Tamoxifen


Article Author:
Maela Farrar


Article Editor:
Tibb Jacobs


Editors In Chief:
Charles St Hill
Richard Orr
Lisa Bellin


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/29/2018 7:45:00 PM

Indications

Tamoxifen is indicated for the treatment of breast cancer in a variety of settings. It should be noted that evidence suggests that patients with estrogen receptor positive tumors are more likely to benefit from tamoxifen.[1] Tamoxifen also has many off-labeled uses, and they may require additional data. 

FDA-Approved Indications

  • Treatment of breast cancer in both females and males[2]
  • Adjuvant treatment of breast cancer after patients have completed their primary treatment with surgery and radiation[3]
  • Treatment of female patients with ductal carcinoma in situ (non-invasive breast cancer) after surgery and radiation to reduce the risk of invasive breast cancer[4]
  • Breast cancer risk reduction in certain patients at high risk (5-year risk = 1.67% calculated by the Gail Model).[5]

Non-FDA-Approved Indications

  • Treatment of progressive or recurrent desmoid tumors in combination with sulindac[6]
  • Treatment of endometrioid histologies that are recurrent, metastatic, or at high-risk[7][8]
  • Treatment of primary or secondary gynecomastia along with breast pain associated with it[9]
  • Induction of ovulation in the treatment of infertility[10]
  • Treatment of oligospermia in combination with testosterone[11]
  • Prophylaxis of coronary arteriosclerosis in men with triple vessel[12]
  • Treatment of advanced or recurrent ovarian cancer[13][14]
  • Treatment of bladder cancer[15]
  • Treatment of lung cancer in addition to initial chemotherapy treatment[16][17]
  • Treatment of precocious puberty due to McCune-Albright syndrome in females[18]
  • Treatment of metastatic malignant melanoma in combination with other agents including carmustine, cisplatin, and dacarbazine[19][20][21][22]
  • Treatment of benign mammary dysplasia[23]
  • Treatment of bone metastasis[24]
  • Treatment of carcinoid tumor [25]
  • Treatment of cutaneous polyarteritis nodosa[26]
  • Treatment of hypertrophy of uterus[27]
  • Treatment of meningioma[28]
  • Treatment of primary breast pain, premenstrual mastodynia, or breast pain that originated from liver cirrhosis[29][30][31][32]
  • Prophylaxis of postmenopausal osteoporosis[33]
  • Improvement of length and quality of life in patients with retinoblastoma in addition to treatment protocols[34]
  • Treatment of Riedel's thyroiditis[35]
  • Treatment of solid tumor secondary malignant neoplasms[36]

Mechanism of Action

Tamoxifen exhibits both estrogenic agonist and antagonist effects in different parts of the body. Because it has two actions, it is patient-specific as a selective estrogen receptor modulator (SERM). In the breast tissue, it competes with estrogen for binding sites and causes antiestrogenic and antitumor effects. Through downstream intracellular processes, it slows cell cycling which classifies it as cytostatic. In the bone it stimulates estrogen receptors instead of blocking them, exerting an estrogenic agonist effect, and may prevent osteoporosis in postmenopausal women.[37]

Administration

Tamoxifen is available in a tablet (10 mg or 20 mg) or an oral solution (10 mg/5 mL). If it as administered as an oral solution, it is important to use the supplied dosing cup for adequate administration. The American Society of Clinical Oncology (ASCO) guidelines for Adjuvant Endocrine Therapy of Hormone-Receptor Positive Breast Cancer recommends a dose of 20 mg daily for breast cancer prevention after completion of chemotherapy. The duration of endocrine therapy depends on the patient's menopausal status and can last 5 to 10 years.[38] For the treatment of metastatic breast cancer, 20 to 40 mg daily is recommended, although clinical benefit has not been shown for doses above 20 mg daily.[39] In some off-label clinical trials, 10 mg was used as the dose. It may be taken with or without food.

Adverse Effects

Tamoxifen has a black box warning for uterine malignancies, pulmonary embolism, and stroke in patients who are at high risk for cancer or who have ductal carcinoma in situ.[40] In patients who are female, tamoxifen is associated with an increased incidence of uterine or endometrial cancers, with some being fatal. In patients who were already diagnosed with breast cancer, however, the benefits outweigh the risks.[41]

Like many cancer drugs, tamoxifen has many adverse effects associated with it, though serious and fatal ones are rare. The most common adverse effects seen in treatment are hot flashes, irregular periods, and vaginal discharge. Other common adverse effects include peripheral edema, hypertension, mood changes, pain, depression, skin changes and skin rashes, nausea and vomiting, weakness, arthritis, arthralgia, lymphedema, and pharyngitis.

Less common adverse effects may include insomnia, dizziness, headache, weight gain, abdominal pain, diarrhea, indigestion, urinary tract infections, thrombocytopenia, back pain, alopecia, ostealgia, and cataracts among many more. Due to the extensive adverse effects of tamoxifen, it is important for patients to discuss all adverse effects they are experiencing with their doctor.[42]

Tamoxifen can also cause a local disease flare which may lead to increased bone and tumor pain. This can be associated with good tumor response and usually resolves quickly. In patients with bone metastasis, hypercalcemia may occur. If hypercalcemia becomes severe and not manageable, discontinue tamoxifen.[43]

Contraindications

Tamoxifen should not be used in patients with a known allergy to it or any component in its formulation or concomitantly with warfarin. For patients taking tamoxifen for breast cancer risk reduction who are at high risk for breast cancer or with ductal carcinoma in situ, it should be avoided if the patient has a history of deep vein thrombosis (DVT) or pulmonary embolism (PE). In patients that have been diagnosed with breast cancer, the benefits outweigh the risks, but it should still be used in caution in patients with a history of thromboembolic events.

