American Board of Internal Medicine (ABIM) Certification Practice Exam

In patients with aggressive breast cancer encountering severe arthralgia on aromatase inhibitors, the next step should be?

1. Initiate a second aromatase inhibitor

2. Switch to tamoxifen

3. Increase the dosage of the current aromatase inhibitor

4. Stop all hormonal therapy

The correct answer is: Initiate a second aromatase inhibitor

In cases of aggressive breast cancer where patients are experiencing severe arthralgia as a side effect of aromatase inhibitors, the best approach is to initiate a second aromatase inhibitor. This is based on the understanding that while aromatase inhibitors can cause musculoskeletal side effects such as arthralgia, different aromatase inhibitors may have varying side effect profiles and tolerability. Switching to another aromatase inhibitor could potentially alleviate the arthralgic symptoms while still providing the necessary estrogen suppression that is vital in the management of hormone receptor-positive breast cancer. In contrast, switching to tamoxifen may not be the ideal choice in this scenario since tamoxifen operates via a different mechanism and may not provide the same level of estrogen suppression as aromatase inhibitors in postmenopausal women. Increasing the dosage of the current aromatase inhibitor is generally not a viable solution, as it is unlikely to reduce arthralgia and may, in fact, exacerbate side effects. Stopping all hormonal therapy would not be appropriate, as it would halt essential treatment and could lead to disease progression. Overall, initiating a second aromatase inhibitor strikes a balance between managing side effects while maintaining effective treatment for breast cancer.