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ALERT: U.S. Boxed Warning
The FDA-approved labeling includes a boxed warning. See Warnings/Precautions section for a concise summary of this information. For verbatim wording of the boxed warning, consult the product labeling or www.fda.gov.
Medication Safety Issues
Sound-alike/look-alike issues:
Tamoxifen may be confused with pentoxifylline, Tambocor™, tamsulosin, temazepam
Pronunciation
(ta MOKS i fen)
Index Terms
Generic Available
Yes
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Treatment of metastatic (female and male) breast cancer; adjuvant treatment of breast cancer; reduce risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS); reduce the incidence of breast cancer in women at high risk
Use: Unlabeled/Investigational
Treatment of mastalgia, gynecomastia, ovarian cancer, endometrial cancer, uterine sarcoma, and desmoid tumors; risk reduction in women with Paget's disease of the breast (with DCIS or without associated cancer); induction of ovulation; treatment of precocious puberty in females, secondary to McCune-Albright syndrome
Pregnancy Risk Factor
D
Pregnancy Considerations
Animal studies have demonstrated fetal adverse effects and fetal loss. There have been reports of vaginal bleeding, birth defects and fetal loss in pregnant women. Tamoxifen use during pregnancy may have a potential long term risk to the fetus of a DES-like syndrome. For sexually-active women of childbearing age, initiate during menstruation (negative ?-hCG immediately prior to initiation in women with irregular cycles). Tamoxifen may induce ovulation. Barrier or nonhormonal contraceptives are recommended. Pregnancy should be avoided during treatment and for 2 months after treatment has been discontinued.
Lactation
Excretion in breast milk unknown/not recommended
Breast-Feeding Considerations
It is not known if tamoxifen is excreted in breast milk, however, it has been shown to inhibit lactation. Due to the potential for adverse reactions, women taking tamoxifen should not breast-feed.
Contraindications
Hypersensitivity to tamoxifen or any component of the formulation; concurrent warfarin therapy or history of deep vein thrombosis or pulmonary embolism (when tamoxifen is used for cancer risk reduction)
Warnings/Precautions
Boxed warnings:
• Gynecologic effects/malignancies: See “Concerns related to adverse effects” below.
• Thromboembolic events: See “Concerns related to adverse effects” below.
Special handling:
• Hazardous agent: Use appropriate precautions for handling and disposal.
Concerns related to adverse effects:
• Bone marrow suppression: Thrombocytopenia and/or leukopenia may occur; neutropenia and pancytopenia have been reported rarely. Although the relationship to tamoxifen therapy is uncertain, rare hemorrhagic episodes have occurred in patients with significant thrombocytopenia.
• Gynecologic effects/malignancies: [U.S. Boxed Warning]: Tamoxifen use for breast cancer risk reduction is associated with an increased incidence of uterine or endometrial cancers. Endometrial hyperplasia, polyps, endometriosis, uterine fibroids, and ovarian cysts have occurred. Amenorrhea and menstrual irregularities have been reported with tamoxifen use. Monitor and promptly evaluate any report of abnormal vaginal bleeding.
• Hepatotoxicity: Liver abnormalities such as cholestasis, fatty liver, hepatitis, and hepatic necrosis have occurred. Hepatocellular carcinomas have been reported in some studies; relationship to treatment is unclear.
• Ocular effects: Decreased visual acuity, retinal vein thrombosis, retinopathy, corneal changes, color perception changes and increased incidence of cataracts (and the need for cataract surgery) have been reported.
• Thromboembolic events: [U.S. Boxed Warning]: Serious and life-threatening events, including stroke and pulmonary emboli have occurred at an incidence greater than placebo during use for breast cancer risk reduction; these events are rare, but require consideration in risk:benefit evaluation. In patients already diagnosed with breast cancer, the benefits of tamoxifen use are greater than the risks. An increased incidence of thromboembolic events has been associated with use; risk is increased with concomitant chemotherapy; use with caution in individuals with a history of thromboembolic events.
Disease-related concerns:
• Bone mineral density: Tamoxifen use may be associated with changes in bone mineral density (BMD) and the effects may be dependant upon menstrual status. In postmenopausal women, tamoxifen use is associated with a protective effect on bone mineral density (BMD), preventing loss of BMD which lasts over the 5-year treatment period. In premenopausal women, a decline (from baseline) in BMD mineral density has been observed in women who continued to menstruate; may be associated with an increased risk of fractures.
