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8.3 Sex hormones and hormone antagonists in malignant disease

8.3.1 Oestrogens

Diethylstilbestrol tablets
Ethinylestradiol (see section 6.4 for more details)

 

8.3.2 Progestogens

Medroxyprogesterone acetate tablets
Megestrol acetate tablets
Norethisterone (see section 6.4 for more details)

 

8.3.4 Hormone antagonists

8.3.4.1 Breast cancer

Anastrozole tablets - see NICE TA 112 
Exemestane tablets - see NICE TA 112
Fulvestrant injection - see note
Letrozole tablets - see NICE TA 112
Fulvestrant injection - see note
Tamoxifen tablets - see note 

Notes:

1. Aromatase inhibitors should be used in line with the Cancer Network Breast Cancer guidelines.

2. Effect of tamoxifen in patients treated with potent CYP2D6 inhibitors

A population-based cohort study on SSRI antidepressants and breast-cancer mortality in women receiving tamoxifen found that the risk of death from breast cancer increased with the length of concomitant treatment with paroxetine—a potent inhibitor of CYP2D6. Therefore, concomitant use of drugs that are potent inhibitors of the CYP2D6 enzyme (e.g. Fluoxetine, paroxetine, cinacalcet) should be avoided whenever possible in patients treated with tamoxifen for breast cancer.

3. Fulvestrant is available as 3rd/4th line treatment of post menopausal women with hormone receptor positive advanced breast cancer.

Please note: Fulvestrant may cross-react with the Elecsys Estradiol assay, giving a falsely increased result. Please discuss with Pathology when monitoring estradiol levels in patients being treated with fulvestrant as an alternative assay method will be needed. 

 4. Prophylactic tamoxifen (10mg daily, increasing to 20mg if needed) is also used in males treated with bicalutamide for prostate cancer to prevent the development of gynaecomastia / mastalgia (unlicensed indication). Low-dose radiotherapy to the breast buds is preferred in patients with contraindications to tamoxifen: those with CV risk factors, thrombotic risk etc.

 

8.3.4.2 Prostate cancer and gonadorelin analogues

Gonadorelin analogues and anti-androgens
Leuprorelin injection
Buserelin injection, nasal spray
Cyproterone acetate tablets
Flutamide tablets - in combination with goserelin patients intolerant of cyproterone
Bicalutamide tablets - see approved indications below
Goserelin implant
Triptorelin (Decapeptyl) - Preferred in urology as LHRH agonist of choice as available in 1,3, and 6-monthly injections
Degarelix injection (For adult male patients with advanced hormone-dependent prostate cancer - see shared care guideline); see NICE TA 404

 

Bicalutamide approved indications

i). Indications approved by the trust: 

  • 50mg once daily: licensed for treatment of locally advanced prostate cancer in combination with LHRH analogue therapy or surgical castration in patients intolerant of flutamide / cyproterone.
  • 150mg once daily: Unlicensed indication as monotherapy in metastatic prostate cancer in men willing to accept adverse impact on overall survival and gynaecomastia in the hope of retaining sexual function.
  • 50mg once daily: unlicensed indication to be used for tumour flare when LHRH initiated in patients intolerant of flutamide/cyproterone. Give for 3 days prior to LHRH initiation and continue for up to 3 weeks after.
  • 150mg once daily: Unlicensed indication in patients with prostate cancer requiring cyto-reduction prior to High Intensity Focused Ultrasound (HIFU). Continue for eight weeks. Other indications whether licensed or not have NOT been approved by the trust.

Note:

1. Patients with existing meningioma or a history of meningioma must not be prescribed high-dose (³25 mg per day) cyproterone acetate. This advice does not apply to low-dose cyproterone acetate products such as co-cyprindiol (Dianette). See the MHRA Drug Safety Update for October 2009.

 

8.3.4.3 Somatostatin analogues

Octreotide injection
Octreotide depot injection (Sandostatin LAR®) - click here for shared care
Lanreotide pre-filled syringes - click here for shared care


Note

Lanreotide should be used first line treatment for acromegaly/symptoms associated with neuroendocrine tumours.

Octreotide is reserved for use if lanreotide has been stopped due to adverse effects of lack of efficacy.


 

 

 

For link to BNF section: 8.3 Sex hormones and hormone antagonists in malignant disease