Distress caused by hot flushes seriously under-played

A study by UK researchers of over 200 breast cancer patients receiving hormone treatments such as tamoxifen has found that nearly two-thirds would prefer to take a tablet daily and around a quarter would prefer a monthly injection, given that both treatments would be equally effective and have similar side-effects.

However, when presented with a hypothetical situation that injections would result in fewer hot flushes the choices reversed with those opting for tablets slumping to around 27% and those preferring injections soaring to around 60%.

The proportion that would opt for injections also rose - to nearly three-quarters - when they were given a hypothetical situation where a monthly double injection would control the cancer better. Only a fifth in this case would prefer daily tablets.

The research is published on-line (Thursday 20 October) in Annals of Oncology. It involved 208 women with early or advanced breast cancer from different parts of the UK, who had been diagnosed at least two years before.

"These findings provide two potentially important messages," said lead researcher Professor Lesley Fallowfield, "The first is that the distress caused by the side-effect of the hot flushes that all endocrine treatments produce is seriously under-played. The second is that, although the assumption of many health professionals that patients generally dislike injections is correct, most patients are willing to sacrifice preference for efficacy. That information may be important if future research demonstrates a benefit for higher doses, which would necessitate injections."

Professor Fallowfield, who is Cancer Research UK Professor of Psychosocial Oncology at Brighton & Sussex Medical School, University of Sussex, said that patients' concerns or preferences about treatment are rarely explored and the views of healthcare professionals varied widely. She found some findings unexpected.

"I was surprised with the initial finding that a quarter would prefer injections to tablets if both had the same efficacy and side effects. The reasons for their choice were that injections would help ensure adherence and be more convenient. Those who preferred tablets cited convenience and dislike of needles."

However, the research threw up one extremely worrying result: that nearly half of women said they sometimes forgot their tablets and more than one in ten deliberately didn't take them at times.

"The principle reason that women are not adhering to their breast cancer treatments is hot flushes and this affects post and pre-menopausal patients," said Professor Fallowfield, "Some doctors are unconcerned about this as nobody actually dies of a hot flush; but post menopausal women are embarking on treatment that brings back hot flushes and night sweats when they thought they had finished with them. For pre-menopausal women, possibly taking hormone tablets, who have also been hit by chemotherapy, the sudden onset of menopausal hot flushes and night sweats is a devastating assault on their well-being."

She said that much more attention needed to be paid to these particular side-effects, which are seriously under-estimated and can make life utterly miserable. Doctors or nurses did offer advice such as wearing layers of clothing, avoiding spicy foods, hot drinks etc., but most women will have already tried the obvious. Mild anti-depressants sometimes helped.

"A third of women are still getting hot flushes after two years - so that's why we are seeing these 'little drug holidays'," she said.

"It is serious because we don't know how many tablets have to be missed before efficacy is affected. But, we know up to 40% of women often miss tablets, and it could be argued that the likely benefits of hormone treatment are even greater than has been proven in trials because the results are skewed by non-compliance. Hormone treatments are playing a major role in reducing recurrence of breast cancer and, ultimately, deaths, so it is essential for women to adhere fully to their treatment programme."

She said doctors should be more pro-active in getting patients to tell them how much of a problem hot flushes were, so they could watch out for the patients more likely not to adhere to treatment and offer them extra help.

"Women should not be embarrassed to report hot flushes and night sweats if they are a significant problem. If enough complain we may see some serious endeavour put into reducing side-effects.

"Personally, I would give a Nobel prize to the doctor who could eliminate hot flushes. It really is important," Professor Fallowfield concluded.

Key findings include:

1. If daily tablets and a double injection a month had equal efficacy and side-effects, 63% preferred tablets, 24.5% preferred injections, 12.5% had no preference;
2. Main reasons for the preference for tablets in this initial scenario, were convenience and dislike of needles, while reasons for preferring injections also included convenience, plus a desire to ensure adherence;
3. Despite the initial scenario describing tablets and injections as equally effective, of those patients with a preference, 95.4% of those who preferred injections thought injections were more effective and 58.8% of those preferring tablets thought tablets were more effective;
4. In an imagined scenario where a double injection a month produced fewer hot flushes, 27.4% opted for tablets, 60.6% for injections, 12% had no preference;
5. In an imagined scenario where a double injection a month would better control the cancer, 19.2% chose tablets, 74.5% chose injections and 6.3% had no preference;
6. Of those admitting to non-adherence, 48.7% said they sometimes forgot and 13.1% said they deliberately omitted taking their tablets at times;
7. Asked about their feelings on injections, 37.5% said they were generally anxious about them, 17.3% said that anxiety or dislike of needles might cause them to avoid injections, and 13.5% reported having had needle phobia at some time.

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