Should estrogen therapy be used by breast cancer survivors?
Click Here to Manage Email Alerts
Click here to read the Cover Story
Yes, it is time.
For medicine to advance, entrenched paradigms must yield to new evidence. The widely held belief that menopausal hormone therapy causes breast cancer, and thus should never be given to breast cancer survivors, must be reassessed.
Decades of evidence support the benefits of HT for menopausal symptoms, improved cardiac health, prevention of hip fracture, reduction in risk of cognitive decline, and enhanced longevity. Why deprive breast cancer survivors of these benefits, especially when more of them will die of heart disease than of recurrent breast cancer?
Even the Women’s Health Initiative, which raised alarms about HT in 2002, has walked back all but one, still maintaining that combination estrogen-progestin administered to menopausal women increases the risk for breast cancer. Yet this conclusion resulted from a misinterpretation of their own data: The experimental group given hormones did not have a higher risk; the control group, many of whom had been on HT before entering the study, had a lower risk. When all previous HT users were removed from comparison, the difference in breast cancer incidence vanished.
A review of 25 reported studies of women given HT after breast cancer found only one, the HABITS trial, that reported an increased risk for recurrence. No difference between estrogen receptor (ER)-positive and ER-negative patients was reported, and although the increased risk reported in HABITS involved only local or contralateral recurrence, there had been no baseline breast imaging upon entry to the study.
Finally, if estrogen is carcinogenic, survivors should be advised to avoid pregnancy, yet pregnancy subsequent to treated breast cancer, even ER-positive breast cancer, has been reported to have no effect on prognosis. For our patients’ well-being and health, it is time to reconsider outdated practice.
- For more information:
- Avrum Bluming, MD, is a medical oncologist, master of the American College of Physicians and an emeritus clinical professor of medicine at the University of Southern California, Los Angeles. He can be reached at avrumzbluming@yahoo.com.
- Reference:
- Bluming AZ, et al. Cancer J. 2022;doi:10.1097/PPO.0000000000000595.
No. Although systemic hormone replacement therapy can provide much symptom relief, multiple studies have suggested increased rates of cancer recurrence, therefore making systemic therapy relatively contraindicated.
As the result of successful breast cancer treatment, many younger women may enter menopause. These patients can experience side effects associated with a low estrogen state. Nonadherence to adjuvant endocrine therapy may occur as a result, risking inferior breast cancer survival outcomes. Thus, relieving menopausal side effects not only may improve a patient’s quality of life, but also may improve her overall breast cancer outcomes.
Multidisciplinary care is highly relevant and necessary in the management of menopausal symptoms in breast cancer survivors. Multiple interventional and complementary approaches are available for the management of vasomotor symptoms, such as lifestyle changes, acupuncture or cognitive behavioral therapy, with variable degrees of success. Nonhormonal medical treatments for vasomotor symptoms, such as use of SSRI/SNRI agents or gabapentin, have demonstrated efficacy in randomized controlled trials and are in common use. Vaginal dryness is typically treated with nonhormonal moisturizing and lubricating agents. Vaginal estrogen treatment can be more effective than nonhormonal approaches and is thought to have minimal systemic absorption. Yet given limitations in available safety data, vaginal estrogen therapy tends to be recommended only if other measures are not effective, after a thorough risk/benefit discussion.
Excellent communication between breast cancer survivors and their treatment team is strongly encouraged to improve knowledge about any emergent symptoms and their duration and severity, and, importantly, to appreciate and acknowledge the impact of symptoms on an individual’s life. Joint decision-making and involvement of a multidisciplinary team, with medical and complementary support as needed, may help provide the best outcomes for cancer survivors.
- For more information:
- Erica L. Mayer, MD, MPH, is director of Breast Cancer Clinical Research and institute physician at the Dana-Farber Cancer Institute, Boston. He can be reached at erica_mayer@dfci@harvard.edu.
Collapse
Read more about
Click Here to Manage Email Alerts