Dear Dr. Roach: I am an 80-year-old woman and a 25-year survivor of ovarian cancer. In the past three years, I have also had Merkel cell cancer, breast cancer, and now squamous cell cancer on my lip.
I have been on an aromatase inhibitor for the past eight months and have side effects that keep me from having a good quality of life. I am supposed to be on it for five years, but I do not want to live the rest of my life like this. I cannot find any statistics for someone my age. I would appreciate any advice you have for me.
S.M.
There’s no statistics on anyone like you because you are unique. I doubt anyone in the world has had your experience. So, in absence of data, we physicians have to use our clinical judgement.
The real issue here isn’t the ovarian cancer, the Merkel call cancer, or the squamous cell cancer. It’s the breast cancer and its treatment — an aromatase inhibitor (AI). Aromatase is the enzyme that makes estrogen from androgens, which are mostly made by the adrenal gland. Estrogen levels are very low in patients who are on AIs; these medications suppress the growth of receptor-positive breast cancer cells, but can have side effects.
The most common side effects I see are musculoskeletal: bone pain and joint stiffness. There are other side effects, including osteoporosis, but the ones that affect quality of life the most are pain and stiffness. Regular moderate exercise, both aerobic and strength training, as well as anti-inflammatory drugs are the first-line treatment and are effective for most women at reducing symptoms.
Sometimes oncologists will try a different AI; some often work well for one particular woman but not for another. Some experts believe a trial showing improvement with acupuncture and an antidepressant medicine commonly used for pain syndromes, duloxetine, can be helpful.
Although AIs are slightly superior to an older medicine, tamoxifen, at preventing breast cancer recurrence, I certainly suggest you discuss switching to tamoxifen with your oncologist if the usual treatments don’t improve your quality of life. Tamoxifen is usually much better tolerated than AIs. Especially given your age and complicated cancer history, I don’t think it makes any sense for you to have a miserable quality of life for the next four years.
Dear Dr. Roach: I am a 73-year-old woman who has been diagnosed with osteoporosis. I have taken calcium for years now as a supplement to a yearly infusion of zoledronic acid.
I have read that calcium and magnesium need to be taken, but shouldn’t be taken together. Yet most of the suppleme nts I find pair them together. What is the bottom line on this combo, yes or no?
S.K.
Calcium by itself does not appear to have a significant benefit in preventing or treating osteoporosis, but every trial using medicines like alendronate or zoledronic acid has included calcium. Ideally, calcium should come from the diet, but it’s hard for most people to get enough calcium in their diet, in which case calcium supplementation is recommended.
Magnesium deficiency is very bad for bone health. Without magnesium, your body can’t make parathyroid hormone efficiently or activate vitamin D.
In people with a magnesium deficiency, magnesium replacement is important. However, giving magnesium to a person without a magnesium deficiency probably isn’t helpful.
The body absorbs magnesium and calcium competitively; too much of one reduces absorption of the other, so if both are needed, it’s best to separate them.
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