizing hormone–releasing hormone in pre-menopausal women.

Recent developments:

Newer and said to be “pure” anti-estrogens (as they are free of agonistic effects) are at present under clinical trial.        

There is a myth about generic drugs, and the myth is that the generic drugs are of inferior quality and less efficacious than brand name drugs. There is no basis in this myth. The USFDA accepts generic drugs as equal with that of brand name drugs in terms of efficacy, pharmacokinetic and pharmacodynamic properties. Generic drugs are not less efficacious or poorer quality than brand name drugs. Many generic drugs are produced in the same manufacturing facilities as that for brand name drugs, which is approved by FDA. This practice is approved by FDA, because they apply the same quality control standards for all drug manufacturing facilities, including facilities that manufacture generic drugs. FDA estimates that approximately half (50%) of all generic drugs are produced and marketed by brand-name companies. Almost all of these companies use the same manufacturing facilities for both brand-name and generic drugs.

What is a generic drug?

Generic drug is a drug whose patent protection has expired any can be manufactured and sold by any company, which has the know-how to manufacture it. There is no need to take permission from a patented company.

In terms of intended use (therapeutic use), side effects, route of administration, risks, safety, and strength there is no difference of generic drug with that of the original drug (brand name drug) and this fact is accepted by FDA.

The present genric drug names list is vary vast and the number of drug falling into generic category is increasing day by day. This due to the fact that any drug whose patent protection expires (no patent of drug is for very long duration and after some years patent expires) becomes, theoretically generic drug.

The list of generic drugs is very big and here are some examples of generic drugs such as generic propecia, generic Viagra, generic xenical and many more like older antihistaminics (phenyramine, dicyclomine, promethazine etc.) and pain relievers (paracetamol, ibuprofen etc.).

Cephalexin is a first generation cephalosporin. Cephalosporin group of antibiotics are similar to penicillin and they are know as beta-lactam antibiotics, as they contain beta-lactam ring in their structure. Both the groups of antibiotics are effective against gram positive bacteria and less effective against gram negative bacteria. But newer generation of these groups are effective equally against gram positive as well as gram negative bacteria.

Cephalexin is available as Keflex (trade name of Cephalexin). Being a first generation Cephalexin antibiotic, it has more activity against gram positive and lesser activity against gram negative bacteria. Keflex is active against streptococci, staphylococci, gonococci, meningococci, chorinebacterium diphtheriae, clostridium and actinomyces.

The main use of Cephalexin is as an alternative to penicillin. The extensive use of penicillin has come down due to development of resistance by the previously sensitive bacteria. There are many mechanisms of development of resistance and one of the mechanism is to destroy the antibiotic before it can act, by producing the destroying enzyme (in this case beta-lactamase enzyme produced by many bacteria which were sensitive to penicillin previously). Keflex has replaced the use of penicillin (older generation penicillins).

You can buy many medicines online including antibiotics like Cephalexin (and other cephalosporin drugs), penicillin like amoxicillin etc. t name a few. The availability of Cephalexin and other medicines in pharmacy online has made it simple and easy to buy medicines what you need. Many drug stores are going online and selling their products online, as this is the trend at present.

The development of a breast mass during pregnancy or lactation should never be attributed to hormonal changes. Breast mass during pregnancy or lactation should be viewed and treated with the same concern as any other woman. Breast cancer can develop in 1 in every 3000 to 4000 pregnancies, so any breast mass during pregnancy or lactation should be viewed seriously.

Development of breast and lactation:

The breasts grow under the influence of estrogen, progesterone, prolactin, and human placental lactogen during pregnancy. Progesterone is the hormone which is responsible for blocking the effects of prolactin and thus suppresses lactation during pregnancy. But, after delivery, progesterone levels falls, which in turn promote lactation due to unopposed action of prolactin, lactation starts after delivery.

Behavior of breast mass (or breast cancer) during pregnancy:

Stage for stage, breast cancer in pregnant patients is no different from pre-menopausal breast cancer in non-pregnant patients and so the treatment or management is the same as non pregnant patient. But, pregnant women may often have more advanced disease because the significance size of the breast mass and the mass may not have been fully considered. There is also endogenous hormone stimulation during pregnancy, which makes the breast cancer more aggressive.

Persistent breast lumps in the pregnant or lactating women cannot (and should not) be attributed to benign changes and such patients with breast lump during pregnancy should be promptly sent for diagnostic evaluation without delay.

Types of mammography:

Mammography is of two types. One type of mammography is screening mammography and the other type is diagnostic mammography. These two types of mammography should not be confused, as they are separate and their aims are separate. Screening mammography is performed after detection of palpable breast mass. Diagnostic mammography is for evaluating the rest of the breast before biopsy is performed or sometimes it is done as part of the triple-test strategy to exclude immediate biopsy.  

Screening mammography can detect some nonspecific abnormalities (clustered micro-calcifications, densities and new or enlarging architectural distortions) and these should be evaluated carefully by compression or magnified views.

What should be done after mammography?

(a)    If there is no palpable lesion and detailed mammography studies are clearly (unequivocally) benign, the patient should be follow-up routinely, which is appropriate to the patient’s age.

(b)   If breast lesion is not palpable, but some abnormality in the mammogram is seen, ultrasound can be sometimes helpful either to identify the lesion or to guide biopsy.

(c)    If a non-palpable lesion of mammography has a low index of suspicion, it should be followed-up in 3 to 6 months.

(d)   Indeterminate and suspicious lesions should be biopsied, because the procedure can eliminate need of additional surgery.

(e)    If the chance of malignancy is high, open biopsy should be performed with a needle localization technique. But some experts suggest use of core biopsies for non-palpable lesions because they are cost-effective and because diagnosis leads to earlier treatment planning (but after a breast biopsy with needle localization technique, which means local excision, of a diagnosed malignancy, re-excision may still be necessary to achieve negative margins).