Clinical Integration of Nonhormonal Treatments for VMS: Patient Selection and Practical Considerations

The clinical management of VMS in patients with breast cancer requires a structured, patient-centered approach that begins with systematic symptom collection. In this video, Carmine Valenza, MD, MPH, PhD(c), notes that surveys indicate approximately 30% of patients are unsatisfied with how their clinicians discuss VMS, and that more thorough assessment is associated with better symptom control and improved treatment adherence. Before initiating any pharmacologic intervention, clinicians should explore both pharmacologic and nonpharmacologic options with patients, as individual preferences—factoring in lifestyle, daily schedule, and comorbid conditions such as depression or anxiety—may appropriately guide initial management choices.

Among pharmacologic agents, elinzanetant (Lynkuet) and gabapentin are currently the only National Comprehensive Cancer Network-preferred options for VMS in patients with a prior breast cancer diagnosis; MHT remains generally contraindicated in this setting except in highly selected patients with hormone receptor–negative disease. Valenza acknowledges the absence of direct head-to-head comparisons among available nonhormonal agents but points to network meta-analyses demonstrating that NK receptor inhibitors achieve efficacy comparable to MHT and superior to SSRIs, serotonin-norepinephrine reuptake inhibitors, gabapentin, and oxybutynin in the general menopause population. For patients with comorbid depression or chronic anxiety, SSRIs may represent a reasonable choice given the potential to address both VMS and mood symptoms with a single agent.

The ideal candidate for elinzanetant, in Valenza's clinical judgment, is a patient with moderate-to-severe VMS that is impacting quality of life and potentially compromising adherence to endocrine therapy. The early onset of action—with measurable VMS reduction observed as soon as week 1—is clinically advantageous, as it enables rapid feedback to patients and supports continued engagement with therapy. For clinicians working in co-treatment models with oncologists, Valenza recommends proactive communication with the oncology team regarding the indication, symptom severity, and any concurrent genitourinary symptoms that may warrant consideration of local hormonal therapy. A collaborative, integrated approach supports both optimal VMS management and the preservation of endocrine therapy adherence.