• Hyperlipidemia: Use with caution in patients with hyperlipidemias; infrequent postmarketing cases of hyperlipidemias have been reported.
• Metastatic breast cancer: Local disease flare and increased bone and tumor pain may occur; may be associated with (good) tumor response; onset is shortly after therapy initiation and usually resolves rapidly. In patients with bone metastasis, hypercalcemia has occurred usually within a few weeks of therapy initiation. Institute appropriate hypercalcemia management; discontinue if severe.
Concurrent drug therapy issues:
• High potential for interactions: Tamoxifen is associated with a high potential for drug interactions, including CYP-and Pgp-mediated interactions. Decreased efficacy and an increased risk of breast cancer recurrence has been reported with concurrent moderate or strong CYP2D6 inhibitors (Aubert, 2009; Dezentje, 2009).
• Selective serotonin reuptake inhibitors (SSRI): Concomitant use with select SSRIs may result in decreased tamoxifen efficacy. Strong CYP2D6 inhibitors (eg, fluoxetine, paroxetine) and moderate CYP2D6 inhibitors (eg, sertraline) are reported to interfere with transformation to the active metabolite endoxifen. Weak CYP2D6 inhibitors (eg, venlafaxine, citalopram) have minimal effect on the conversion to endoxifen (Jin, 2005; NCCN Breast Cancer Risk Reduction Guidelines v.1.2009); escitalopram is also a weak CYP2D6 inhibitor.
Special populations:
• CYP2D6 poor metabolizers: Lower plasma concentrations of endoxifen (active metabolite) have been observed in patients associated with reduced CYP2D6 activity (Jin, 2005) and may be associated with reduced efficacy.
Adverse Reactions
>10%:
Cardiovascular: Flushing (33% to 41%), hypertension (11%), peripheral edema (11%)
Central nervous system: Mood changes (12% to 18%), pain (3% to 16%), depression (2% to 12%)
Dermatologic: Skin changes (6% to 19%), rash (13%)
Endocrine & metabolic: Hot flashes (3% to 80%), fluid retention (32%), altered menses (13% to 25%), amenorrhea (16%)
Gastrointestinal: Nausea (5% to 26%), weight loss (23%)
Genitourinary: Vaginal discharge (13% to 55%), vaginal bleeding (2% to 23%)
Neuromuscular & skeletal: Weakness (19%), arthritis (14%), arthralgia (11%)
Respiratory: Pharyngitis (14%)
1% to 10%:
Cardiovascular: Chest pain (5%), venous thrombotic events (5%), edema (4%), cardiovascular ischemia (3%), cerebrovascular ischemia (3%), angina (2%), deep venous thrombus (?2%), MI (1%)
Central nervous system: Insomnia (9%), dizziness (8%), headache (8%), anxiety (6%), fatigue (4%)
Dermatologic: Alopecia (<1% to 5%)
Endocrine & metabolic: Oligomenorrhea (9%), breast pain (6%), menstrual disorder (6%), breast neoplasm (5%), hypercholesterolemia (4%)
Gastrointestinal: Abdominal pain (9%), weight gain (9%), constipation (4% to 8%), diarrhea (7%), dyspepsia (6%), throat irritation (oral solution 5%), abdominal cramps (1%), anorexia (1%)
Genitourinary: Urinary tract infection (10%), leukorrhea (9%), vaginal hemorrhage (6%), vaginitis (5%), ovarian cyst (3%)
Hematologic: Thrombocytopenia (?10%), anemia (5%)
Hepatic: AST increased (5%), serum bilirubin increased (2%)
Neuromuscular & skeletal: Back pain (10%), bone pain (6% to 10%), osteoporosis (7%), fracture (7%), arthrosis (5%), myalgia (5%), paresthesia (5%), musculoskeletal pain (3%)
Ocular: Cataract (7%)
Renal: Serum creatinine increased (?2%)
Respiratory: Cough (4% to 9%), dyspnea (8%), bronchitis (5%), sinusitis (5%)
Miscellaneous: Infection/sepsis (?9%), diaphoresis (6%), flu-like syndrome (6%), allergic reaction (3%)
<1%, infrequent, or frequency not defined: Cholestasis, corneal changes, endometriosis, endometrial cancer, endometrial hyperplasia, endometrial polyps, fatty liver, hepatic necrosis, hepatitis, hypercalcemia, hyperlipidemia, lightheadedness, phlebitis, pruritus vulvae, pulmonary embolism, retinal vein thrombosis, retinopathy, second primary tumors, stroke, superficial phlebitis, taste disturbances, tumor pain and local disease flare (including increase in lesion size and erythema) during treatment of metastatic breast cancer (generally resolves with continuation), uterine fibroids, vaginal dryness
