Clinical Review

Weighing HRT use after breast cancer

OBG Manag. 2002 June;14(6):16-32

References

1. Clemons M, Goss P. Estrogen and the risk of breast cancer. N Engl J Med. 2001;344:276.-

2. Cauley JA, Lucas FL, Kuller LH, et al. Elevated serum estradiol and testosterone concentrations are associated with a high risk for breast cancer. Ann Intern Med. 1999;130:270.-

3. Lippman M, Bolan G, Huff K. The effects of estrogens and anti-estrogens on hormone-responsive human breast cancer in long-term tissue cultures. Cancer Res. 1976;36:4595.-

4. Blankenstein MA, Maitimu-Smeele I, Donker GH, et al. On the significance of in-situ production of estrogens in human breast cancer tissue. J Steroid Biochem Mol Biol. 1992;41:891.-

5. Collaborative Group on Hormone Factors in Breast Cancer. Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet. 1997;350:1047.-

6. Gradstein F, Stampfer MJ, Colditz GA, et al. Postmenopausal hormone therapy and mortality. N Engl J Med. 1997;336:1769.-

7. Sellers TA, Minko PJ, Cerhan JR, et al. The role of hormone replacement therapy in the risk for breast cancer and total mortality in women with a family history of breast cancer. Ann Intern Med. 1997;127:973.-

8. Haagerson CD, Stout AP. Carcinoma of the breast: criteria of operability. Ann Surg. 1943;118:59.-

9. Cheek JH. Survey of current opinion concerning carcinoma of the breast in association with pregnancy. Arch Surg. 1953;66:664.-

10. Zemlickis D, Lishner M, Degendorfer P, et al. Maternal and fetal outcome after breast cancer in pregnancy. Am J Obstet Gynecol. 1992;166:781.-

11. DiFronzo LA, O’Connell TX. Breast cancer in pregnancy and lactation. Surg Clin North Am. 1996;76:267.-

12. Kroman N, Jensen MB, Melbye M, et al. Should women be advised against pregnancy after breast cancer treatment? Lancet. 1997;350:319.-

13. Ravdin RG, Lewison EF, Slack NH, et al. Results of a clinical trial concerning the worth of prophylactic oophorectomy for breast carcinoma. Surg Gynecol Obstet. 1970;131:1055.-

14. Bluming VAZ, Waishman JR, Doski GM, et al. Hormone replacement therapy in women with previously treated primary breast cancer. Update. Proceedings of ASCO. 1999;l>18:471.-

15. Powles TJ, Hickish T, Casey S, et al. Hormone replacement after breast cancer. Lancet. 1993;342:60.-

16. Stoll BA, Parbhoo S. Treatment of menopausal symptoms in breast cancer patients. Lancet. 1988;1:278.-

17. Vassilopoulou-Sellin R, Asmur L, Hortobagyi GN, et al. Estrogen replacement therapy after localized breast cancer: clinical outcome of 319 women followed prospectively. J Clin Oncol. 1999;17:1482.-

18. Natray an PK, Soumakis K, Gambrell RD, et al. Estrogen replacement therapy in women with previous breast cancer. Am J Obstet Gynecol. 1999;181:288.-

19. Brewster WR, DiSaia PJ, Grosen EA, et al. An experience with estrogen replacement therapy in breast cancer survivors. Int J Fertil. 1999;44:86.-

20. DiSaia PJ, Brewstser WR, Ziogas A, et al. Breast cancer survival and hormone replacement therapy: a cohort analysis. Am J Clin Oncol. 2000;23:541.-

21. O’Meara ES, Rossing MA, Daling JR, et al. Hormone replacement therapy after a diagnosis of breast cancer in relation to recurrence and mortality. J Natl Cancer Inst. 2001;93:54.-

22. AmericanCollege of Obstetricians and Gynecologists Hormone replacement therapy in women with previously treated breast cancer. ACOG Committee Opinion #226. Washington,DC:ACOG; 1999.

23. Vassilopoulou-Sellin R, Zolinski C. Estrogen replacement therapy in women with breast cancer: a survey of patient’s attitudes. Am J Med Sci. 1992;304:145.-

Pending evidence

While gold-standard clinical trials (double-blinded, prospective, randomized studies) on HRT use after breast cancer have not been completed, 2 such studies are presently ongoing in Europe, including the HABITS Trial in Sweden and a similar study in the United Kingdom. In addition, a prospective trial is underway at the M.D. Anderson Hospital in Houston, Tex. The Gynecologic Oncology Group also has approved a prospective, randomized, double-blind study comparing estrogen with a placebo in women who have had breast cancer. And the Eastern Cooperative Oncology Group (ECOG) recently completed a feasibility study of HRT in patients who have had breast cancer. Unfortunately, it will be several years before these trials yield definitive answers.—William Creasman, MD

Conclusion

The American College of Obstetricians and Gynecologists (ACOG) states in a committee opinion that “there is no conclusive data to indicate an increased risk of recurrent breast cancer in postmenopausal women taking HRT. No woman can be guaranteed protection from recurrence. Late manifestations of recurrent disease and an apparent predisposition to recur (as shown by a selected subgroup of women) cannot be ignored; however, the benefits of HRT are well recognized and contribute to the quality and length of life in postmenopausal women.”²²

The data to date suggest that HRT in the patient who has had breast cancer is not detrimental. In fact, some of the larger studies note significantly fewer recurrences and breast cancer deaths, and less total mortality in HRT users, compared with matched controls.

ACOG states in a committee opinion that “there is no conclusive data to indicate an increased risk of recurrent breast cancer in postmenopausal women taking HRT.”

Many women who have had breast cancer express an interest in HRT. A recent study of 224 women with breast cancer reported that 34% of the menopausal patients wanted to consider HRT as an option. Among women treated for breast cancer with surgery only, 71% also would consider its use.²³ In addition, 59% of the premenopausal patients expressed interest in eventual HRT treatment. Therefore, to reject HRT out of hand for a patient who may be having significant vasomotor symptoms, or one who is several years beyond breast cancer therapy and may want preventive measures for cardiovascular disease and osteoporosis, is not in the patient’s best interest. Women want information so they can make an appropriate choice. As health-care providers, we need to be sensitive to their desires and supportive of their decisions.

The author reports no financial relationship with any companies whose products are mentioned in this article.