Fast track — ArticlesEffects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study
Introduction
Hot flushes are one of the most common symptoms associated with menopause, reportedly occurring in 68–82% of women undergoing natural menopause.1 Surgical menopause is associated with an increased incidence and severity of hot flushes compared with natural menopause.2 Carpenter and colleagues3 report that women who have survived breast cancer have hot flushes that are “significantly more frequent, severe, distressing, and of greater duration” than in other women. These researchers also note that several unique factors, such as ovarian disruption caused by chemotherapy and subsequent early and artificial menopause, might mean that generalisations about healthy women with hot flushes cannot be applied to survivors of breast cancer.
Hot flushes can have a substantial effect on daily living, by disrupting sleep and causing fatigue and irritability during the day.4 Severe hot flushes, which can cause rapid heartbeat, diaphoresis, nausea, dizziness, anxiety, headache, and weakness, also substantially increase the risk of sleep deprivation, depression, sexual dysfunction, and other serious medical conditions.
Hot flushes are a frequent and serious side-effect of pharmacological treatments for breast cancer, including oestrogen-synthesis inhibitors, oestrogen antagonists, and aromatase inhibitors. In survivors of breast cancer taking anti-oestrogen medications, hot flushes can even contribute to cancer recurrence by discouraging compliance with treatment regimens. Data show that more than 50% of such patients might be non-compliant after 180 days from initiation of anti-oestrogen treatment.5 Poor adherence to medication regimens in patients with breast cancer is a serious issue, because these treatments have a major role in decreasing the recurrence of disease.5
In the past, many physicians might have under-rated the severity of hot flushes that result from anti-oestrogen medications and the negative effects of severe hot flushes on patients' lives and health. Although the scale of this issue after breast-cancer treatment is probably still underestimated, hot flushes are beginning to receive attention from health-care professionals.6
Current treatment options for hot flushes have varying degrees of effectiveness. Available options include: hormone treatment; herbal remedies; and non-hormonal pharmaceuticals.
Hot flushes are the most common reason for women to seek hormone treatment,7 and this treatment option can be effective. However, hormone treatment has substantial complications, including headache, nausea, water retention, premenstrual irritability, and vaginal bleeding, which have a deleterious effect on quality of life.8 Withdrawal bleeding is the most common reason for why women discontinue hormone treatment.9 Moreover, for survivors of breast cancer, hormone treatment is generally considered contraindicated. A study published in 200410 showed a substantial increase in new breast-cancer events in survivors of breast cancer on hormone treatment, leading to early termination of the study because of “unacceptable risk”. Consequently, survivors of breast cancer use hormone treatment much less frequently (fewer than 5% of survivors of breast cancer are on hormone treatment) than women who have not had breast cancer.10 Use of this treatment option in patients with breast cancer has also decreased noticeably since the Women's Health Initiative reported conflicting and disturbing findings regarding its efficacy and side-effects in survivors of breast cancer.11
For herbal remedies, data suggest that these and lifestyle interventions are, at best, only slightly more effective than placebo.4, 8, 12, 13 Specifically, reviews of non-hormonal treatments for hot flushes concluded that phyto-oestrogens14 and black cohosh,15, 16 are both ineffective in providing symptomatic relief.
The most promising non-hormonal pharmaceutical treatments include selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), and gabapentin. These drugs have been reported to decrease hot-flush scores. However, SSRIs seem to be much less effective than hormone treatment.13 Venlafaxine, an SNRI, can lead to rapid development of anasarca17 and possible Q–T extension with a possible increase in sudden death.18 Gabapentin has been reported to decrease hot flushes, but has been associated with a higher risk of suicide19 and with weight gain,20 compared with placebo.
Another possible treatment for debilitating hot flushes is stellate-ganglion block, used as a means of interrupting parts of the sympathetic nervous system involved in temperature regulation. This procedure might also help treat sleep dysfunction, which is often reported by menopausal women, including survivors of breast cancer on anti-oestrogen medications.
Stellate-ganglion blocks have been done safely for more than 60 years.21 We suggest that a properly done stellate-ganglion block might be a safer and more effective treatment for hot flushes and sleep dysfunction in survivors of breast cancer than current pharmacological alternatives. To investigate this hypothesis, we did a pilot study to assess the safety and efficacy of this procedure in a group of survivors of breast cancer. To our knowledge, there have been no previous reports investigating the potential benefits of stellate-ganglion block for hot flushes and night awakening in this patient population. Our previously published anecdotal research on this procedure in 2005 reports a significant decrease of hot flushes in six patients without breast cancer.22 The current study includes survivors of breast cancer.
Section snippets
Patients and procedure
Female survivors of breast cancer were referred, by their oncologists or gynaecologists, for assessment for stellate-ganglion block as a treatment for their hot flushes and sleep dysfunction. Participation in the study group was elective. Women who had acute infections or cardiac compromise at the time of assessment, who were on hormone treatment, or who had a blood-clotting disorder or an American Society of Anesthesiologists (ASA) physical status score23 of 3 or higher were excluded from the
Results
13 female survivors of breast cancer (age range 38–71 years) with severe hot flushes were included in this pilot study (table). All patients remained in the study throughout the 12-week follow-up period.
Of the 13 patients, five had only one stellate-ganglion block and eight had two stellate-ganglion blocks. There were no adverse events resulting from this procedure. Patients reported minimum pain or no pain on injection because all blocks were done under local anesthaetic or local anaesthetic
Discussion
This study shows that stellate-ganglion block can significantly decrease the number and intensity of hot flushes and night awakenings in survivors of breast cancer. The total number of hot flushes was significantly decreased, and the number of very severe hot flushes was decreased to near zero.
The symptoms of hot flushes that occur in menopausal women—eg, sudden sensations of intense heat with sweating, flushing, and peripheral vasodilation—are characteristic of a heat-dissipation response.
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