Postmarketing and/or case reports: Angioedema, bullous pemphigoid, erythema multiforme, hypersensitivity reactions, hypertriglyceridemia, impotence (males), interstitial pneumonitis, loss of libido (males), pancreatitis, Stevens-Johnson syndrome, visual color perception changes
Metabolism/Transport Effects
Substrate of CYP2A6 (minor), 2B6 (minor), 2C9 (major), 2D6 (major), 2E1 (minor), 3A4 (major); Inhibits CYP2B6 (weak), 2C8 (moderate), 2C9 (weak), 3A4 (weak), p-glycoprotein
Drug Interactions
Aminoglutethimide: May increase the metabolism of Tamoxifen. Risk D: Consider therapy modification
Anastrozole: Tamoxifen may decrease the serum concentration of Anastrozole. Risk D: Consider therapy modification
Colchicine: P-Glycoprotein Inhibitors may increase the serum concentration of Colchicine. Colchicine distribution into certain tissues (e.g., brain) may also be increased. Management: Colchicine is contraindicated in patients with impaired renal or hepatic function who are also receiving a p-glycoprotein inhibitor. In those with normal renal and hepatic function, reduce colchicine dose as directed. Risk D: Consider therapy modification
CYP2C8 Substrates (High risk): CYP2C8 Inhibitors (Moderate) may decrease the metabolism of CYP2C8 Substrates (High risk). Risk C: Monitor therapy
CYP2C9 Inducers (Highly Effective): May increase the metabolism of CYP2C9 Substrates (High risk). Risk C: Monitor therapy
CYP2C9 Inhibitors (Moderate): May decrease the metabolism of CYP2C9 Substrates (High risk). Risk C: Monitor therapy
CYP2C9 Inhibitors (Strong): May decrease the metabolism of CYP2C9 Substrates (High risk). Risk D: Consider therapy modification
CYP2D6 Inhibitors (Moderate): May decrease the metabolism of Tamoxifen. Specifically, CYP2D6 inhibitors may decrease the formation of highly potent active metabolites. Risk D: Consider therapy modification
CYP2D6 Inhibitors (Strong): May decrease the metabolism of Tamoxifen. Specifically, strong CYP2D6 inhibitors may decrease the formation of highly potent active metabolites. Risk X: Avoid combination
CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates. Risk C: Monitor therapy
CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Risk C: Monitor therapy
CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates. Risk D: Consider therapy modification
Dabigatran Etexilate: P-Glycoprotein Inhibitors may increase the serum concentration of Dabigatran Etexilate. Risk X: Avoid combination
Darunavir: May increase the serum concentration of CYP2D6 Substrates. Risk C: Monitor therapy
Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Risk C: Monitor therapy
Deferasirox: May decrease the serum concentration of CYP3A4 Substrates. Risk C: Monitor therapy
Herbs (CYP3A4 Inducers): May increase the metabolism of CYP3A4 Substrates. Risk C: Monitor therapy
Letrozole: Tamoxifen may decrease the serum concentration of Letrozole. Risk C: Monitor therapy
Peginterferon Alfa-2b: May decrease the serum concentration of CYP2C9 Substrates (High risk). Risk C: Monitor therapy
Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates. Risk C: Monitor therapy
P-Glycoprotein Substrates: P-Glycoprotein Inhibitors may increase the serum concentration of P-Glycoprotein Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Risk C: Monitor therapy
Rifamycin Derivatives: May increase the metabolism of Tamoxifen. Risk C: Monitor therapy
Rivaroxaban: P-Glycoprotein Inhibitors may increase the serum concentration of Rivaroxaban. Risk C: Monitor therapy
Silodosin: P-Glycoprotein Inhibitors may increase the serum concentration of Silodosin. Risk X: Avoid combination
Topotecan: P-Glycoprotein Inhibitors may increase the serum concentration of Topotecan. Risk X: Avoid combination
Vitamin K Antagonists (eg, warfarin): Tamoxifen may increase the serum concentration of Vitamin K Antagonists. Risk X: Avoid combination
Ethanol/Nutrition/Herb Interactions
Food: Avoid grapefruit juice (may decrease the metabolism of tamoxifen).
Herb/Nutraceutical: Avoid black cohosh, dong quai in estrogen-dependent tumors. Avoid St John's wort (may decrease levels/effects of tamoxifen).