Tamoxifen also has many drug-drug interactions, so a comprehensive medication list in all patients receiving it is vital.[44]

Monitoring

All patients on tamoxifen should have routine lab work including a complete blood count with platelets, serum calcium, and liver function tests. Female patients should monitor for abnormal vaginal bleeding and receive a breast and gynecologic exam at baseline and routinely after. Patients should also watch for signs and symptoms of a DVT or PE.

Other monitoring parameters tend to vary, depending on patient-specific factors. In patients with pre-existing hyperlipidemia, triglycerides and cholesterol should be monitored.[45] Patients on vitamin K antagonists should have their INR and PT checked.[46] Reproductive female patients need a pregnancy test before treatment and should use reliable birth control methods during treatment.[47] Premenopausal women should receive a bone mineral density test. All patients should get an ophthalmic exam if vision problems or cataracts occur.[48]

Toxicity

There is currently no antidote available for tamoxifen.

Enhancing Healthcare Team Outcomes

Interprofessional teamwork and communication provide success for all patients, especially those undergoing cancer treatments. Oncologists should thoroughly evaluate the patient and select an appropriate treatment regimen based on guidelines and patient-specific factors. For example, in estrogen receptor-negative breast cancer, tamoxifen may not be appropriate. Nurses should be aware of the more severe adverse effects tamoxifen may cause and look out for them in their patients. Pharmacists should examine the patient’s current and complete drug regimen and make sure there are no interactions as tamoxifen has many. These are just a few examples, and roles tend to overlap in many different professions, but every healthcare professional provides a vital role that, in turn, benefits the patient greatly. (Level V)


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Tamoxifen - Questions

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Which of the following drugs is known to induce hot flashes?



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Which cancer is associated with the use of tamoxifen?



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What kind of drug is tamoxifen?



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Tamoxifen works by which of the following mechanisms?



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Which of the following conditions often is treated with Tamoxifen\?



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Which of the following anti-cancer drugs is linked to an increased incidence of uterine cancer?



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Women who are prescribed tamoxifen for more than 5 years are at a risk for developing which of the following?



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A postoperative patient is receiving tamoxifen 20 mg twice a day by mouth as adjunct therapy for breast cancer. When the patient asks about the purpose of this drug, what is the best response?



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Which anti-cancer drug works by binding to specific receptors?



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Which of the following is false regarding tamoxifen therapy for breast cancer?



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Tamoxifen increases the risk of which of the following?



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What type of drug is tamoxifen?



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Endometrial carcinoma is most likely to occur in a patient taking?



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What receptor is affected by tamoxifen?



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You have a breast cancer patient who is being treated with dual therapy of trastuzumab and tamoxifen. Her sister also had breast cancer and received trastuzumab, but she is unfamiliar with tamoxifen and wants to know what role it plays in her cancer therapy. Which of the following is your response?



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In which category would you place the medication tamoxifen?



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Nolvadex is the brand name for which generic drug?



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In which drug class is tamoxifen correctly placed?



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Tamoxifen - References

References

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Cvancara JL,Meffert JJ,Elston DM, Estrogen-sensitive cutaneous polyarteritis nodosa: response to tamoxifen. Journal of the American Academy of Dermatology. 1998 Oct     [PubMed]
Fraser IS, Menorrhagia due to myometrial hypertrophy: treatment with tamoxifen. Obstetrics and gynecology. 1987 Sep     [PubMed]
Markwalder TM,Seiler RW,Zava DT, Antiestrogenic therapy of meningiomas--a pilot study. Surgical neurology. 1985 Sep     [PubMed]
Serels S,Melman A, Tamoxifen as treatment for gynecomastia and mastodynia resulting from hormonal deprivation. The Journal of urology. 1998 Apr     [PubMed]
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Grio R,Cellura A,Geranio R,Porpiglia M,Piacentino R, [Clinical efficacy of tamoxifen in the treatment of premenstrual mastodynia]. Minerva ginecologica. 1998 Mar     [PubMed]
Li CP,Lee FY,Hwang SJ,Chang FY,Lin HC,Kuo BI,Chu CJ,Lee SD, Treatment of mastalgia with tamoxifen in male patients with liver cirrhosis: a randomized crossover study. The American journal of gastroenterology. 2000 Apr     [PubMed]
Kristensen B,Ejlertsen B,Dalgaard P,Larsen L,Holmegaard SN,Transbøl I,Mouridsen HT, Tamoxifen and bone metabolism in postmenopausal low-risk breast cancer patients: a randomized study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 1994 May     [PubMed]
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De M,Jaap A,Dempster J, Tamoxifen therapy in steroid resistant Reidel's thyroiditis. Scottish medical journal. 2001 Apr     [PubMed]
Lissoni P,Paolorossi F,Tancini G,Ardizzoia A,Barni S,Brivio F,Maestroni GJ,Chilelli M, A phase II study of tamoxifen plus melatonin in metastatic solid tumour patients. British journal of cancer. 1996 Nov     [PubMed]
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Fisher B,Costantino JP,Redmond CK,Fisher ER,Wickerham DL,Cronin WM, Endometrial cancer in tamoxifen-treated breast cancer patients: findings from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-14. Journal of the National Cancer Institute. 1994 Apr 6     [PubMed]
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Antunes MV,Timm TA,de Oliveira V,Staudt DE,Raymundo S,Gössling G,Biazús JV,Cavalheiro JA,Rosa DD,Wallemacq P,Haufroid V,Linden R,Schwartsmann G, Influence of CYP2D6 and CYP3A4 Phenotypes, Drug Interactions, and Vitamin D Status on Tamoxifen Biotransformation. Therapeutic drug monitoring. 2015 Dec     [PubMed]
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