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NCCN Guidelines for Patients



Breast Cancer – Metastatic (STAGE IV), Version 2.2017


Treatment guide

Hormone receptor–positive cancers

Ovarian ablation

permanently stops the ovaries

from making hormones. Most often, both ovaries

are removed from the body. This surgery is called a

bilateral oophorectomy. Radiation to the ovaries also

stops the making of hormones, but isn’t used often.

Ovarian suppression

temporarily stops the

ovaries from making hormones. It is achieved with

drugs called LHRH (








ormone) agonists. LHRH is a hormone in the

brain that helps control the making of estrogen by

the ovaries. LHRH agonists stop LHRH from being

made, which stops the ovaries from making more


What to expect

. Some endocrine therapies greatly

differ by how they are given and what’s required of

you. An example is one day of surgery versus a few

days of radiation therapy. Some drugs are given

as monthly injections while others are pills that are

taken every day. Your treatment team will give you

more information. Questions to ask about treatment

are listed in Part 4.

For many women, endocrine therapy causes

symptoms of menopause. Menopausal symptoms

include hot flashes, vaginal discharge or dryness,

sleep problems, weight gain, hair thinning, fatigue,

bone loss, and changes in mood. You may have

different symptoms from other women.

Tamoxifen also has two rare but more serious side

effects: 1) cancer of the uterus; and 2) blood clots.

For most women with breast cancer, the benefits of

taking tamoxifen far outweigh the risks. Aromatase

inhibitors don’t cause cancer and very rarely cause

blood clots.

Not all the side effects of endocrine therapy are listed

here. Please ask your treatment team for a list of all

common and rare side effects. If a side effect bothers

you, tell your treatment team. There may be ways to

help you feel better.

Targeted therapy

Many targeted therapies stop the signals that tell

a cell to grow. Within signal pathways are protein

kinases. Protein kinases are molecules that move

chemicals, called phosphates, from one molecule to


See Figure 8.

The phosphate “turns on”

the next molecule in the signal pathway.

Targeted therapy for hormone receptor–positive

cancers blocks protein kinases. This type of targeted

therapy is called kinase inhibitors.

See Figure 9.

CDK inhibitors

stop the action of CDK (






inase). CDK is a protein kinase within

the cell nucleus. CDK4 and CDK6 promote cancer

growth in hormone receptor–positive cancers. CDK

inhibitors attach to CDK and stop growth signals.

Palbociclib and


are made in pill form. They

are taken in a 4-week cycle. You will be on treatment

for the first 3 weeks and off treatment for 1 week.

Common side effects include tiredness, nausea,

vomiting, diarrhea, constipation, headache, and hair

loss. Your white blood cell counts may drop. This

may lead to serious infections. Palbociclib can also

cause serious blood clots, and ribociclib, liver and

heart problems.

mTOR inhibitors

stop the action of mTOR









apamycin). mTOR is a protein

kinase within a cell’s gel-like substance. Sometimes,

endocrine therapy stops working because mTOR is

turned on. mTOR inhibitors attach to mTOR and stop

growth signals.

Everolimus is a pill that is taken around the same

time every day. Common side effects include

diarrhea, tiredness, mouth sores, skin rash, cough,

and low blood counts. Serious side effects include

other cancers, lung problems, infections, and kidney