Storage
Store at room temperature of 20°C to 25°C (68°F to 77°F). Protect from light.
Mechanism of Action
Competitively binds to estrogen receptors on tumors and other tissue targets, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects; nonsteroidal agent with potent antiestrogenic properties which compete with estrogen for binding sites in breast and other tissues; cells accumulate in the G0 and G1 phases; therefore, tamoxifen is cytostatic rather than cytocidal.
Pharmacodynamics/Kinetics
Absorption: Well absorbed
Distribution: High concentrations found in uterus, endometrial and breast tissue
Protein binding: 99%
Metabolism: Hepatic; via CYP2D6 to 4-hydroxytamoxifen and via CYP3A4/5 to N-desmethyl-tamoxifen. Each is then further metabolized into endoxifen (4-hydroxy-tamoxifen via CYP3A4/5 and N-desmethyl-tamoxifen via CYP2D6); both 4-hydroxy-tamoxifen and endoxifen are 30- to 100-fold more potent than tamoxifen
Half-life elimination: Tamoxifen: ~5-7 days; N-desmethyl tamoxifen: ~14 days
Time to peak, serum: ~5 hours
Excretion: Feces (26% to 51%); urine (9% to 13%)
Dosage
Oral: Note: For the treatment of breast cancer, patients receiving both tamoxifen and chemotherapy, should receive treatment sequentially, with tamoxifen following completion of chemotherapy.
Children: Females: Precocious puberty and McCune-Albright syndrome (unlabeled use): A dose of 20 mg/day has been reported in patients 2-10 years of age; safety and efficacy have not been established for treatment of longer than 1 year duration
Adults:
Breast cancer treatment:
Adjuvant therapy (females): 20 mg once daily for 5 years
Metastatic (males and females): 20-40 mg/day; daily doses >20 mg should be given in 2 divided doses (morning and evening)
DCIS (females): 20 mg once daily for 5 years
Breast cancer risk reduction (pre- and postmenopausal high-risk females): 20 mg once daily for 5 years
Induction of ovulation (unlabeled use): 20 mg once daily (range: 20-80 mg once daily) for 5 days (Steiner, 2005)
Paget's disease of the breast (risk reduction; with DCIS or without associated cancer): 20 mg once daily for 5 years (NCCN Breast Cancer Guidelines, v.1.2009)
Dosage adjustment for DVT, pulmonary embolism, cerebrovascular accident, or prolonged immobilization: Discontinue tamoxifen (NCCN Breast Cancer Risk Reduction Guidelines, v.1.2009)
Dosage: Combination Regimens
Breast cancer: Tamoxifen-Epirubicin
Melanoma:
CCDT (Melanoma)
Dartmouth Regimen
Administration: Oral
Administer once or twice daily with or without food. Doses >20 mg/day should be given in divided doses.
Monitoring Parameters
CBC with platelets, serum calcium, LFTs; triglycerides and cholesterol (in patients with pre-existing hyperlipidemias); abnormal vaginal bleeding; breast and gynecologic exams (baseline and routine), mammogram (baseline and routine); signs/symptoms of DVT (leg swelling, tenderness) or PE (shortness of breath); ophthalmic exam (if vision problem or cataracts); bone mineral density (premenopausal women)
Test Interactions
T4 elevations (which may be explained by increases in thyroid-binding globulin) have been reported; not accompanied by clinical hyperthyroidism
Dietary Considerations
May be taken with or without food. Avoid grapefruit and grapefruit juice.
Patient Education
Do not take any new medication during therapy without consulting prescriber. Take exactly as directed. It is important to maintain adequate hydration unless instructed to restrict fluid intake and adequate nutrition (small frequent meals may help). You should schedule an annual ophthalmic examination, gynecological exam, and mammogram if this medication is used long-term. You may experience hot flashes, hair loss, loss of libido (these will subside when treatment is completed). Bone pain may indicate a good therapeutic responses (consult prescriber for mild analgesics). May cause nausea, vomiting, loss of appetite (small frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help); photosensitivity (use sunscreen, wear protective clothing and eyewear, and avoid direct sunlight); hot flashes (a cool room or cool compresses may help). Notify prescriber if menstrual irregularities, vaginal bleeding, or intolerable hot flashes occur. Report unusual bleeding or bruising; severe weakness or unusual fatigue; CNS changes (depression, mood changes); swelling or pain in calves; respiratory difficulty; vision changes; or other adverse effects. Pregnancy/breast-feeding precautions: Do not get pregnant while taking this medication and for 2 months after treatment is discontinued; consult prescriber for appropriate barrier or nonhormonal contraceptive measures. Do not breast-feed.
