From the Guidelines
For breast cancer patients with adrenal insufficiency complicated by hepatitis, the treatment strategy should prioritize managing the hepatitis while maintaining adrenal support, and the use of Interferon (IFN) therapy is not recommended due to its potential to exacerbate hepatitis and adrenal insufficiency, as suggested by the most recent guidelines 1.
Treatment Approach
The treatment approach for breast cancer patients with adrenal insufficiency complicated by hepatitis involves:
- Temporarily discontinuing any hepatotoxic agents, including anthracyclines, until hepatitis resolves
- Initiating corticosteroid treatment with prednisone 1-2 mg/kg/day or methylprednisolone equivalent for severe hepatitis (Grade 3-4 with ALT/AST >5x upper limit of normal)
- Monitoring liver function tests every 3-5 days initially and beginning a slow steroid taper over 4-6 weeks to avoid rebound once improvement occurs (typically Grade 1 or less)
- Maintaining adrenal insufficiency management with physiologic hydrocortisone (typically 15-25 mg daily in divided doses), increasing to stress dosing during illness
- Considering the addition of mycophenolate mofetil 1000 mg twice daily for steroid-refractory cases, but avoiding tacrolimus due to potential hepatotoxicity
Rationale
The rationale for this approach is based on the high risk of hepatitis B reactivation in breast cancer patients, particularly those receiving anthracycline-based chemotherapy and steroids, as reported in the most recent guidelines 1. The use of prophylactic antiviral agents has been shown to significantly reduce the rates of hepatitis B reactivation and discontinuation of chemotherapy treatment 1. Additionally, the management of adrenal insufficiency is crucial to prevent adrenal crisis and ensure the patient's overall well-being.
Key Considerations
Key considerations in the treatment of breast cancer patients with adrenal insufficiency complicated by hepatitis include:
- Close monitoring for infections due to immunosuppression from both steroids and cancer treatments
- Modification of breast cancer treatment to avoid hepatotoxic agents until hepatitis resolves
- Patient participation in prospective clinical trials as the preferred option of treatment
- Comprehensive geriatric assessment for elderly patients to add important information for treatment decisions
- Early introduction of expert palliative care to better control symptoms and improve quality of life, as recommended by the ESMO guidelines 1 and NCCN guidelines 1.
From the Research
Treatment Strategy for Breast Cancer Complicated by Adrenal Insufficiency
- The treatment strategy for breast cancer complicated by adrenal insufficiency is complex and requires a multidisciplinary approach 2, 3.
- Adrenal insufficiency can be a consequence of metastatic breast cancer, and its evaluation should be included in the periodical follow-ups of patients who underwent radical mastectomy for breast cancer 4.
- Immunotherapy, such as pembrolizumab, can also induce adrenal insufficiency, which is a rare but underdiagnosed cause of persistent hypotension in cancer patients 5.
Interferon (IFN) Therapy for Hepatitis
- There is no direct evidence in the provided studies regarding the use of Interferon (IFN) therapy for hepatitis in patients with breast cancer complicated by adrenal insufficiency.
- However, it is essential to consider the potential interactions between IFN therapy and adrenal insufficiency, as well as the overall treatment strategy for breast cancer, in a multidisciplinary setting 2, 3.
Management of Adrenal Insufficiency in Breast Cancer Patients
- The management of adrenal insufficiency in breast cancer patients requires supportive treatment, such as fludrocortisone, prednisone, and midodrine, and early diagnostic testing, identification, and management are critical 5.
- In some cases, adrenal insufficiency can be caused by bilateral tumour invasion of the adrenals, and primary adrenal insufficiency can develop 6.