Geriatric Considerations
Studies have shown tamoxifen to be effective in the treatment of primary breast cancer in elderly women. Comparative studies with other antineoplastic agents in elderly women with breast cancer had more favorable survival rates with tamoxifen. Initiation of hormone therapy rather than chemotherapy is justified for elderly patients with metastatic breast cancer who are responsive. Reduction of mortality and recurrence was greater in those studies that used tamoxifen for ?2 years than those that use it for <2 years.
Additional Information
Oral clonidine is being studied for the treatment of tamoxifen-induced “hot flashes.” The tumor flare reaction may indicate a good therapeutic response, and is often considered a good prognostic factor.
Estrogen receptor status may predict if adjuvant treatment with tamoxifen is of benefit. In metastatic breast cancer, patients with estrogen receptor positive tumors are more likely to benefit from tamoxifen treatment. With tamoxifen use to reduce the incidence of breast cancer in high risk-women, high risk is defined as women ?35 years of age with a 5 year NCI Gail model predicted risk of breast cancer ?1.67%.
Dental Health: Effects on Dental Treatment
No significant effects or complications reported
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
May cause dizziness, drowsiness, or confusion
Mental Health: Effects on Psychiatric Treatment
May cause leukopenia; use caution with clozapine and carbamazepine
Nursing: Physical Assessment/Monitoring
Use caution in presence of leukopenia, thrombocytopenia, or hyperlipidemia or history of thrombolytic events. Assess potential for interactions with other pharmacological agents and herbal products patient may be taking (increased or decreased levels/effects of tamoxifen or other drugs administered concurrently). Assess results of CBC and platelet counts, therapeutic effectiveness (eg, complaints of bone pain may be an indication of a good therapeutic effectiveness in metastatic breast cancer patients and will usually subside as treatment continues), and adverse reactions (eg, flushing, fluid retention, hot flashes, vaginal bleeding or discharge, constipation, rash, mood changes). Teach patient proper use, possible side effects/appropriate interventions (eg, periodic ophthalmic evaluations and annual gynecological exams and mammogram with long-term use), and adverse symptoms to report.
Oncology: Emetic Potential
Low (10% to 30%)
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet: 10 mg, 20 mg
Pricing: U.S. (www.drugstore.com)
Tablets (Nolvadex)
10 mg (60): $114.79
20 mg (60): $220.37
Tablets (Tamoxifen Citrate)
20 mg (30): $21.99
References
Aubert RE, Stanek EJ, Yao J, et al, “Risk of Breast Cancer Recurrence in Women Initiating Tamoxifen With CYP2D6 Inhibitors,” J Clin Oncol, 2009, 27(18S):CRA508 [abstract from 2009 ASCO Annual Meeting].
Boostanfar R, Jain JK, Mishell DR Jr, et al, “A Prospective Randomized Trial Comparing Clomiphene Citrate With Tamoxifen Citrate for Ovulation Induction,” Fertil Steril, 2001, 75(5):1024-6.
Cohen I, Altaras MM, Lew S, et al, “Ovarian Endometrioid Carcinoma and Endometriosis Developing in a Postmenopausal Breast Cancer Patient During Tamoxifen Therapy: A Case Report and Review of the Literature,” Gynecol Oncol, 1994, 55(3 Pt 1):443-7.
Dezentje V, Van Blijderveen NJ, Gelderblom H, et al, “Concomitant CYP2D6 Inhibitor Use and Tamoxifen Adherence in Early-Stage Breast Cancer: A Pharmacoepidemiologic Study,” J Clin Oncol, 2009, 27(18S):CRA509 [abstract from 2009 ASCO Annual Meeting].
Early Breast Cancer Trialists' Collaborative Group (EBCTCG), “Effects of Chemotherapy and Hormonal Therapy for Early Breast Cancer on Recurrence and 15-Year Survival: An Overview of the Randomised Trials,” Lancet, 2005, 365(9472):1687-717.
Eastell R, Adams JE, Coleman RE, et al, “Effect of Anastrozole on Bone Mineral Density: 5-Year Results From the Anastrozole, Tamoxifen, Alone or in Combination Trial 18233230,” J Clin Oncol, 2008, 26(7):1051-7.
Eugster EA, Rubin SD, Reiter EO, et al, “Tamoxifen Treatment for Precocious Puberty in McCune-Albright Syndrome: A Multicenter Trial,” J Pediatr, 2003, 143(1):60-6.
Goetz MP, Kamal A, and Ames MM, “Tamoxifen Pharmacogenomics: The Role of CYP2D6 as a Predictor of Drug Response,” Clin Pharmacol Ther, 2008, 83(1):160-6.
Hochner-Celnikier D, Anteby E, and Yagel S, “Ovarian Cysts in Tamoxifen-Treated Premenopausal Women With Breast Cancer - A Management Dilemma,” Am J Obstet Gynecol, 1995, 172(4 Pt 1):1323-4.
Jin Y, Desta Z, Stearns V, et al, “CYP2D6 Genotype, Antidepressant Use, and Tamoxifen Metabolism During Adjuvant Breast Cancer Treatment,” J Natl Cancer Inst, 2005, 97(1):30-9.
Jordan VC, "Tamoxifen: A Most Unlikely Pioneering Medicine," Nat Rev Drug Discov, 2003, 2(3):205-13.
Jubelirer SJ, “The Management of Menopausal Symptoms in Women With Breast Cancer,” W V Med J, 1995, 91(2):54-6.
Khatcheressian JL, Wolff AC, Smith TJ, et al, “American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting,” J Clin Oncol, 2006, 24(31):5091-7.
LiVolsi VA, Salhany KE, and Dowdy YG, “Endocervical Adenocarcinoma in Tamoxifen-Treated Patient,” Am J Obstet Gynecol, 1995, 172(3):1065.
National Comprehensive Cancer Network® (NCCN), “Clinical Practice Guidelines in Oncology™: Breast Cancer,” Version 1.2009. Available at http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf.
National Comprehensive Cancer Network® (NCCN), “Clinical Practice Guidelines in Oncology™: Breast Cancer Risk Reduction, Version 1.2009.” Accessible at http://www.nccn.org/professionals/physician_gls/PDF/breast_risk.pdf
National Comprehensive Cancer Network® (NCCN), “Clinical Practice Guidelines in Oncology™: Ovarian Cancer,” Version 1.2009. Available at http://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf
National Comprehensive Cancer Network® (NCCN), “Clinical Practice Guidelines in Oncology™: Uterine Neoplasms,” Version 2.2009. Available at http://www.nccn.org/professionals/physician_gls/PDF/uterine.pdf
Pandya KJ, Raubertas RF, Flynn PJ, et al, “Oral Clonidine in Postmenopausal Patients With Breast Cancer Experiencing Tamoxifen-Induced Hot Flashes: A University of Rochester Cancer Center Community Clinical Oncology Program Study,” Ann Intern Med, 2000, 132:788-93.
Rutqvist LE, Johansson H, Signomklao T, et al, “Adjuvant Tamoxifen Therapy for Early Stage Breast Cancer and Second Primary Malignancies. Stockholm Breast Cancer Study Group,” J Natl Cancer Inst, 1995, 87(9):645-51.
Steiner AZ, Terplan M, and Paulson RJ, “Comparison of Tamoxifen and Clomifene Citrate for Ovulation Induction: A Meta-Analysis,” Hum Reprod, 2005, 20(6):1511-5.
Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, “Consensus on Infertility Treatment Related to Polycystic Ovary Syndrome,” Fertil Steril, 2008, 89(3):505-22.
Vehmanen L, Elomaa I, Blomqvist C, et al, “Tamoxifen Treatment After Adjuvant Chemotherapy Has Opposite Effects on Bone Mineral Density in Premenopausal Patients Depending on Menstrual Status,” J Clin Oncol, 2006, 24(4):675-80.
Visvanathan K, Chlebowski RT, Hurley P, et al, “American Society of Clinical Oncology Clinical Practice Guideline Update on the Use of Pharmacologic Interventions Including Tamoxifen, Raloxifene, and Aromatase Inhibition for Breast Cancer Risk Reduction,” J Clin Oncol, 2009, 27(19):3235-58.
Winer EP, Hudis C, Burstein HJ, et al, “American Society of Clinical Oncology Technology Assessment on the Use of Aromatase Inhibitors as Adjuvant Therapy for Postmenopausal Women With Hormone Receptor-Positive Breast Cancer: Status Report 2004,” J Clin Oncol, 2005, 23(3):619-29.
International Brand Names
Lexi-Comp.com
Last full review/revision September 2009
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